The patients from my clinic in Louisville, Kentucky are the most complex patients I have ever seen. A new patient will easily have 30 diagnoses and 20 medications. These are geriatric patients where the majority of them still smoke. There is a lot of substance abuse, including cocaine and alcohol. The patients also have poor living situations, with plenty of them coming to the clinic with either bed bugs or roaches crawling on them and their belongings.
It’s been quite challenging caring for this population because of their social issues. Fortunately, we have an amazing social worker and case manager that help support them. The patients come from poor socioeconomics backgrounds and unfortunately do not take care of themselves.
As far as medical illness, lets just say everyone has Heart Failure, COPD, Chronic Respiratory Failure, Coronary Atherosclerosis with Angina Pectoris, Chronic Kidney Disease, Hypertension, Hyperlipidemia, Major Depression, Hepatitis C, Polysubstance Abuse, Major Depression, Chronic Pain or Osteoarthritis etc.
I saw a patient that was 2 weeks post-op for a small bowel obstruction and incarcerated ventral hernia. Apparently, she never cleaned the wound, refused to let home health into her home, and continued to smoke. By the time I saw her, her wound had reopened, there was a large amount of purulent drainage, strong foul odor you could smell a mile away, and dead tissue surrounding the wound. She absolutely refused to go back to the hospital where she had the surgery. She blamed them for her complicated wound.
I gave her some antibiotics and told her I would see if another surgeon would see her, although I knew it was doubtful. She wanted to leave because she needed to get to work (yes with that horrible wound), so I made her follow up the next day. Within 1 day the wound was 5x worse and of course no other surgeon would accept her. Luckily, I was able to convince her to go to the emergency room where she had the original surgery because she clearly needed debridement and IV antibiotics. Of course, it took a 20-minute conversation to convince her. I had to scare her and explain that she will eventually get peritonitis and/or sepsis and die.
We offered to call an ambulance for her but she insisted that she go home and eat first. I was flabbergasted that she even had an appetite with that foul smelling wound. The entire clinic reeked after she left. Eventually she made it to the hospital and they took her to the OR for immediate surgery.
This is just one example of the type of patients we have. A lot of them have attitudes. One lady started yelling at me just for suggesting she start taking a medication for diabetes. And when I offer them the flu shot, they don’t proceed with the usual “no thanks, I had problems with the flu shot before.” They literally raise their voice and start yelling at me about how they wont take the shot and a 5 min ranting fest of why not. I won’t even mention the challenges of weaning them off opioids or declining to refill their narcotics. Let’s just say there is a reason gabapentin is a controlled substance in the state of Kentucky.
Although taking care of this patient population has been exhausting, I have learned a lot. It also makes me appreciate how good I had it with my patient panel in Chicago. I continue to be impressed at how the physicians at my clinic care for their patients despite all the above challenges.
This is exactly like the patient population in a lot of West Virginia as well. A lot of refusals for care, most of the patients smoke, poor living conditions, and tons of chronic disease with a slew of chronic medications.
Yes I heard West Virginia a strong rival being the top state with the most smokers.
OK, you win for having the most seriously sick/co-morbidities/poor lifestyle!!
Please tell me you have more time than 4 pts scheduled in the same 15 min block!! I did locums last week for a doc I had interviewed with in Jan. They have a mid-70’s doc who has been sick as a dog for 2 weeks, feels too bad to even go to ER to get tested for Covid.
A doc I was supposed to do locums for this week, told me she called either Quest or LabCorp to get test kits for Covid-19. We were able to get 5.
Since doc is so sick, I asked owner doc, why don’t we use sick doc as our guinea pig, to see how the whole process works. ‘No, too much liability’. Say what?!
The only liability I see is that her practice will be closed down for 2 weeks if this doc tests positive. It will still close down if she ends up going somewhere else to be tested and is positive.
If it was flu, she should be on the mend. She’s not. I’m filling in for her. The doc has since offered me a 3 day/wk job on a permanent basis.
When I go back to work on Monday, that will be the 3rd day I’ll be wearing the same mask! We all spray them with Lysol at the end of our shifts. The doc who owns the practice, needs to get off her behind and buy us masks from Amazon if our usual vendors can’t find them. I don’t care if she has to pay a fortune.
The only saving grace to this ridiculous practice, is that a girl from my PNP program started the week before I did. We are both having a good time laughing at the lunacy that is this place.
I interviewed with another place a few weeks back, who called me yesterday to shadow the doc. So I must be in the final few. I def want to shadow HIM. I want to see the flow, what do the MA’s do (or don’t do) i.e. cleaning, which I did Tuesday a.m. Cleaned the knobs & faucets in my exam rooms, then cleaned the top of the counters we lean on. The germicidal wipes were black!
The doc thinks the staff is wiping down everything 1X/hr. The manager, an MA, is too busy rooming my pts and talking on her cell phone to do any actual cleaning. Nor does she make any of the staff clean.
I hate giving the type of care I’m giving now. I had a family of 5 pts all in one exam room on Tuesday. I was so mad. Asked why the heck were so many scheduled at one time – ‘doc wants every pt that calls to be seen’.
Of course I was totally confused as to which kid was whom, 3 of the five had impetigo from ringworm that they scratched so bad. Then of course they all needed their allergy & asthma meds refilled. Mom spoke little English, dad did, when I could get his attention from his phone!
10 hand-written rx slips later, each with 3 meds per page, I was telling mom/dad what I wrote. Of course I wrote kid A’s scripts under kid B’s name. At this point, I was like, don’t even worry about it. You fix it after you get home!
My poor dog, who I had to put down 2 weeks ago, got much better care from her Vet, than we are giving to these kids, bc of the over-scheduling due to high rate of no-shows, except, they have been showing up! And bringing extra sibs along for the ride! Since schools are closed, I guess this is the big outing for the day.
I swear this is true. 1 kid had an 11 yr WCC scheduled – BMI 99%. Mom brought 2 ‘extra sibs’. One with c/o intermittent abdominal pain for 2 1/2 YEARS, with decreased appetite. Wanted appetite stimulants. Kid’s BMI was 93%!!
The other kid had R knee pain for 6-12 mo, tender at tibial tuberosity. Referred him to Ortho. Mom didn’t speak much English. Had to depend on the ‘knee pain kid’ who was 13 to translate. Mom was not happy when she left that I wouldn’t give the kid appetite stimulants. ‘He used to eat whole frozen pizza, now only eat half. Is no good”!!
Thanks for sharing. My patients also typically have 10+ diagnoses. I have never experienced issues with that level of drug abuse. Interesting that Gabapentin is controlled! Hang in there and keep sharing!
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