Aaron Sherwood-Blog

For my second interview searching for stories I interviewed a physicians assistant. He wanted to remain anonymous. Here are the stories, told in the 1st person:

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Story 1

I saw a 55 year old pt for the first time, for a physical–he had never been to our practice before and we had no records. In fact, I think he had not been to a doctor in years. As I usually do somewhere near the beginning of a physical, I asked him “Was there anything in particular you wanted to talk to me about today?” He said, “well, I feel like I ain’t got no private life no more ever since that thing’s been moving around in my back. I want it gone.” My incredulous interest was immediately aroused. As the conversation went on, and after I took a look at his back, it became clear that he was referring to a benign growth in his back called a sebaceous cyst. It was true, this one was more mobile than most–I could move it under the skin a little less than an inch back and forth. He had become convinced that somebody had placed an electronic device in his back, the purpose of which was to monitor his thoughts. I of course knew he was crazy when I heard that but not being a psychiatric specialist, I just resorted to plainspoken reassurance. I told him what it really was, and while trying to keep a straight face, told him “this is definitely not something that was put there to listen to your thoughts. It does not have to be taken out, it won’t hurt you in any way. However, if you really feel strongly about it, it’s something I could remove here in the office.”

We finished the physical, he went away pondering whether to have it done, and then I got a message a week or so later that he wanted to have it removed, and he made an appointment with me. When the day arrived, I brought him to our procedure room, had him lie down on his stomach, got all the equipment in place to do an elliptical excision. This involves cutting an ellipse around the thing that has to be removed, then carefully cutting away the skin from the underlying fat. I had trouble from the beginning, mostly because of the movable nature of the growth, but I did cut down as usual into the fatty tissue just under the skin.

However, it became apparent that something was not as expected. I got a fellow provider to take a look with me, and we decided that this growth was actually a lipoma, a fatty benign tumor that lies deeper down, beneath further layers of tissue. Removing one of these is too involved for a family practice office, and is usually taken care of by a general surgeon. I apologized to the patient, sewed him up without doing anything, and sent him on his way, to come back in a week for suture removal and then probably referral to a surgeon.

The day he was to have the sutures removed, I had a visit from our center manager. Apparently, the patient had arrived a couple of hours early, and asked to speak with her. He was very agitated, being convinced that, far from removing the thought monitor, I had actually added a GPS unit, so that not only thoughts but also location could be tracked at all times. She told me she had done her best to calm him, and hinted that if he finally has this “problem” taken care of surgically but STILL feels convinced he is being monitored, he might consider seeing a psychiatrist.

To complicate matters, when I saw him it was evident that his surgical wound was infected, probably due to insufficient caution on my part in the confusion and delay of the previous week’s encounter. I had to give him an antibiotic for this, and fortunately it got better over time. I never did tell him, as I joked to my colleagues with cruel humor, that he really should check out the website tracking his thoughts and movements–it was working splendidly! I did refer him to surgery and he eventually had the offending lipoma removed, along with the hideous-looking scar produced by the infection. Now I haven’t seen him in quite a while–I think since he went to the surgeon. Perhaps he no longer trusts me.

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Story 2

A couple of months ago, I met a woman and her two adopted sons of 11 and 15, in two separate appointments on different days to establish care with the boys. The boys seemed quite healthy and normal but the mother seemed slightly off. When I met her and the 11-year-old, one thing that instantly put me on edge was that the mother told me proudly that she had purposely undervaccinated him. I regard vaccines as one of the great medical advances of the last century which have saved countless lives. Accordingly, I have a certain antipathy towards those who, through their ignorance and boneheaded ideologies, refuse to vaccinate their kids and thus potentially expose them to deadly diseases. We still didn’t have medical records, so I couldn’t confirm the details, but the mother assured me that she just didn’t think small children should have so many vaccines but that now that he was 11 he had been fully brought up to date.

