Karen Childress

For gastroenterologist Timothy Orphanides, leaving the Philadelphia-area group practice he was with for more than two decades was no small decision. He enjoyed his work and his patients, but the time finally came when it simply didn't make sense to stay. "The overhead was high, the reimbursement was low, [and] there was no negotiating with the insurance companies. Even though I was working hard, I wasn't getting ahead financially," says Orphanides.

Although he'd seen the handwriting on the wall several years before he took the plunge and relocated to Martinsburg, W. Va., where he practices today, Orphanides waited until his children were pretty much grown before making the move. "You have to have everyone in the family onboard," he says. "You can't make these decisions on your own."

Once he secured his position at University Healthcare Physicians in West Virginia, Orphanides gave 90-days' notice. The group's business manager oversaw details such as making sure patients and insurance companies were notified, and scheduling was adjusted so that Orphanides stopped taking new patients and had time for final visits with established ones.

Naturally, patients wanted a recommendation about who to see for continuing care, and Orphanides took care to match each patient with the doctor in his group he felt they'd be most compatible with. "They're all very qualified, but I tried to tailor my recommendation to the individual patient," he says. "I wanted everyone to feel comfortable staying with the group."

Orphanides' story makes the process of leaving a practice sound relatively stress free, but make no mistake, there are a great many details to tend to if you want to make a smooth transition. Whether you are permanently closing the doors to a practice or leaving a group that will carry on after you relocate or retire, you'll probably want to work with your practice management consultant, accountant, and attorney to make sure every "i" is dotted and every "t" is crossed.

Professional help aside, educate yourself on the ins and outs of wrapping up a practice, starting with a call to your state and/or county medical society. These organizations have information available to members about how to exit a practice. Checklists include giving proper notice to patients and referring physicians, notifying licensing and regulatory agencies as well as third-party payers, terminating lease agreements, and so forth.

Assuming you've maintained occurrence-based liability insurance (as opposed to claims made) you won't need to purchase tail malpractice coverage. If it turns out that you need tail insurance, be prepared for this lump-sum premium to cost about twice the amount of your most recent annual premium, and maybe even more.

If you are leaving a group, patient records will likely be maintained by the practice so that continuing care can be provided by the colleagues you leave behind. That said, you should still personally confirm that patients are properly notified of your plans to move on, that they're informed about their options for ongoing care, and that they know how to obtain copies of their medical records or how to have them transferred to another healthcare provider. If you are closing the doors to your practice permanently, you are responsible for taking these steps in accordance with what your state mandates so that there is no question of patient abandonment. Find out, also, what is required in terms of how long you must store medical records. The rules for adult and pediatric records are different and the details should be spelled out in the information you obtain from your local medical society.

All the planning in the world doesn't guarantee there won't be bumps in the road. Santa Rosa, Ca.-based practice management consultant Keith Borglum has helped physicians navigate many unexpected obstacles related to transitioning out of a practice. One such bump involves non-compete agreements. Although they are not always enforced (or enforceable, depending on the state and situation), non-compete clauses are common in physician employment and partnership agreements. One physician Borglum worked with honored this portion of his contract and moved his practice 30 miles away when he left a group. "He thought his patients would follow, but they didn't. I have him going back to the group in which he worked to negotiate a buyout of the non-compete so he can move back closer to his original location," says Borglum.

Another of Borglum's clients came face-to-face with the realities of how important the Internet has become. "She left a large group and they kept all of her information on their site so that when someone searched for her by name they'd find her previous employer's website," says Borglum. This caused the doctor months of trouble and she eventually had to hire an attorney to get the group to remove her from their website.

How physicians speak to patients and referral sources about the departure of a member of the group should be thought out ahead of time. "This often doesn't make the list, but it's important for the reputation of the group and the individual who's leaving," says Borglum. "I try to get doctors to come up with a prepared statement that's 20 words or fewer and neutral such as, 'We have different ideas about the direction of the practice.'"

Borglum also advises practices on how to handle a physician's departure. "When a doctor gives notice [the practice] should quickly move to prepare for switching patients to another physician in the group," he says. "If the practice doesn't have the capacity to spread the volume to others they might need to bring in a locum tenens to bridge the gap while they recruit."

