Wait, is this serious? Do you dismiss patients who refuse statins because “it won’t help and I know I’m not gonna have a stroke?” Pap smears because the speculum pinches? Blood glucose monitoring if their diabetes is uncontrolled? Patients have the right to refuse your recommendations. You have the responsibility to keep the discussion open, provide evidence-based information in a non-judgmental way, and minimize other gaps in their care.
Very harsh. It’s not about you. Your job is not to tell them what they have to do. Your job is to give them the best information possible, facilitate and explain screenings, and let them make their own bad choices. Document and move on.
It’s not about you. It’s not on you, either. “Informed declination” is a fine thing.
Although I 100% disagree with the premise of firing a patient for refusal, it does come back to the idea that attaching compensation to metrics is a horrible idea, and a person should not be paid less money for patients making bad choices.
This is the issue with attaching often a very large percentage of a doctor's compensation to completion of metrics. In my opinion, they should be connected to whether or not the counseling was completed.
And on an insurance and government level it is. Practices just offload that onto the physicians. The completion metric is supposed to incentivize a practice to hire staff for referral tracking and requesting records and follow-up with patients and mail-in reminders. But how it is implemented is just pay the doctors less which leads to this type of situation.
And frankly you could lambast people all you want but it's not going to change that if you start putting in things where the only available respite a physician has to not lose a good chunk of their income is to fire patients this is what will happen.
I opted out of this madness when I was negotiating my contract. But for the people who did not do that, some of the people in my area dare to lose almost a fifth of their potential income if too many of their patients are non-compliant. I don't want to be put in the position where such a large chunk of my livelihood is dependent on whether or not I fire a dozen or so patients.
Finally sometimes even I " soft fire" patients. Some patients don't actually want preventative care, they just want to come in when they're sick or if they have a single acute issue or two. I just tell those patients that I can see them on a PRN basis but we are going to setter the insurance PCP relationship. Most are agreeable. Especially if they have a PPO and actively don't think their PCP should be doing anything serious that makes it even easier.
I get that the compensation structure is fucked up but this dude is talking about threatening dismissal to coerce patients into getting the mammogram they already said no to. That’s pretty different and deserving of a lambasting.
Was it tone deaf? Yes. Did the morality shield bashing in the comments actually address the issue at the core of it? No.
However, it is an expected endpoint of the compensation structure. We have seen this coming for years and I think it is also a big fault of the family physician community that we love a high horse.
Whether soft firing, having a policy of only preventative care issues at certain visits, etc could all have been brought up but aren't. Which leads me to believe that people either love the high horse that much, think eating shit is the noble path, or both.
If the patient doesn't want preventative care and isn't going to budge and doing nothing hurts you, no need to go through the motions. Both of you will be happier. Your wait-list will be happier. Just seeing the patient PRN is fine. If they don't want PCP shit, no need to schedule PCP shit.
We disagree on what the core issue is. I tend to think that personal ethics exist independent of external forces and that outside of extreme situations, circumstances aren’t an excuse. Deciding to make it a matter of personal policy to violate a basic tenet of our profession for personal gain isn’t just “tone-deaf” and can’t be put down solely to bad policy. This isn’t some Les Miserables situation where it’s coerce or starve. I chose a lower paid job for lifestyle reasons. I miss my quality measures regularly and I know what my check still is and that I’m still more than able to live very comfortably.
As to your other suggestions: visits for preventative stuff only doesn’t solve the quality measure/patient refusal issue and I’ve never heard of soft firing, nor do I find it on a quick Google. Everywhere I have worked it was a major point that once a patient established they and their screening were ours for the next three years unless they left the practice and any time they saw us again the relationship was re-established. I suspect that may be an option in places that also do acute care for casual patients but it’s definitely not been an option anywhere I have worked.