She also told me that he had been on Adderall (amphetamine) for ADHD for a while, and she thought she might want him to go on it again when school started for the year. However, she was not sure about this, and the patient was not too enthusiastic about taking it again. As I always do when ADHD is questioned, I asked, “Has there been a thorough evaluation with a psychologist to establish the diagnosis?” This involves a couple of long questionnaires and usually 2 or 3 visits of an hour each. Mom assured me this had been done. I said, again as usual, “OK, I’ll have to review the records and once I see them I would be willing to prescribe the med if that’s what you decide. If it turns out that it wasn’t a full eval, I would ask you to get one with Sam Withers, our guy upstairs who knows how to do this.”

in due time, I got and reviewed the medical records. The child had had, actually, just a few vaccines so was woefully unprotected from many illnesses. As for the ADHD eval, when I showed it to Sam Withers, he told me, “this is really the kind of ADHD eval based on ‘I knows it when I sees it’ “. So, I sent a message on the patient portal (kind of like email, through our website) to the mom, telling her that the kid should really have a bunch of catchup vaccines and that if Adderall was desired, I wanted them to get the eval. I also noted a telling detail in the medical records–mother had taken the child to the emergency room because she thought he was having an anaphylactic reaction to a bee sting. He apparently actually had some localized pain and swelling around the sting. The ER doctor’s note said, “Pt’s mother told me that he had been given an EpiPen by mouth. After discussion, it became clear that he had actually taken benadryl. She repeated numerous times that he had had an EpiPen pill, not Benadryl.” An EpiPen is an injectable epinephrine for emergencies with a serious allergic reaction, i.e. anaphylaxis. It does not come in pill form. Benadryl is a pill frequently given for itching, hives, swelling. Two quite different meds, but the woman was absolutely certain to the point of aggressiveness in her error.

The next time I saw them (actually it was the 15 year old’s physical, but all of them were there), the mother completely denied that she had been considering putting the 11 year old back on Adderall. I knew this was untrue, but said, “OK, fine, better not to use these potentially dangerous meds anyway.” She would not let it go though–seemed very concerned about how I had misunderstood her. I then mentioned about the vaccines and started trying my sales pitch about vaccines being a great advance in medical science that has saved many lives etc, but she interrupted me to say that “This is the US and it’s a free country and you can’t force me to vaccinate my child. We have different opinions about this and you’ll have to respect that.” I just slightly shook my head and attempted to minimize my smile and the rolling of my eyes, with questionable success. I didn’t respond but went on to the next item on my agenda. Oddly, the 15 year old WAS fully vaccinated, but I wasn’t about to point out the discrepancy. Towards the end of the visit, mother made some inappropriate joke to the 15 year old about how she could shave his legs for him, then started offering to shave my legs. I tried to brush this off with a smile. She went on about how we might disagree about some things but we’re good friends now. I tried to ignore this too, but while keeping a smile on my face.

About 3 weeks later, I received a very formally written message from her on the patient portal, in the form of one long paragraph. The purpose of this message was to inform me that as of this moment, I was released from her employ due to my lack of respect. This caused me to laugh with joy and relief. I wish her next provider good luck.

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Story 3

I had this patient named Jack (pseudonym) who had a bad alcoholism history. I was a fairly new medical provider then, and Jack complained incessantly of very severe pain, while assuring me that he was now completely sober. Reluctantly (and with the benefit of hindsight, unwisely), I decided to give him the narcotic pain meds he was requesting.

As I often do when starting people on controlled substances, I had him come back monthly and do several urine drug screens to make sure all was on the up and up. As I recall, there were a few questionable situations–too many pills used, other substances in the urine. But ultimately, after a few months, he wore me down–I got sick of listening to him complain and blah blah blah incessantly once a month or more, so I put him on the regular refill program where pts pick up scripts at reception monthly and have to come see me only every three months.

This continued for about 18 months. At one point, my supervising physician told me he had happened to be driving through Jack’s town and saw him stumbling around and almost falling into traffic, obviously schnockered. I confronted Jack about this and he denied it vociferously, though his story shifted the more I questioned him, admitting that he had drank more and more recently than he had previously admitted. For some reason, I decided to give him the benefit of the doubt and continued him on the meds, probably because he was sooo insistent and soooo distressed.

After a few months, jack was enrolled in “drug court”, an alternative to incarceration, due to having had 3 DUIs in the past. As part of this, he had a very attentive probation officer who would show up unannounced at his house a couple of times a week to breathalyze him, and according to her, jack was doing great and had never been caught with alcohol on his breath. During this time, he himself professed to be ‘owning his recovery’, as they say. He DID have a urine showing Vicodin, which I was not giving him, and suspiciously little morphine, which I was. Meanwhile, the provider for his girlfriend told me that she had tested positive for lots of morphine, which she was not prescribed (it is highly illegal and grounds for stopping controlled substances when you share them with others). Still, I didn’t want to deal with the shitstorm of complaining and rationalization that would have accompanied my stopping his meds, and I wanted to believe that basically, jack was doing well.