Whether to replace a provider who is leaving - and with whom - is a question that should be thought through carefully. "Consider replacing a doctor with a physician extender," says Borglum. "I worked with an ophthalmology group who had two doctors retiring out and I explained the trend of hiring optometrists and opticians. They can do routine eye exams and keep the ophthalmologists in surgery." Another option for specialists, says Borglum, is to hire a family physician instead of nurse practitioner or physician assistant to replace a doctor who is leaving. Doing so makes supervision less of an issue, patients get a higher level of service, and reimbursement is not reduced because "incident-to" billing rules don't apply.

As far as logistics such as notifying patients, the state licensing board, the DEA, third-party payers, and the malpractice carrier, Borglum says that while the individual doctor may do some of this legwork, it's ultimately the practice's responsibility to make sure it all gets done. "All liability goes back to the employer," says Borglum.

Change is good. It's also a lot of work. If you're contemplating retiring or relocating, plan ahead, make lists, be methodical in your process, and engage professional help where you need it. By managing the transition step by step and paying attention to detail, tying up loose ends when you're ready to step into a new chapter of your life should not be an overly daunting process.

 is a former practice management consultant and physician career coach who now works full-time as a freelance healthcare writer. She lives in Cortez, Colo. Karen can be reached at editor@physicianspractice.com.

This article originally appeared in the November/December 2013 issue of 

Articles

Whether you are the physician leaving the office, or the practice being left behind, there are critical steps to take when a doctor gives notice

Dealing With Physician Departures at Your Practice

Take a look at the brochure for your next professional society meeting and you'll likely find a session about patient safety on the agenda. Preventing medical errors, communication systems to improve patient compliance, maintaining problem and medication lists, and patient education are all hot topics. 

As these issues grab headlines, however, don't overlook some of the more basic aspects of office safety. Providing a physically safe practice setting is an important component of quality care and is good business, too; many of the measures you put in place to protect patients also safeguard your staff and reduce the risk for accidents and lawsuits.  

Many medical offices are safer today thanks to two prominent government mandates. "OSHA was the big bogeyman 10 years ago, but now people are in compliance and as a result, patients are safer," says Bruce Bagley, MD, medical director of quality improvement at the American Academy of Family Physicians. 

The other directive that ultimately improved safety is the Americans with Disabilities Act (ADA). "The requirements for ramps, safety bars in bathrooms, and that sort of thing have all made the offices safer for everyone," adds Bagley.

What makes your office a "safe office" varies by specialty, the scope of services you offer, the size of the practice, and even geographic location. What constitutes risk in a two-physician, small-town surgical group is quite different than in a large, inner-city primary-care clinic. In terms of your location, you'll need special procedures in place if you have icy sidewalks in the winter or if your office is in a tornado-prone area. Lab and radiology services add complexity to the safety equation.  

G. Steve Rebagliati, MD, MBA, director of medical affairs and quality management at the Oregon Health Sciences University in Portland, says times have changed when it comes to medical-office safety. "The trend in the past has been to look backward. This was called critical event review. The new trend is to look ahead, to anticipate what can go wrong, and plan for that. You should think about the major categories of emergencies you could have depending on where you are," he says.  

The supplies and equipment you keep on hand for emergencies will depend on your patient population and how close you are to a hospital with an ER. If you have a crash cart it should be stocked in proportion to the size of your practice. Put someone in charge of checking it monthly to make sure everything is in working order and in the proper place and that drugs are not outdated. (For an example of crash cart supplies and set-up, go to 

www.ucdmc.ucdavis.edu/cne/Resources/ClinSkil/Crashcrt/topdrawer.htm

.) 
Automatic external defibrillators (AEDs), now commonplace in airports, shopping centers, and other public areas, can also be practical for medical offices, especially in rural or congested areas where getting an ambulance to the office could cost valuable minutes. The machines are simple enough that almost anyone can use them and they are reasonably priced at around $1,500. Remember, however, that purchasing an AED is not a substitute for having staff trained in CPR.

