Rock and Hard Place

Here is a dilemma for you.  Imagine if a school bus driver came to your rehab facility after a motorcycle accident that caused a few vertebral fractures.  Add to this that the dude is not happy there and leaves in about five days AMA. You hardly know him but when you do a Rx search you find that this guy has gotten1,600 pills from several different doctors in less than four years.  Remember, we are in a world where “opioid abuse” is the new catchphrase. You also realize this guy has been getting sleeping pills and anxiolytic Rxs as well.  And he is driving kids to school!  Would you:

  1. Do nothing?
  2. Call his doctor or one of his doctors?
  3. Call this school system he works for?

Well, the story is real and happened in Alabama. The doctor called the school board and yada, yada, yada he gets sued for $6 million for malpractice and defamation of character.  The patient stated, in his deposition, “that he hadn’t taken all the pills that had been dispensed and had passed random drug tests.” He also said “he was out on medical leave during the time he was taking opioids.”

I think this falls under: NO GOOD DEED GOES UNPUNISHED.

You can read the rest of the article here. Some things I learned from it was that HIPAA has a provision that says it’s not a violation to disclose private health information for a public health reason, but even if there’s not a HIPAA violation, a patient can still sue under state law.  Isnt that great?

The good news is that the doctor won the case.  The stress of a lawsuit, however, is extremely damaging and no one wants to go through that.  In these times it is really hard to know the right answer.   Even if you just call his primary care doctor, you aren’t guaranteed he or she will do something.  You may be legally covered but what if this guy does kill someone?  Or what if YOU are the primary care doctor and this guy is getting drugs everywhere?  You have to discuss this with him but the odds are you fire him.  Then what?  Report him? Yup.  But you will be sued as well.  It kills me that this profession always puts us between a rock and a hard place.

What do you think?

What would you do?

 

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Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  10 comments for “Rock and Hard Place

  1. Chris
    August 7, 2018 at 6:46 pm

    I think you have fallen into the hysterical politician/newsperson trap of listing the number of doses a person takes to make a dramatic impact. Over a 4 year period 1600 doses is really not that many. If you had a really serious injury you might be taking 2 Norco every 4 hours and one month of that is 360 doses. Also, who cares if its multiple doctors. He might have seen a surgeon in the hospital, another doctor in the rehab hospital, maybe that doctor’s partner, a pain management doc after discharge, etc. What would be an issue would be the pattern of the medications being filled being inconsistent with legitimate use such as overlapping prescriptions, early refills, filling overlapping prescriptions at different pharmacies, etc. If there is a pattern that is inappropriate then the police officer on my local drug enforcement task force gets a call from me and this guy gets a visit from them and I wash my hands of it. There is NO WAY I am calling this guys employer. I am surprised the jury found for the physician in this case.

    The trouble that this physician got into is that he decided he was going to become a crusader against what he perceived was this patient’s prescription drug abuse and driving under the influence (which I think he had little evidence for). The physician admitted that he “barely got to know the patient” before he checked out AMA so how in the world could he possibly make the determination that he had opioid and benzodiazepine dependence. He had no reason to query the PDMP on this patient unless he was going to prescribe a controlled med to him (which I would not if I had a patient leaving AMA on me). His use of the PDMP in this manner is strictly forbidden in MY state, I don’t know about Alabama. This is exactly the kind of think that makes the public less willing to have the government keep this kind of database.

  2. PW
    August 6, 2018 at 11:44 am

    Damned if you do, damned if you don’t…

    • Kurt
      August 8, 2018 at 3:31 pm

      Needs to be like child/elder abuse. One is immune for reporting to the proper authorities. Period.
      If that’s not the case then the doc (unfortunately) has to mind their own business.
      Incidentally, in a few cases of perceived elder abuse some families were doing the best they could
      (no exploitation) and the authorities actually got them the additional help they needed to care for their loved one.

  3. Pat
    August 6, 2018 at 10:11 am

    I’m going to second Lance: I keep trying to find new ways to mind my own business. I have long since outgrown any of the stupid idealism I used to have about being one of the guardians and protectors of society. People can go fry themselves, and if in the course they commit illegalities, then that is for the cops to handle. Screw it.

  4. bbneo
    August 6, 2018 at 7:29 am

    So what is the point of these state prescription monitoring programs if the state authorities don’t scrutinize somebody like this under suspicion of drug diversion?
    That is where I would turn first… bring his case to state authorities to investigate. Particularly if there is evidence of suspicious prescription practices… multiple doctors, early refills, lack of urine drug screens or appropriate medical followup.

  5. Sir Lance-a-lot
    August 6, 2018 at 6:43 am

    When I worked for an Urgent Care in a rural area, where there were several Urgent Cares and two hospitals more or less along the same road, if someone came in inappropriately seeking narcotics, we would call the other places along the road and alert them. Generally, the places in one direction would have seen him already, and the places in the other direction would be grateful.

    When I had a kid in for a sports physical once, with an non-worked-up and concerning heart murmur, and the mom first lied and then when caught became Irate and said she would just sign the form herself and give it to the school, we called the school and told them.

    In the case described, as a Rehab, i would consider myself to be working for the PCP (or maybe for Ortho), and call them and let them know, and then I would drop it. After I have informed the proper medical person, it is no longer any of my business. Aside from imminent and specific threats, as understood under Tarasoff (1974), I won’t tell nobody nothin’. I am not the patient’s mom, and I am not a cop. The patient is an adult, making his own decisions and judgements, and if he does anything stupid, it is his fault, and not mine.

    • chris
      August 9, 2018 at 11:49 am

      You are perfectly safe with discussing a patient’s care with another physician who has treated that patient…you don’t need a patient’s authorization. That is an exception to the HIPAA law under coordination of care. You would be on thin ice giving protected patient information to a physician pre-emptively. Although I think you would be ok in saying “If you have a patient by this name walk in your door you might want to call me.”

      I once had a pregnant patient present to me taking teratogenic medications that she wanted me to refill. So I refused and notified her OB next door of what she was taking. They ended up referring her to a maternal-fetal specialist and she got mad at me and threatened legal action for supposedly violating her HIPAA protections so I handed her a copy of the law and told her never to come back to my office.

      • Eric Lonergan
        August 9, 2018 at 11:13 pm

        “You would be on thin ice giving protected patient information to a physician pre-emptively.”

        But not if you gave the other offices nearby a description of the person and a quick run-down on their story (they’ve all got a favorite story), with no name or personal info, which is what we did.

        • Chris
          August 10, 2018 at 11:58 am

          Granted…as long as no protected patient info is disclosed you are safe. Like: “We had a middle age white guy that came in the office complaining of an acute clavicle fracture. Turns out we found out he has had non-union for 5 years and goes around getting xrays and bottles of pain pills…so be wary. If you have a patient matching that description call us to see if it’s the same guy.”

  6. Thomas D Guastavino
    August 6, 2018 at 6:43 am

    Another excellent argument for loser pays.

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