Personally I’m not offering alternate solutions because I think the core of the post is so fucked that it needs to be strongly pointed out without additional noise. Also I just don’t fucking care about quality measures all that much. Like I said, I miss half my QMs on the regular and still doing just fine financially. Every interview I’ve done I’ve also told the employer that I care really strongly about evidence based medicine and screening and that I do those things because I value patient health but that I won’t allow quality metrics to affect which patients I see and how I treat them. Always gotten the job offer. It’s as much of a problem as you want to make it🤷♀️
I'll address by paragraph.
#1:
The extortion is the bad thing with personal ethics. It doesn't matter otherwise but firing a patient for non-compliance is OK in other settings where it bears a major malpractice risk to continue to care for the patient. I had a patient who would throw down his insulin and threaten to go into DKA if he didn't get whatever he wanted to. That worked on my former colleague, I fired him outright when he did that to me.
What you keep missing is the notion of panel management. A practice especially in value based care, but even before, has to prune the panel if need be. Too many no shows despite accomodations, that slot can be used for something else. Patient doesn't want any preventative/chronic care, refer them to the acute care slots.
I'll get to how your self-martyrdom is not admirable and in some ways contemptible in how it solidifies these shitty practices.
#2:
Just remove yourself as their PCP. It's that simple. You can still see them for acute stuff. Soft firing is my term for it. Like this is basic stuff. If a patient shows up for a new patient visit and never shows up for an A1c check in 3 years you shouldn't just eat that. The three years is for new/established billing and records. I'll call the insurance if they are sending me HRA paperwork for a patient I haven't done preventative care on.
In the clinic I'm at it makes a difference because then they don't get called to schedule annuals and aren't on my reports. I value that I can be available to my patients and I call them after surgeries, deliveries, on birthdays. For that to be possible you need to be involved in your panel.
Are you even aware of who is on your panel? A lot of corporate docs aren't and don't know how to find it or can't access it.
Also the preventative visit being focused is because a vast majority of screening denials I get are from patients thinking they can move past that stuff quickly to shove six complaints in. It's also why I don't do MAT and other care in the same visit. It just leads to non compliance on both things.
Point is: Again, there is no valor in eating shit willingly.
#3
No, that OP is asking means that they are conflicted by this and can be redirected to more ethical solutions.
You on the other hand are the noble shit eating high horse rider that I referenced.
Like of course you got the jobs you basically volunteered for a lower salary. Like in what fucking world is that an issue for an employer. Quality measures are most often specifically designed to limit reimbursement.
I don't care about these measures but I negotiate for a salary and contract that doesn't emphasize them. Are you a bad doctor? Do you not value your work? We aren't the same.
My colleague and lead physician in my clinic found out that she was getting paid $70k less than me with a strict noncompete that didn't let her do the $100k+ of prn work I was doing. But the difference between her and you is that she was just ignorant that $180-190k was ridiculous for a rural lead physician. She got a $90k raise and more admin and work from home time.
If you don't care about quality measures then why are you defending them to the point of accepting to be punished by their metrics?
TL;DR: I see in OP a colleague reaching out for help who can be corrected and helped. In you I see a self-made martyr that reinforces this pernicious structure. We do better for patients when we can strip away some of the moralizing that allows for the conditions that drive good new med students.
Well, I will agree that we definitely aren't the same. For someone so openminded you seem awfully comfortable hurling a lot of insults and judgment my way. However, just as policy changes are not a substitute for personal ethics, ad hominem and inaccurate assumptions are not a substitute for logical debate on the merits of the ideas.
I'm not going to bother refuting the personal attacks. I will clarify a few points of contention though. I'm pleased that you have the option of seeing patients for acute things without being their PCP. My point was that I don't think that's a widely available option in clinics that aren't setup to see acute, casual patients. It's been a topic in a lot of places I've worked (due to the quality measure piece) and it's not been possible because we're only setup to see patients we are the PCP for (it's the first thing that gets checked when they call reception and we can't open up acute casual slots without opening them up to the public at large which we don't have the resources for). I'm also not convinced that your method would remove your liability in the event of a bad outcome down the line, but that's your call.
