I had planned on attending the SAM Podiatry conference. I was all set to leave on Wed. Wouldn't you know it, a new patient walks into the office about 40 minutes prior to me leaving my office on Wednesday.
A 61 year old female comes in sits in my chair. I entered the room asking "so, how can I help you today, what is the problem?".
She responded "oh, I have an ulcer on my foot for about a year now" was her reply.
The little bubble over my head was saying "are you freaking kidding me, 40 minutes before I am running to catch a plane".
I, quickly started trying to gather as much history as possible.
She told me she was seeing other Podiatrists and she really just came for a second opinion. (Even though I was the third podiatrist she came too. Yeah, I know, I figured that made me the third opinion as well.)
Anyway, after taking x-rays and seeing her completely rigid flatfeet from charcot breakdown and the ulcer on the bottom of the foot, I suggested conservative treatment of a contact cast and if it failed possible reduction of the bony prominence (cuboid) under the ulcer to help alleviate the pressure on the ulcer.
In my haste to get a complete history as this is one of those cases, I try and document every little thing - I noticed she had not taken off her other sock.
I, informed the patient I needed to see the other foot. Upon removal of the sock a forefoot cellulitis was present on the distal lateral aspect of the foot.
She informs me it had been present for a few weeks. She tells me she received a 5 day course of Keflex from her podiatrist and since that did not work her PCP gave her in his office, IV Rocephin for 4 days straight.
My follow-up was when was the last time you had bloodwork - to which she told me on Monday by her Podiatrist. Of course she had no results for me.
I, looked at my watch, closed the chart and told the patient my recommendation is immediate HOSPITALIZATION. I informed her she was a high risk patient. That, I had no idea how well her diabetes was being controlled and had no idea of her white count etc.
She repeatedly asked me for a "stronger" antibiotic as she told me she did not and would not go to the hospital. I informed her she could do what she wants but if G-d forbid she lost her leg it would be on her and not on me.
I informed her a 5 day course of Keflex is not a complete course that even if she had a staph infection they live for 10 days so she in my opinoin should of had at least a 10 day course. Similiarly, the 4 day course of Rocephin was under treatment as if it was a gram negative infection she needed a 14 day course of antibiotics.
She could have a suprainfection as a result, could be building resistance with all this under treatment and I will NOT play any role in treatment that is not upto par.
Again, please for a stronger antibiotic were made. She even said "so, your not going to give me an antibiotic for my infection?" - and I shot back at her, "Don't put words in my mouth". I NEVER said that. I said you will be given the appropriate antibiotics in the HOSPITAL where we can have blood results on the spot and have you fully evaluated as you are a high risk patient.
I called her Internist on the phone in front of her - and reviewed her problem, her prior treatment, and I told him I am not letting the patient dictate her own treatment because if she loses her leg, I don't want anyone telling me she should of been in the hospital after multiple attempts of outpatient antibiotics.
He agreed. I made the patient sign a note stipulating she was informed to go straight to the ER, and I gave her a referral with a colleagues name as I was soon to be boarding a plane.

Part two: After spending an hour with the patient, she asked me if I could wave the 40 dollar copayment. She told me all her other doctors did this for her. In prior years, this is something that I would of contemplated. However, it simply can't be done anymore. My practice is not the same practice it was a year ago. It is becoming increasingly harder to run.
My problem is that I always feel bad for people.
Perhaps, it was that I needed to catch a plane, perhaps it was because I felt I just spent a long time with the patient - I don't know what it was within me - but, I turned to her and said "You know, you chose your insurance and I am obligated by law to honor my contract with them and it stipulates that I have to collect the co-payment. If you really can't pay the co-payment why don't you call your insurance and ask them if they can give you a discount?"
She shot back at me - its the doctors prerogative to waive the co-pay if he wants to.
I didn't want to get into a fight with the patient - and I let it end there. I hope she goes to the hospital and gets admitted and that her infection goes away.

Lessons of the day: 1) Don't ever let a high risk patient dictate their own treatment.
2) More so in these cases DOCUMENT EVERYTHING.
3) AMA letters are good to have as part of documentation.
4) Its the start of a new year - COLLECT YOUR CO-PAYS or you won't be in business in 2015.
5) Don't let patients guilt you into something -
6) Self respect is Joy.
7) Microbiology comes in handy when prescribing antibiotics.

