family practice issues and general life events

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My fitbit #Fitstats for 6/28/2014: 5,764 steps and 2.6 miles traveled.


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My fitbit #Fitstats for 5/23/2014: 4,143 steps and 1.9 miles traveled.

Daily Fitbit stats

My fitbit #Fitstats for 5/21/2014: 6,537 steps and 2.9 miles traveled.

The Daily Oklahoma seems to be refusing to address both sides of the issue as to why physicians are against HB1820 and why they don’t want to check the Physician’s Monitoring System (PMP).  I think you would be hard to find a physician who would say that it is a bad idea to check it on new patients, or a occasionally or when there is a reason for suspicion.  The PMP is a tool for helping to find that patient that is “doctor shopping” but it’s creators at the Oklahoma Bureau of Narcotics and Dangerous Drugs even admit that it is inaccurate and treatment decisions should not be based on it.  So why are we wanting to require physicians to check every time on every patient on a tool that is known to be inaccurate?

There is a Pugh study that was flawed trying to show how the PMP decreases the amount of narcotics on the streets and this is what the state legislature is stuck on following.  Subsequent studies have shown that it does not decrease the amount of narcotics on the streets.

As for Dr Cox stating that it only takes 90 seconds, I would disagree it probably takes 2-3 minutes, but we can say 90 seconds.  The average patient is scheduled for 15 minutes in my practice.  Say they are diabetic but take hydrocodone for their arthritis.  So of the 15 minute encounter, I am down to either 13:30 or 12 minutes to discuss her diabetes, as well as document a pain scale.  Doable, maybe?  But maybe this patient has a form to fill out, or they are here for their once a year physical or they need an EKG?  That 15 minutes is a lot more cramped, even more so if you believe my actual time, and on average I would get to do this probably 22 times out of my 30 appointments a day.

The legislatures argue that my ancillary staff could do that.  OK, my nurses who are rooming patients, doing EKGs and drawing blood could possibly do that.  Not sure when.  Before we start?  Even if you accept the 90 second theory, at 30 patients a day, they had better start 45 minutes early for their day just to make sure they don’t miss someone.  Or and that is just my patient, they will also have to look up my partner (husband) so they will need to come in 90 minutes before patients start arriving.  Except for the fact I am not allowed to have staff with over time, so that will now mean 45 minutes times 4 days, that I lose 3 hours on Friday.  And since most of my staff hit overtime slightly afternoon usually, that means I will now be able to see patients for exactly one hour on Fridays, from 8 am to 9 am.  Fantastic, guessing my boss won’t like me using the staff that way, so it’s back to me.

I usually arrive at the office fairly close to 8 am when I start.  I have children to get to school, and while I understand that the OBNDD doesn’t care about my personal life, I do.  And if they are still rooming patients, I can start with the checks.  But rarely will I have time to check more than one or two of my patients.  So I take the high risk ones, seems reasonable.  Rarely have I been surprised.  I will admit sometimes one will, but it is few and far between.  And many of those, actually tell me about it when I walk in the room.  See I like to have an honest relationship with my patients.

Then there is the question of accuracy.  Tuesday, I checked the PMP on a patient who calls for refills every month, and I could guarantee that she picks them up.  Strangely, her last prescription was in February.  Now this system is supposed to be in real time, 3 months is quite a time span.  And while I am at it, on average we probably have 30-40 prescription that flood our system daily.  (more on mondays)  Most of these refills I do between patient visits as I am walking down the hall.  Since half are now hydrocodone due to the state not allowing refills on the medication, under this new law, my refilling scripts walking down the hallway will stop.  I will have to be using my lunch break, looking up each prescription which say 15 are hydrocodone, no telling what are lyrica, benzodiazepines or other medications, but let’s say 15-30, at 90 seconds a check, almost 30 minutes at the upper end.  So if I am running behind in the morning, my lunch break is gone, and those that come in after lunch, well they will wait until I get finished for the day, and now the patient will have to wait for the next day.