Kathleen LePar, RN, MBA, senior consultant with Beacon Partners in Weymouth, Mass., is an advocate of concrete policies, procedures, and systems-based safety plans. "Training staff on your policies is so important," says LePar. "If you make a policy and put it in a book on a shelf, you won't get the outcome you want." 

A good safety manual accomplishes several things. First, it forces physicians and staff to think about safety and the issues that are unique to the practice. Second, it's an excellent training tool for new staff and for refresher courses for everyone. Third, it can help you stay in compliance with OSHA, CLIA, ADA, HIPAA, and local building codes. 

The Medical Group Management Association (MGMA) publishes "Operating Policies and Procedures Manual for Medical Practices" by Bette Warn and Elizabeth Woodcock. It includes sample policies on exposure control, sharps disposal, fire control, developing a safety committee, and more. 

Buying a manual like this is an excellent place to start, but the best option is creating a handbook unique to your practice. A three-ring binder with sections on bloodborne pathogen exposure, infectious disease, hazardous waste disposal, emergency procedures, hazardous substances, building exit plans, and reporting unsafe situations -- to name a few -- can be easily updated and used for training new staff.   

Too many practices make the mistake of assuming an experienced medical office employee knows how to recognize, prevent, and deal with safety hazards or emergencies. Just as bad is presuming that when staff has been trained once that's the end of the story.


"The best-run groups set aside regular staff training hours," says Rebagliati. "They'll create a training roster and over the course of a year cover subjects that will give them the biggest return on the investment of time, depending on the patient population. 

Developing something like this just takes a few hours of thinking, and then creating a plan that fits your budget and that you'll follow through on."  

Sandra Adams, OSHA compliance manager for West Clinic, an oncology/hematology practice in Memphis, Tenn. has instituted a comprehensive online training program for staff. "It's on our intranet," she says. "I let managers know when training is due so that during a slow time staff can log on and do the program and answer the questions. Then they enter a code word to move on to the next training." Adams says her staff members are trained every year around their anniversary dates; many safety experts agree that annual training is a good idea. 

If you don't have the technical capabilities to provide online training, there are plenty of low-tech ways to keep staff up to speed. Presentations at staff meetings, hands-on practice sessions, video training (

), and sending staff to seminars are all good options.  

Your local hospital most likely offers CPR courses for their staff. Inquire about sending members of your office staff to this training. 

Depending on your patient population, you may want to have clinical and physician staff trained in advanced cardiac life support as well. Having employees certified in basic cardiac life support (BCLS) or advanced cardiac life support (ACLS) raises the confidence level among staff so that they are better prepared to handle an emergency should one arise.  

Good communication is another key factor in maintaining a safe office. "Staff should know how important it is to report something when it happens. Tell them it's not about blame or shame when someone makes a mistake," says LePar. "It's often a systems problem and it should be addressed. Let the staff know who to go to and that it's OK to make a report."  

When HIV/AIDS first made headlines in earnest, the push was on to protect staff and physicians from potentially infected blood products. "Universal precautions" was the name of the game and everyone jumped on board (much to the delight of latex glove manufacturers). It has been reported recently in the lay press that "AIDS fatigue" may be setting in -- younger people don't remember the initial scare and have become more casual in their behaviors.  

Likewise, be sure your practice doesn't suffer from "universal precaution fatigue." It's worth looking around, quizzing staff about procedures, and retraining everyone periodically on the importance of consistently using gloves, eye protection, and other personal protective gear, as well as avoiding needle sticks and the proper disposal of infectious waste.

In 2001, OSHA updated standards on needle-stick prevention to state that employers should involve staff in the selection of safer needle devices and keep a log of injuries caused by contaminated sharps. Comprehensive information is on OSHA's Web site (

www.osha-slc.gov/SLTC/bloodbornepathogens/index.html

) where you can also find documents that can be used for training or inclusion in your safety manual.

Sandra Adams says one way to drive home the point about wearing personal protective equipment is to use real-life illustrations. "Without revealing names, I give examples of people I know who have been exposed to let staff know it really can happen. Even though we think we know our patients well, we don't always know if they have a communicable disease," she says. 