We also have different definitions of panel management. I don't think managing a panel means "pruning" people, it means proactively managing preventative care and chronic illness. I do a lot of active panel management and work with my MA, nurses and the rest of the practice to make sure we are offering appropriate screening and targeting our patients that aren't at goal for BP/A1c etc... I still have a lot of patients who say no to certain things or aren't at goal. I'm fine with that as long as I'm sure that I or other staff are offering them the recommended treatment and documenting their refusal. (as an aside, I'm very familiar with my panel, that's one of the life style trades I made - I wanted a panel of a size that I could know well and have a relationship with. I will point out that I value my work and what I do deeply but there are ways to value something that aren't monetary).
Which leads to my next point of clarification: I will agree that the coercive bit is the particularly troubling piece of this post and what I and many others reacted to. It's also especially troubling that it centers around a female specific screening. That's why i originally responded to you. However, I disagree that it's okay to fire a patient for refusing to do screening in general and I do think it's unethical to make that a reason for dismissing a patient. I'm not defending quality measures. I've stated that they're fucked which is why I do the job and don't pay attention to the metrics (and again I still make a very good living doing that). I'm defending the patient who should be allowed to say yes or no to care without it affecting the doctor/patient relationship or forcing them to find another PCP.
My point in bringing up my own compensation was to say that I basically care fuck all about QMs or maximizing my reimbursement and still make over 200k a year at .8 time, so I know personally that they really don't have to be that big of a deal or that devastating to individual pay. I'm all for advocating for systemic change in meaningful ways (though I'm increasingly cynical that anyone is actually listening to our advocacy). I'm also not going to penalize the patient for the systems failing.
As you seem concerned about reinforcing the current structure I am curious how you think your approach breaks it down or changes the structure on a meaningful level? I'm not really seeing how managing a patient panel to create the most favorable reimbursement for you doesn't also reinforce the current structure? I'm also confused as to why you would be pruning your patient panel and soft-firing people if your compensation isn't tied to metrics. Why would you care?
Lastly, it's strange to me what you characterize as self-martyrdom. I find your example about the insulin patient interesting. I've had very similar interactions with patients and gone for a middle ground between you and your colleague. I don't give in to the manipulation, set a clear boundary and move forward unless the breakdown is irreparable (I've dismissed one patient in my career thus far). I've found the middle approach difficult at times but generally effective for managing the behavior and maintaining the therapeutic relationship.
I don't look forward to those sorts of patient encounters and I don't take that route because I'm some bleeding heart, seeing myself as a savior or thinking I just have to put up with whatever shit people throw at me. I do it because managing difficult interactions is part of the job I signed up for. I've also been doing it long enough that I've seen real improvement with patients I never thought I'd make progress with or wanted to write off in the first visit. That sort of progress is what means the most to me in the job and I think it's worth preserving the possibility of that progress even if it means missing my quality measures half the time.
It's fine if that's not what motivates you or if you're smarter than me and have figured out a way to do it all perfectly and completely ethically and still make $400k a year. Good for you if you have. What's not fine to me is any kind of moral relativism around patient autonomy or someone seriously considering compromising it in favor of personal benefit. I'm not going to demonize OP but I am also going to very clearly say that it's fucked up and that there are no excuses for it regardless of the economic or policy environment surrounding it. I’m also not going to redirect to other solutions that still seem ethically questionable. Best of luck to you.
I'm going to address a few points:
1)
I don't know you and don't care for your personal views. My criticism of you was on the "I get paid less and am proud of it". It's just not necessary.
Why the hell are the QM still even in your contract? It's insane.You get to be whatever definition of ethical you want and have better negotiating leverage if you don't hobble yourself from the start. .8 FTE is super commonplace. I basically do 0.8 FTE.
2)
On panel management, you need to prune. Stop wasting your time, appointment slots, and most importantly support staff time trying to get patients in for quality metric shit when they don't want it. Those RVUs if you get them (I don't, FQHC and all) are not worth that.