Some time after, jack left the girlfriend, though told me they were still friends. Then I saw the girlfriend in an urgent care visit for something completely different, but she told me in a confidential tone that she had to talk to me about jack. Now, this could well have been some BS as retribution for him having left her, but she claimed that jack was somehow fooling the breathalyzer and had been continuing to drink all along. As for the pills, far from taking them as directed, he would chop them up and snort them in large quantities, running out long before his scheduled refill dates (which, incidentally, could explain his continual complaints of insufficiently treated pain and his constant push for more frequent and higher doses). Who knew if she was telling the truth? But I called him in for a pill count anyway, about a week after his pickup date, and lo and behold, he was 20 pills short.

As a result, I finally decided I had had enough and told him to go to the suboxone clinic. Suboxone is a med used to treat opiate dependence–it’s not easily abused. Kind of like methadone, but pts get a supply to take home so they don’t have to show up at the clinic every day. He complied, kicking and screaming the entire time. That was several months ago. Since then I have gotten repeated insistent messages from him about how inadequate suboxone is for his terrible pain and how it only makes him sleep all the time.

A couple of weeks ago, I got a message from him saying that he had been going to the wound care clinic, and they had put him back on regular narcotics for pain; he was requesting more from me, since his pain was unbearable and Percocet is the only thing that works. He did not understand why he was taken off the Percocet before when his count was off only once. He thinks that the fact that he is in soooo much pain should override everything else and that I should put him back on his narcotics. I did not respond to him but just appended a note to his message that if the wound care clinic felt he should be back on narcotics, then they can continue prescribing them.

The next week, I got yet another message from him: he had gone back to the wound clinic for more meds and they gave him a small amount but told him to get more from me. He left a phone number to call “so they can explain my wound to you.” My reaction was, like hell! I am not giving this guy any narcotics and the wound clinic had no business taking him off suboxone!

By the time I called the wound clinic, it was closed and I had to leave a message. It probably sounded pretty snippy–I remember it ended, “if you thought it was a good idea to stop suboxone and put him back on Percocet, I feel pretty strongly that you should be the ones to continue it.” The next day, I got a message to call Dr Subramanian (pseudonym), the surgeon who runs the wound clinic.

Dr S was told about my message by the nurses, who were “freaking out”, and called me back. We discussed the situation. When the pt went to wound clinic initially, he complained of very severe pain and need for pain meds, and did not mention any of his history with me or that he was taking suboxone. Dr S gave him some percocet to take every 6 hours. When pt ran out (and asked me for more and i refused), he talked to another doctor who followed Dr. S’s lead and gave a refill. Supposedly, pt had mentioned suboxone in passing to the wound care nurses but they never documented it so the MDs had no way of knowing. Most recently, pt and Dr S had a talk and pt told him he was taking the percocet q4h. Dr S told him he needed to take them q6h and refused to write a script for q4h, whereupon pt became angry and upset. The outcome was that Dr S told him that one single person should manage his pain meds, and recommended that it be his PCP, me. (He had tried to send pt to a pain mgt clinic but they “refused to deal with this guy”). Overall, Dr S apologetic to me saying he did not know any of the history or that pt had been on suboxone before coming to wound clinic. We agreed that Dr S would tell pt that we spoke, that I recommended that pt go back to suboxone clinic, and that I would not be providing any narcotics now or in future.

In the next couple of days, I got two or three messages that Jack had called looking for a response to his request for more meds. Often, I get my medical assistant to call in situations like this, so she can just give a succinct message and I can avoid getting stuck in some bullshit conversation. In this case, I decided that Jack was a special case and that hearing directly from me might stop his endless insistence on narcotics.

Result: a long, distressed conversation with patient begging me repeatedly for “something to hold me over” until he gets to the pain management clinic where I am sending him in lieu of providing any more narcotics. He also put his mother on the phone who begged me on his behalf for some narcotics. I refused repeatedly, and reminded Kip that it was not only one pill count that was off, but many questionable situations with UDSs, overuse of meds, questions of abuse of other substances, and that the final wrong pill count was just the straw that broke the camel’s back. I told him to get back to the suboxone clinic. At first he told me via his mother that he had no way of getting there since he needed a wheelchair, then when he came back on the line, he told me he would not go back there since suboxone just made him sleep all the time. I told him to continue with the wound clinic and go to pain mgt and suboxone clinic. I also told him that it might be time to find someone else to prescribe him these meds, because I am done. I suspect he will ask again, though….

Health Care Interview – Physicians Assistant

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