Peace Out -

  • Comments (7)
  • 1) perhaps it is bad practice but I do not screen any patients. I welcome all. This is how we generate income. I have a solo practice. We only produce money when people come and pay for services. I feel comfortable evaluating and deciding what to do with patients that come to the office. Every now and then a patient may present with something that I feel would be better treated by someone else and in those cases I make appropriate referrals.
    2) I am not exactly sure what occurred with the copay in my story as I left without discussing with the office. I believe my front office collected it before she went in but the woman asked at the end in an attempt to recoup. I'll find out on Monday and let you know how it went down as I am curious myself.
  • Quote:

    Finding all of this practice / patient management instructive, thanks.

    About the co-pay: why don't you / secretary collect prior to your consultation? Seems that many / most health care providers now do so.   

    Probably would have avoided  this patient if co pay collections happen before going back to the exam room.

    I agree with Deiter. 

  • Patients have to dictate their own treatment so long as they fully understand the risks of noncompliance with a podiatrists  suggestions. Patients have their own lifestyles. 

    For example bunion surgery the risk of an infection and them being out of work and losing their job in this economy could be explained to the patient as a low risk and it should be up to the patient to take that risk and proceed with the suggested care.

    Also a patient can refuse hospitalization to a vascular surgeon and hospitalization and in office care can be given to attempt some sort of treatment to avoid amputations. Document document document. Problem with such an approach is if a complication does occur you still could get sued. Then again such podiatric care done out of the hospital might actually possibly succeed in preventing amputations if the patient refuses hospitalization. 


    personal opinions and questions from Dan.

  • Sometimes, there's more than meets the eye, as Carla suggested, and sometimes there isn't. We can't always figure out which is which.  This patient may have issues beyond the all too common one of the diabetic not taking proper care of themselves until they perceive an emergency. or it could be that the other doctors saw they weren't getting paid either and did just enough to make an obviously noncompliant yet demanding patient happy and get them out of their offices. That's a healthy cycle (NOT!).

    You were true to yourself and followed a plan that would be the most helpful for everybody involved, at least in the long run. Between sticking to your guns medically and the AMA letter, you wisely avoided shortcuts which could put both the patient and you at undue risk.  At teh same time, the patientw as told that she needs to participate actively and appropriately in her own care or else you won't partner with her in the effort.

    Entirely commendable, as aggravating and frustrating as it is.

    BTW, I had the diabetic emergency come in 3 hours before I was due on a plane many years ago.  She had gone 2 weeks with a swollen foot that had just become an emergency because coworkers told her to get checked out.  At least this involved "only" fractured 4th/5th mets. She later had the same sort of ulcers and infections that were emergencies 2+ weeks after they developed. Goes with the territory, unfortunately.

  • Jeff, I feel your frustration.  I think most of us have experienced similar situations.  We understand your dilemma.  There are a lot of issues involved here, both from the perspective of the practitioner and patient.

    There's no law I've ever heard of that is as consistent, as unfair, and as frustrating as Murphy's Law.  Super complex patients have a way of entering our lives at THE MOST sensitive  or inconvenient times.  It's then that we have to take a deep breath and make the most of the situation.  This was a particularly charged encounter as you needed to catch a plane, and the patient was on her third opinion.  Both sides of the chair had strong emotions.  Things that would have helped this situation would have been: 1. Screen the patient prior to visit to determine the seriousness of the problem.  2. Have the staff triage patients before they see you--get a thorough history, take off the socks and shoes and get a cursory exam to give you a heads up.  3.  Schedule plenty of time off prior to a flight so when Murphy's Law roars it's head, you're prepared.

    Here are some other thoughts/observations on this issue:

    I'm of the camp that while patients shouldn't dictate their care, they should have a say in it.  We are a medical team, and the patient is really the important part, since they are the ones who have to carry out the tasks to ultimately resolve the issue.  Patients are consulting us, and it's good when they are involved enough in their care to ask questions.

    I agree with the prior comment of making sure the copay is collected up front, before the patient enters the exam room.  That way you're not in a spot.  If they aren't able to pay the copay, especially for a third opinion, then your staff can mitigate the situation in a way you stipulate prior to any patient visit.