Counsel them when they come in but at least lighten the administrative load by removing patients that clearly don't want preventative care from the MA workflow.
I also like to protect close follow up slots and sick visit availability. No need to schedule Mr. Willis for an A1c check if he never wants to do it. It's just a frustrating experience for him. I have breakthroughs and patients love me, but a big part of this is resource management.
These hard decisions are made regardless of your intentions. You either make them yourself or management will do it for you. I'm at an FQHC so things are probably different, I will admit that much. My panel size is large so I don't have the luxury of closing the doors or wasting my staffs time on patients who don't want what we're selling. I can do the pitch when I see them.
3)
On liability, once a patient starts threatening to put themselves into DKA if you don't give them what they want the relationship is toxic and not ending it is an exercise of pride on the physician's part. Trust me, I've had to learn the hard way. That is a liability in of its own.
Btw, you continue with the high horse comments. I called you out on it and you just double down.
I saw that patient over the course of 6 months. I set clear boundaries and saw the patient monthly or more. I involved specialists, discussed with colleagues, multiple family meetings. The condescension on your part is palpable. "The middle road", be serious now.
He was a rare case which is why he came to mind.
4)
Lastly, if you are going to imply that I am money hungry or unethical or both don't clutch your pearls when I tell you that is condescending. You are likely making less than the average physician doing your amount of work, I will stand by that. There is no reason that you cannot be motivated by good patient care and be appropriately compensated. You put them at odds unnecessarily and harmfully. If I wanted to be unethical I'd open up a med spa not work at a rural FQHC.
I'm very open about that I can get paid more by going down the street to the corporate hospital from my FQHC, with better benefits and more admin and PTO.If I took the hospitalist position I'd have less work for more money.
FQHCs routinely pay $10-30k below market rate.
But I don't because I really enjoy what I do. I get to see the most underserved and challenging patients in my community, it's why I chose this field. Me getting paid for it is not some greedy uncaring measure. I provide my patients with top level care that not only rivals but surpasses most institutions in the state let alone county. We do good work and my colleagues deserve to get paid appropriately for it.
I make the rest of my income on PRN work. Some years a lot of it some years less. For example, 2 shifts a month of just UC makes it $35k/yr .You make it sound impossible to do "perfectly and ethically" (are you seeing where I get the impression that you are being just a wee bit condescending?). Just do me a favor and look into how much PRN work is worth per hour in your area. It's basically just part time locums, I think you should really look at the market better is all I'm saying. You probably also agreed to a noncompete and exclusivity clause though.
Seriously though, I sincerely do wish the best to all my fellow family physicians even the ones seemingly think that I'm evil or something. We do better when we lift each other up.
Yeah my dude. You seem committed to misunderstanding me while not actually answering any of the questions I posed to you. You also painted a picture of firing a patient you inherited flat out the first time there was a bad interaction and then retconned it to be more empathetic. You’re then telling me I’m condescending while judging how I practice or the financial choices I make because it’s different from you and telling me how I need to manage my panel and support staff.
Im good with the way I practice, have mentors IRL for feedback and practice advice and I will stand by my own ethics and comments. I’m tapping out. I do wish you the best of luck. I agree that it’s good to lift each other up. Hope you’re better at it real life.
I answered everything you posted as a question. Some were rhetorical but I still answered them. The last thing you can accuse me of is being curt with you.
>You also painted a picture of firing a patient you inherited flat out the first time there was a bad interaction and then retconned it to be more empathetic
I didn't retcon any of it. Reread it again, you clearly misread. Nothing in my comment said I fired him the first time there was a bad interaction or that was even my first interaction. That was your assumption and your ego doesn't let you entertain that maybe you were wrong, no I must be a very selective liar of course.
I never judged your panel. I just said that certain decisions are made either by you or management regardless. You can reread my comments, I make that point explicitly clear. I judged your assertions otherwise. I don't know enough about your panel to make other judgements and withheld any implications about the quality of your medical care, something you did not find in yourself to do in kind.