Have a plan in place in the event there is exposure to HIV, hepatitis, TB, staph, or other serious infectious diseases. "Think ahead of time about your patient population and what relative exposures you have. Keep a packet on hand with lab forms, consents, information about where an exposed individual goes for follow-up, and whether immediate prophylaxis is needed," says Rebagliati.  

Practices with in-office lab and X-ray facilities have special safety issues. If you are diligent about CLIA guidelines, that should cover you for safety as well as quality in your lab. Everyone -- not just lab techs --  should be aware of which chemicals are hazardous and what to do if there is a spill or exposure. Include this in your training and keep medical safety data sheets updated.


Well-trained radiology techs are safety conscious and keenly aware of the risks of radiation exposure. But what about other staff who may come into contact with radiation? The nurse who comes in to help position a patient, for example? Or the receptionist who breezes in and out to deliver messages? Anyone who goes into the imaging area should have a safety orientation and wear a radiation detection badge. Set a good example for staff by being safety-conscious yourself.

Although the threat of bioterrorism may be remote, the possibility does exist. Appoint someone in your office to review CDC bulletins and stay in contact with your local health department. Periodically remind staff and physicians to be on alert for patients presenting with unusual symptoms that might indicate biological or chemical exposures. If you notice anything unusual, contact your county health department.  

Violence in the medical office, while rare, is something you should be aware of. Whether it's an unruly patient, the angry spouse of a staff member, or a random intruder, a threatening situation must be handled in a way that protects the safety of both staff and patients. 

Never hesitate to dial 911 in an emergency. Staff should never try to physically subdue a violent person by themselves. Alternative ways to exit the building should be available and clearly marked, with the doors kept unlocked. Designate a "safe room" which can be locked from the inside and keep a charged cell phone in that room. 

Basic things that make a home safe also make a medical office safe. Ice on the walkways outside, loose rugs, bumps in the flooring, uneven door thresholds, doors that are hard to open --  these can all be accidents waiting to happen. Common sense dictates keeping an eye out for potential safety hazards and making repairs as needed. 

"Just because it's common sense doesn't mean it's happening," says Bagley. Do a walk-through to look for potentially unsafe situations. Toddler-proof the office even if you don't do pediatrics. 

Maintaining a safe environment for patients and staff requires ongoing planning and training, and while some of the suggestions here may seem like overkill for your medical office, it's akin to having good insurance --  you hope you won't ever need it, but if you do you're relieved it's in place and up to date. 

Karen Childress, BA, is a certified coach, freelance writer, and healthcare consultant based in Scottsdale, Ariz., with more than 20 years of experience in the healthcare industry. She is the writer and publisher of "Intentions: The Newsletter for Successful Physicians," an e-newsletter for physicians and other professionals. She can be reached at 

This article originally appeared inthe March 2005 issue of 

Play it Safe

If you've been practicing medicine for more than a week, you've experienced it. You enter an exam room to find an apparently healthy middle-aged woman who woke up this morning with a headache. She wonders what should be done. After all, her co-worker was having headaches and had a CT scan to find the cause. Or you're seeing a young man who has a cold for the second time this season. He heard somewhere that frequent colds can be caused by a suppressed immune system. Could that be his problem? Then there is the patient who dashes into your office with every ache, pain, spasm, twinge, twitch, or itch -- just to be sure. Welcome to the world of the "worried well."

While some worried-well patients in fact have hypochondria --defined as "a morbid concern about one's own health ... a delusion that one is suffering from some disease for which no physical basis is evident" -- many have less severe, more intermittent worries about their health. Emotional distress or depression may play a role as well. 

Family physician Joseph Ewing, MD, who practices in Las Cruces, N.M., sees his share of the worried well. "These are basically normal people with many of the same fears we all have," he says. "They run across all socioeconomic levels but, interestingly, I find it to be more common in people who have time to worry. Someone who is working very hard to make a living and support a family gets a bellyache, but may not have the luxury of running to the doctor."

