Friday, 15 Nov 2019

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Clinic Exorcisms

After a few clinic no-shows, our clinic partner discussions lapsed into a discussion of clinics, especially bad clinics.  Amidst the cussing and discussing of clinic experience, my partner, Dr. Dao, threw out the phrase, “clinic exorcism”!  What a great title for a different kind of blog.

No, it’s not our clinic that needs the exorcism. Our clinic is just fine, nearly perfect (with the exception of the lunchroom refrigerator).  We were unapologetically waxing on the problems of those other clinics – you know, clinics past, across town clinics run by trolls, or clinics that should just be reported.

Exorcisms for the most dire of circumstances need not require a spitting, levitating green-eyed partner.  Maybe they should be considered, especially when relationships have turned ugly, the issues are irreparable or when mental illness is on the wrong side of the stethoscope.

When clinic operations and operators are truly bad, who you gonna call?  Not Clinic Busters. Think about clinic exorcisms designed to eradicate potentially hazardous patients, employees, partners or certain clinic practices.  

Bad Employees.  I’m not an HR specialist and I have completed my fair share of “sensitivity” training, so my advice on bad employee corrective actions are more likely to be driven by common sense than HR policy.  I believe a bad employee can be easily spotted within the first 60 days, but no more than 90 days. Bad employees engage in religious/political/sexual discussions with patients or are characterized by both ignorance and apathy (“I don’t know and I don’t care"). 

Bad employees repeatedly and unabashedly make the same mistakes, go beyond that which they are trained to do and repeatedly risk the patient’s safety.  I think it’s best to let every new hire know that their performance, progress and behavior will be evaluated monthly in the first 3 months and that continued employment is contingent on achieving satisfactory feedback. NO sense, no ethics, no brains, means no job. Adios!

Evil Partners. These vampire peers take everything without giving back. They suck all your energy, consume your spirit and leave you a wilted shell. Dr. Beelzebub can ruin your day with an email or text, even before you’ve read it. While there may be different levels of being a “Bad Partner”, the lowest are those who antagonize and work against you and the group to fulfill their aspirations of wantonness, greed, lust, anger, sloth, etc. They regularly leave a wake of interpersonal damage, sickly or cleverly explained as their being unique, contrary or unhappy. We humans can make mistakes, even reprehensible ones. Yet evil partners and their behaviors are born of forces or tactics not learned in medical school, Sunday church or a 12 step program.  Like bad employees, the evil ones don’t come with a scarlet warning sign and are usually not “found out” until the damage is done. My advice: swiftly and without reservation exorcise the evil one or yourself – if you have to, “Run Forest, Run” and find a better landing place. 

Devil's Work. This describes any effort that requires you to invest time, money or brainpower in activities that are obstructionist, are contrary to healthcare improvement or are flagrant efforts to bend the truth for financial or other unsavory gains. Devil's work should therefore include prior authorizations, disability letters for well-abled folk, EMR work to appease bean counters or any requests from lawyers.  This may also include tasks whose purpose is defined by the statement “that’s just what we do here”. 

Elsewhere Patients. I’m not comfortable in talking badly or negatively about patients (or employees or partners for that matter). After all, they are just seeking help and providing help isn’t always easy, fun or without hazard.  Patients are often seeking medical assistance for symptoms or health changes that they don’t understand.  Patient behaviors can be contrary to prescribed medications or healthcare improvements. What is easy and clear for you is often difficult and nonsensical to the patient.  Their new disease didn’t come with a manual, CliffsNotes or even a clear, pedestrian explanation of what’s going on.  Thus you have to slow down, listen and cut the patient some slack.

Nevertheless there are some patient-physician relationships that are toxic, unproductive, or unsafe – all interfering in the goal of improving health.  If the patient is dissatisfied or disappointed with their doctor, I would strongly advise an honest discussion about what is upsetting to the patient – for instance, “Doctor, can I tell you about what went wrong at our last visit?”   If you are not satisfied, find another doctor.  There are situations where patients should fire their; these include when:

  • Dr. Says, “there’s nothing I can do to help you” (He/She just did you a big favor – time to move on)
  • A doctor who spends less than 5 minutes with you (He/She is either a hummingbird with a stethoscope or has your attention deficit disorder or was actually the clergy there for last rites)
  • The doctor who is abusive, demeaning, repeatedly disrespectful, or sexually inappropriate
  • If you go to the doctor feeling sick or unwell and after each visit you feel worse than you did before went to the visit – you need a new doctor.

It is a physician’s prerogative to terminate certain patients for what is clearly an “unsatisfactory patient-physician relationship”, one that is devoid of trust and respect between parties. In my 35 years of practice I have fired or terminated maybe 4 patients, with difficulty and only after significant reflection, staff discussion and lack of a better option. I’ve always believed that it’s up to me to help the patient, and make even difficult situations workable. I'm suppose to have the answers and solution and provide care in accordance with the Hippocratic Oath.

Under certain situations, I believe that there are isolated patients who must be fired for any of the following reasons:

  • Patients engaged in illegal behaviors that involve their welfare and the physicians obligations to the patient
  • Patients (or family members) who, by their behaviors, endanger the health and welfare of my patient
  • Patients who forge prescriptions, steal medications
  • Those who repeatedly disagree with the prescribers best instructions or plan or fail to follow verbal and written instructions, especially for life saving or life altering intentions
  • Those guilty of elf-neglect or  self-destructive behaviors
  • Patient aggression (physical, sexual) towards the treating physician

Exorcism is the practice of evicting demons and other entities from a person, place or collective because such entities are possessed of a nature that is detrimental to the practice, the work or the necessary relationships to provide healthcare. Especially when there is irreparable harm that no oath, training or ritual can correct.

The rare practice of clinic exorcism may be necessary to maintain a medical practice that is devoted to humankind and health.

 

Disclosures: 
The author has no conflicts of interest to disclose related to this subject
Dr. Cush is the Director of Clinical Rheumatology at the Baylor Research Institute and a Professor of Medicine and Rheumatology at Baylor University Medical Center in Dallas, TX. He a Professor of Clinical Medicine at the University of Texas Southwestern Medical School.
 
Dr. Cush is the Executive Editor of RheumNow.com and also Co-Edits the online textbook RheumaKnowledgy.com. 
 
Dr. Cush's research and interests include novel drug development, rheumatoid arthritis, spondyloarthritis, drug safety, pregnancy and Still's disease/autoinflammatory syndromes. He has published over 140 articles and 2 books in rheumatology.
He can be followed on twitter: @RheumNow.

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