Oh and they didn’t exempt the nursing home patient.  So I get a call that they have just given Ms. Smith her last norco, can I call it in.  (They always call as they are giving their last pill, I don’t know why), there is another 90 seconds in addition to the time to call the nursing home pharmacy to refill her med.  One that she has little to no ability to divert.

Additionally, I live on the state line.  I understand that the state line is a magical line that medication NEVER crosses over, but maybe one day it will.  Some of my patients live in Texas.  And some people who live here go to Texas doctors.  Though I am sure there is no crossing that magical Red River with narcotics.  So why am I even discussing the fact that the Oklahoma PMP refuses to share data with other states and they don’t share with us.  So no need discussing the magical state lines.

The physicians of the state tried to talk to legislatures and discuss the best practices that would benefit the patients and help decrease the diversion of narcotics in this state.  We understand the cost.  However, this bill ignores best practices, the original bill (SB 1821 which was killed in the house committee) wanted $2000 fines per prescription for failure to use the system.  And guess who levied and received the fines, the creator of the PMP, the Oklahoma Bureau of Narcotics and Dangerous Drugs.  And in the original bill, physicians were supposed to keep a file on patients that they couldn’t see.  My understanding about the patient chart is that it is a dual ownership, the patient and I, and yet it originally created a secret patient file they were not allowed access to.  Fortunately this was removed.

The Daily Oklahoman is taking a biased stance, apparently since Dr Cox is a physician, they feel his opinion as the author of the bill qualifies as getting both sides of the issue.  And they allowed the OBNDD and the Department of Mental Health who are pushing for this bill to create the physician as the bad guy.

I do have a question for OBNDD.  What do you do when a physician calls about a “doctor hopper”?  We have called before and were told to call the Ardmore office.  So we did, and we were told they were too busy to take care of the problem.  This patient had visited 7 doctors in less than a month.  I stopped calling 3 or 4 years ago, because this was their answer every single time.

Patient care advocates are against this bill because it has the potential to prevent much needed pain medication at the end of life.  It will also decrease access as those in rural areas become required to see their controlled chronic pain medication patients every single month.  It interferes with the ability to give that claustrophobic patient a valium or two prior to that MRI that they need.

Oklahoma always ranks in the bottom 5 for health related issues, and passage of this bill will not help it.  Instead, I will be spending precious time that should be spent on diabetes on whether they are abusing medications that they were clean on their urine drug screen that I do perform.  Or else I will be forced to have them come back for multiple visits.  One for their diabetes, and one for their pain medications.  This will not help the cost of medical care, instead it will sky rocket.

18% of hydrocodone on the streets comes straight from the physicians script pad, the rest come from other sources.  I guess focusing on that 18% and not on those that are actually diverting the drugs makes the legislature feel like they are doing something.  And while I don’t disagree as physicians we have a duty to decrease that 18% as much as possible, that still leaves 82% that we are ignoring.  Not really sure they are focusing on the correct goal.

And while the public might say, “Well just refer to pain management.”  That is a fantastic idea, but the closest pain management doctor to me, is 30 miles away in another state.  The next closest?  2 and a half hours away.  And all require that I see the patient at least 3 times prior to referral.  And I have many patients who don’t have the transportation to go 30 miles much less 150 miles.  So is that good patient care?  Or are we punishing those that have legitimate need for those few that divert it?  I am sorry, but I can’t accept that.

And these opinions are my own, and not on behalf of anyone else.

Daily Fitbit stats

My fitbit #Fitstats for 5/16/2014: 4,074 steps and 1.8 miles traveled.

Daily Fitbit stats

My fitbit #Fitstats for 5/05/2014: 4,917 steps and 2.2 miles traveled.

Daily Fitbit stats

My fitbit #Fitstats for 3/13/2014: 9,170 steps and 4.1 miles traveled.

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