 Patients with health anxiety often present with symptoms of pain or discomfort -- sometimes vague, other times quite specific in nature. Also common is concern about cancer, heart disease, or symptoms related to a condition that a friend or family member has suffered through or died from recently. 

"A key distinction in these patients is that they don't recognize that symptoms are normal. They assume that every complaint means something is wrong and needs a test. If these patients have any anxiety or depression, then it gets magnified," says Robert C. Smith, MD, professor of medicine and psychiatry at Michigan State University. "Aches and pains are normal -- it's when [patients] start to become high utilizers that it becomes a problem. That's a time to perhaps look for some underlying depression."

According to Steven Taylor, PhD, and Gordon Asmundson, PhD, co-authors of Treating Health Anxiety: A Cognitive-Behavioral Approach, the worried well may be individuals who suffered from childhood diseases or who had family members with serious illnesses. A history of sexual abuse may also contribute, as it can cause feelings of helplessness and vulnerability. Exposure to and excessive reliance on disease-related information can also add to the anxiety level. 

"Modern medicine has been making such impressive advances that some people have come to believe that they can prolong their lives virtually indefinitely if they continue to worry, check, and seek medical advice about their health," says Taylor. 

"Perhaps as a result of technology and today's advanced medical knowledge, many of the worried well expect absolute certainty in diagnoses given to them by their doctors. This need for certainty is, of course, unrealistic. Nothing in life is certain," adds Asmundson. 

While there is an abundance of valuable health-related information available online, for the worried well patient it may be too much of a good thing. It's very easy to look up a common symptom and find some rare or serious disease to match it. If a patient shows up in the office with a ream of printouts from obscure Web sites, physicians need not feel obliged to sort through every piece of information. But don't discount the fact that your patient has taken the time to do some Internet sleuthing. Instead, explain that there is a certain amount of unreliable information in cyberspace. Be sure to note in the chart that you explained your position to the patient and that you are not factoring their Internet research into the treatment plan -- unless, of course, they've stumbled upon something helpful that you do use.

Consider maintaining a short list of reputable Web sites to recommend to patients who are inclined to do their own research. If your practice has a Web site you can provide links there. You might also post information about symptoms common to your patient panel that can usually be treated at home versus conditions for which a patient should seek medical attention, including a timeline (e.g., if symptoms persist for 48 hours, if there is fever, etc.). 
Lacking a Web site, a patient education brochure with this information would be handy. Either way, include the standard disclaimer that the information is not a substitute for direct medical care and that, when in doubt, a patient should indeed seek professional attention.

"Physicians face a challenging task in managing people with excessive health anxiety," says Taylor. "The doctor's first obligation is to make sure that the person truly does not have some undiagnosed disease. The risk, however, is that this can lead to excessive medical testing, which can then fuel the person's health anxiety."

Most physicians are familiar with the "tincture of time," or the watch-and-wait approach. However, reassuring a patient with health anxiety that he doesn't need a diagnostic workup for every symptom can prove challenging and time consuming. Spending a few minutes educating patients about when and why it's OK to "wait-and-see" in certain situations rather than immediately undergoing a battery of expensive tests will be effective with some individuals. However, patients often come in requesting specific diagnostic tests, medications, treatments, and referrals. Couple that with physicians' concerns about being accused of malpractice if they don't thoroughly evaluate every symptom and you have the perfect formula for driving up healthcare costs for everyone -- not to mention making a shambles of the practice's schedule. 

Smith notes that medical-legal issues frequently come into play when treating the worried well. "A key distinction for physicians is to consider whether they're patient-centered or legal-centered. If you are patient-centered, once you've determined that there is nothing serious going on, you reassure the patient and follow them carefully. The legal-centered physician is the one who tells the patient, 'Well, it could be cancer -- and then proceeds to order a carload of tests.'"


In all cases -- but especially when taking care of a worried-well patient who is analyzing or questioning everything you do or don't do -- use your best judgment, common sense, and a consistent practice pattern. Base your decision-making on the most up-to-date information, be as thorough as you feel you need to be, and document carefully so that if questions ever arise you can explain your thought process and action plan -- years after the fact, if needed.