    I also agree with Bryan that the screening of new patients should be thorough, especially with a diabetic with wounds.  While that wouldn't always prevent such an experience (patient's don't always realize how serious their situation is), it can certainly help.

    I would also like to comment from the patient's perspective.  We just never know what it's like in their shoes.  Especially as a doctor, I am petrified at the thought of entering a hospital as a patient.  Between overworked and underpaid doctors and nurses, hospital acquired infections, ridiculously overpriced hospital care (that continues to bill patients on weekends and holidays despite having reduced or unavailable services then), etc, etc, it is a potentially morbid experience.  That's not even counting the fact that so many practitioners stop viewing you as a human being when you're wearing a hospital gown.  Hospitals are just not pleasant experiences in general.

    We also don't know how she was treated or managed by the other doctors.  Suppose they were in a rush and didn't give her the information or treatment she needed.  By the third doctor she must be quite distrustful and unhappy with the system.  I know I would be quite frustrated, especially if I didn't understand what was happening and why.

    We also have to keep in mind that the same process that is damaging the nerves, skin, vascular systems, etc are also having an effect on cognitive thinking.  Often times a diabetic with symptoms this advanced can have impaired decision making.  Having a family member or friend help in their care can be fundamental in helping things progress in a better manner.

    Before leaving NY I had a patient who came in and was treated by both a podiatrist and a PCP for over a year for an "infected toe".   He came to me for a second opinion as they were frustrated at the length of time it was taking for the "infection" to resolve.  One look at the patient and I knew we were dealing with Charcot.  Xrays showed he had significant breakdown of the midtarsal joints.  No one in his prior care had considered Charcot.  Once it was properly diagnosed, his symptoms improved.

    In this case, his wife was very involved in his care and on top of things.  As a patient, he himself wasn't able to understand the seriousness of the situation, so his wife became an important component of his care.

    There are also real life concerns that people have to deal with.  It's not an easy thing to have to give up days or weeks of your life to sit around at a hospital.  Some people have significant responsibilities that need to be tended to.

    As practitioners, we have to realize that patients are people.  If we were in their shoes, how would we want someone to talk to us, explain things to us, manage our care.  As practitioners, if we see a patient is not understanding the seriousness of a situation, we have to figure out a way to help them understand.  Why is it that they don't understand?  Is there a language barrier?  Is my terminology over their head?  Is there a cognitive issue that prevents them from understanding?  Are there personal responsibilities that are preventing the patient from fully embracing their treatment?  (I once had a man with active Charcot--bilateral.  He was a single father with no job, living with a friend, no transportation, and 2 kids in elementary school.  There bus for the kids didn't come near the house, so he had to walk with them a considerable distance twice a day.  He had to walk to most of his appointments.  He had to walk to the grocery.  He was a good guy who was dealt a lousy set of circumstances and he was doing the best he could.  I had to put him in a wheelchair.  You can see why things were difficult for him.)

    Of course, we have to protect ourselves also, which is why the AMA letter is important.  Documentation is important.  Helping patients to understand their own responsibilities in the treatment process is important. 

    We don't have an easy job.  Sorry you were thrust into this situation.  With your help and guidance, perhaps you can turn things around for this patient.  Perhaps the two of you will be a perfect team, and she will not need a fourth opinion.  Good luck Jeff!

  • Finding all of this practice / patient management instructive, thanks.

    About the co-pay: why don't you / secretary collect prior to your consultation? Seems that many / most health care providers now do so.   

  • Your office needs to try to screen new wound patients better. I never see a new wound patient without finding out first on the phone how long the wound was present and who is currently caring for it. If they state that they are currently being treated for an infection, I will insist that the current treating doctor call me and update me. If their primary care physician is not at my hospital, I insist that they get admitted where that doctor has privileges. If the patient states they want a second opinion, that is all they get. I will not assume care. If there is any indication on the phone that there is an infection, they are referred to the emergency room. When this system fails and the patient makes it to my treatment room, it invariably is someone who won't use a wheelchair, won't stop working, won't etc.etc.etc. and will take up a good three hours in the office.

    It may sound heartless, but the risks are too great to not have full control. I fly solo less and less these days, and I rely on infectious disease (EVEN ON AN OUTPATIENT BASIS) to take care of my infections. I recommend this highly. They do it much better from both choice of drugs and the needed medical management with the usual co-morbidities.