Special care should be taken with follow-up when caring for the worried well, particularly when employing the watch-and-wait approach. If you tell a patient to return in five days for a recheck and they don't show up, every effort should be made to contact the patient, and this should be recorded in the chart.  

Once you've determined, based on a good history and physical, your experience, and good old-fashioned intuition, that whatever the patient is in for does not warrant a work-up or complex medical intervention, managing the worried well might include the following tactics:  

expressing genuine concern and acknowledging that the patient does indeed have a physical symptom; 

offering a reasonable, nonaccusatory explanation for the symptom ("That back pain is probably from a muscle strain. take some Tylenol and take it easy for a few days.");

instructing the patient to follow up if symptoms persist, worsen, or recur;

trying to uncover why the patient might be so worried; 

suggesting healthy lifestyle choices if there are reasonable changes that could be made; and 

if you think depression is an issue, beginning discussion or treatment.

"I find that in order to have credibility with a patient in terms of telling [them] that there is nothing wrong that it's important to have done a good physical exam first -- even if I can tell from just listening to them that their symptoms aren't serious," says Ewing. "If I'm kind and nonjudgmental with my approach, then they will usually accept my opinion." This course of action can help establish rapport with the worried-well patient, making caring for them not only less time consuming, but also more rewarding for the physician.  

According to Taylor, things to avoid when managing the worried well include ordering unnecessary studies, a repeated pat assurance that there is "nothing wrong," telling a patient that it's all in her mind, prescribing a placebo, or becoming argumentative or confrontational. Smith adds, "It's not a good idea for the doctor to be painfully honest and tell the patient that "there is a 2 percent chance it's cancer" or something like that. If the patient already has health anxiety, this just encourages them to keep exploring the issue unnecessarily."

What about the possibility of underlying depression among worried-well patients? Patients who do not respond to a treatment plan offered by their primary-care physician may then need to be referred for a psychological or psychiatric evaluation. Be prepared for some resistance, however. "These patients are sometimes insulted if their doctor wants to refer them for counseling, but if they are clearly depressed or become dysfunctional at home or at work, then that would warrant a psych referral," says Smith.

For the busy physician with a full patient load every day, it may seem more efficient to get a worried-well patient in and out of the office as quickly as possible. But if the patient returns to the office again and again with minor complaints, managing him ultimately ends up taking more time -- not less. Spending a few minutes educating patients about their symptoms and explaining what kinds of things tend to be resolved on their own (e.g., cold without a fever, headache with a one-day duration, occasional mild nausea) can help unclog a schedule that is overloaded with patients who could probably come in less frequently.

"Demanding patients take more time and effort to treat," says Ewing. "One reason medical care is getting more expensive is because the easy thing to do is order tests, as opposed to spending more time with the patient getting to the bottom of the issue. If you can take a few minutes and say to the patient, 'It seems that something is really worrying you. Can you tell me more about that?', you can sometimes get on their wavelength and uncover what they're really concerned about."

Practices that employ physician assistants or nurse practitioners can have front-desk staff schedule chronically worried-well patients with these midlevel providers who often have more time to listen and educate patients. Individuals with health anxiety sometimes need only to 'talk it out' and get reassurance in order to feel better about their situation. If a patient insists on seeing the physician, have them scheduled in the last time slot before lunch or at the end of the day.

Taking care of the worried well is a fact of life for most physicians. Keep in mind that the vast majority of these patients are average people who have health concerns along with a little anxiety. Everyone needs a little peace of mind, warmth, and caring from time to time. Sometimes that's the best medicine you can offer.   

This article originally appeared in the July/August 2004 issue of 

How to identify and manage the worried well

Caring for the Worried Well

Imagine being addicted to a prescription drug -- pain medication, muscle relaxants, or perhaps sleeping pills. To what lengths would you go to get your drug of choice? Feign low back pain? Present to an urgent care center holding your left flank, wincing, and claiming that your urine is pink? Would you go so far as to have elective surgery to secure a supply of pain pills and sleeping aids? It may be hard to fathom, but if you were genuinely addicted you'd do all of this -- and more.

According to a recently released President's National Drug Control Strategy report (

), 6.2 million Americans in 2002 reported having used prescription drugs for nonmedical reasons during the month prior to the study. In terms of illegal use of drugs, this ranks second only to marijuana use. As a practicing physician, the odds are that you are faced with the occasional (or more-than-occasional) drug-seeking patient. How you respond to them is important.

Unfortunately, drug-addicted patients are not always easy to spot. College students, executives, suburban moms, academicians -- even physicians themselves -- can all succumb to addiction. In addition to those who self-medicate to ease emotional pain, there are plenty of addicts who started taking narcotics for a legitimate reason -- perhaps following an injury or major surgery. These patients can be more motivated to kick their habit, and physicians would do well to talk to them about getting into treatment for addiction.

You may also encounter individuals trying to secure narcotics for a family member or friend, or to sell on the street for a profit. This is known as diversion.

Phoenix-based addiction specialist Mike Sucher, MD, says the best way to know if you've got a drug-seeking patient in your office is to pay attention to your intuition. "If you think you're being conned, you probably are," says Sucher. "But a lot of the time you don't have a clue." Addicts will go to great lengths to obtain their drugs. As they become more addicted, seeking their next fix becomes a full-time job for many of them. 

"I kept waiting to see if this patient would ever tell me where he was hurting," recalls Timothy McNichols, a Springfield, Mo.-based internist. "He just kept saying he was in pain and needed narcotics. He didn't appear to be in any pain. I ordered a CT to give him the benefit of the doubt but it didn't show anything. When a patient is genuinely in pain they look like they're in pain and they'll tell you where, and describe the pain."

Faking pain, "losing" medications, and claiming allergies to all nonnarcotic pain relievers are common tactics used to get drugs -- but dedicated drug-seekers will go to great lengths to get their drug of choice. L. Todd Stewart, MD, confronted one such patient when he discovered she'd been getting drugs from multiple physicians and multiple pharmacies. "She said she was an undercover agent trying to trap street drug dealers. When I suggested we contact local authorities to confirm her story she said we shouldn't because it would blow her cover," says Stewart from his pain treatment practice in Gainesville, Ga. 

Stewart believes common sense goes a long way in identifying these patients. "I always ask myself if the pain makes sense, if it follows an anatomical pattern. If a patient says their pain starts in the back, runs up the shoulder then to the back of the head, around to the nose and into their chest, well, something's not right."

The flip side of being vigilant in recognizing drug-seeking patients is not allowing yourself (or your staff) to become jaded or overly skeptical, as William Dachman, MD, an internist at the Maricopa Medical Center in Phoenix, found out. "An elderly patient said her daughter had been stealing her medication so she hid her pills in the oven, but forgot they were there and turned on the oven. We had her bring in the ruined medications and, sure enough, she'd baked them." 

Concern over potential legal issues when it comes to prescribing medications can be a stress factor for already overloaded physicians. "In the big scheme of things this is not something I spend a lot of time worrying about. But I do think about it every time I write a prescription. I stop to think if someone is looking over my shoulder. Am I writing too many? What's too many?" says Dachman.

In recent years physicians have found themselves in a difficult situation, at risk for censure both for over-prescribing and for failing to adequately treat the more than 10 million Americans who suffer from chronic pain. The answer lies in having consistent policies and finding the right balance so that you feel confident in prescribing without getting yourself into trouble.

In a joint statement from 21 health organizations and the U.S. Drug Enforcement Administration (DEA), it's clearly stated that undertreatment of pain is an issue, that the use of opiates is "often the only treatment option," and that helping both medical and law enforcement personnel be more aware of the issue will enable wise decisionmaking.  (See the full statement at 

www.deadiversion.usdoj.gov/pubs/pressrel/painrelief.pdf

Physicians can take some comfort in the fact that in 2003, less than 1 percent of practicing physicians were subject to investigation by the DEA. 

"Pain will usually fall into reasonably predictable patterns. If a patient continues to complain of pain beyond the time when the pain from whatever procedure or problem they've had should have dissipated, then there is one of three things going on -- the patient has a complication, another condition has arisen causing new pain, or they're conning you," says Sucher. It's important to have a plan for how you will deal with these patients.

Often physicians just want to get a drug-seeking patient out of the office as quickly as possible. They don't have time to negotiate with a difficult patient, don't want to risk being accused of improper prescribing, and the thought of getting into a conversation about substance abuse can be daunting. 

McNichols makes his policies clear at the outset. "If I'm at all suspect I simply tell people that I don't prescribe narcotics for new patients until I've reviewed their old records. I also tell them that if there is any discrepancy between what they've told me and what their records indicate, they won't be my patient." 

Here are some ways to keep drug-seeking patients from slipping into your practice:

State your position clearly -- don't be seen as an easy mark.

Ask for a list of all previous doctors on the new patient intake form.

Ask about all current medications and those from the recent past.

Get a medical record release and let the patient know you'll be reviewing records from their previous doctors.

If you find yourself caring for a drug-dependent patient who has no diagnosable pain, you can:

Offer nonnarcotic treatment options, but realize that a drug-seeking patient will likely not go along with such a plan and may seek care elsewhere.

Point out the risks of addiction and refer the patient to a psychologist, addiction specialist, or drug treatment program.

It's important to remember that pain medications are not the only problem. Plenty of people are addicted to benzodiazepines, muscle relaxants, and sleeping pills. Sucher points out that it's extremely difficult to get patients off benzodiazepines, the determining factor being the dose they've been taking and for how long. Great care must be taken to wean these patients properly -- or have them undergo supervised withdrawal -- in order to avoid potential adverse effects.

Whether you're prescribing narcotics or choosing not to prescribe them, documentation is critical. Thorough notes regarding your decision-making is the best defense should any questions arise. 

If you are prescribing, records should include a history and physical, evidence of any nonnarcotic treatments that have been tried, what adjunct therapies are being used (such as physical therapy or relaxation techniques), periodic re-evaluation of the diagnosis and pain levels, and how the patient is responding to treatment. If a patient has a history of substance abuse, that should also be included in the record, along with how you are approaching their care given that history.

When you elect not to prescribe narcotics, be honest about your reasons. If you feel that taking care of a patient who needs ongoing narcotics is simply beyond the scope of your practice, you have the right to refer the patient elsewhere. 

Pain specialists are very adept at managing these patients, but they're not immune from being taken advantage of. "You have to care enough to keep a clean practice," says Stewart. "In our practice every patient getting narcotics signs a contract. It says they'll get their meds only from us and only from one pharmacy, that they may be required to be evaluated by a psychologist, that we will drug test them, that we never prescribe on weekends or after 4:00 p.m., and that if any of these conditions aren't met we reserve the right to dismiss them from the practice and refer them elsewhere."

He adds that two-thirds to three-quarters of patients he tests for drugs in their system "come back positive for something -- marijuana or other street drugs, some other prescription medication, or sometimes they don't have the drug I'm prescribing in their system at all. If a patient refuses a drug screen they're dismissed from the practice with arrangements for a weaning schedule." 

Conditions that are difficult to prove or disprove -- low back pain, neck pain, migraine, renal colic, toothache.

Pain that doesn't make sense; symptoms that don't add up.

Requests for medication by name and dose.

Medical knowledge beyond the realm of what you see in the average patient.

Allergies to nearly everything -- except the drug of choice.

Patient calls ahead to see who is on duty at the clinic, ER, or urgent care center.

Hesitant to follow through with a work-up to get to bottom of a problem.

Alert from a pharmacy or insurance that a patient is getting meds from several sources.

The bottom line is, if you suspect a patient is addicted and seeking drugs, use common sense, listen to your intuition, document thoroughly, and always keep the best interest of the patient at the forefront. It's your responsibility to prescribe the right drugs for the right patients at the right time. Be attentive, compassionate, and prudent with your pen so that both you and your patients are comfortable.

This article originally appeared in the June 2004 issue of 

Odds are that you have faced a drug-seeking patient. How you respond to them is important.