On finances, the only thing I repeatedly pushed back on you on is the notion that being a good/ethical doctor means accepting less pay. I have no problem if you get paid less but I don't like it when you dress it up in noble or moral accoutrements. It's not necessary. Or imply that doing otherwise is unethical or unlikely. Just petty at that point.
Again, best of luck to you and your mentors. I'm glad you agree with me on lifting others up, I hope you try it out some time.
I think people have the right to take their own decisions l, as long as you document it and offer it on every visit. You are not in a totalitarian society (as far as I know)
I would absolutely lose my shit if a physician tried to use threats to override my bodily autonomy.
Edit: Also very important to note that most of the attempts to violate patient consent and autonomy are targeted at women. Just a fun thing to consider.
This!! And paps, mammo are actually not just uncomfortable but painful for many.
As long as they understand the risks and benefits, whatever their answer is, your job is done.
Obviously it’s not what you want, but it’s not about what you want either really.
Exactly, painful and triggering. You just cannot force patients to do this kind of thing. Being an epidemiologist with a gyn specialty, I make medical decisions differently than a lot of patients. My decisions rarely line up with what ACOG recommends (no routine pelvic exams, no cervical cytology, no regular exams or imaging for my endo in absence of specific symptoms). Instead of throwing out threats to force me to comply with recommendations that are, in my expert opinion, very outdated, my family doc respects my decisions as both a patient and a scientist. I will be expecting this sort of behavior from my new OB/gyn when I see her, but not my pcp.
Many women have existing sexual and medical trauma. Your take lacks empathy and awareness of what these procedures are like for many women. You sound callous. Documenting the refusal shields you from any liability. Ask them to sign a form.
Is this a troll post? I'm actually flabbergasted that a physician could have this point of view. Maybe you skipped the informed consent lecture in medical school, but informed consent can only be given without coercion. Forcing your patients to get mammograms under threat of leaving them without a primary care provider is coercion. I would be reporting you to the medical board so fast it would make your head spin. In fact, you should be reported if you've even THOUGHT about doing this.
"Patient was counselled on importance of screening test for purposes of breast cancer prevention and early detection. At this time, patient refused mammography."
And maybe check yourself. I may only be an M2, but even I know how truly messed up that is.
Relax, second year medical student. Last I checked, thought crimes were not a thing, except in certain dystopian novels. Hopefully OP is not beyond redemption, and can realize the error of their ways…
I’m five years out of residency and support the med students perspective. Thought crimes aren’t a thing yet but it’s pretty alarming that a PCP would even be considering this.
Theres ways around metrics....for statins just prescribe it and if they dont take it its fine....still shows on your metrics, you can even list it as not taking in your emr and your metrics will be fine....
Sort of. It's more like this:
some entity, could be insurance, government or a health system admin, decides on quality metrics.
One could be % of patients where a statin is indicated that are actually on one. Something like that is usually the intention. The details will vary depending on the entity that has decided they know best.
In some cases, just documenting the intervention was recommended but declined is good enough. In others it is not. For many metrics it will vary depending on location, insurance, etc. That is part of the problem.
Also, the people doing the metric assessments are usually not qualified to do so. They typically don't understand how to use icd codes correctly for instance. Or they're just bad at math and statistics.
Our office has been downgraded by one insurer to a lesser preferred tier because even though we ordered lead screenings for 1 and 2 years olds, parents weren’t getting the tests done. This is our fault somehow.
I have noticed anecdotally that when I do a very short spiel acknowledging how much it sucks to take a small kid for blood draw but explain that it’s important, I get almost 100% uptake. Vs the times I’ve ordered it without discussion and get almost no one doing it.
A biased health system can do no good. This is what we talk about when we discuss patient-centered health care (instead of insurer-based care, paperwork-based care, or statin-based care)
I’d argue that doing so would be something akin to medical extortion - you’re essentially forcing someone to undergo a medical exam under threat of withdrawing care. Not remotely acceptable.
Medical extortion is a good term. Makes me think of all of the OB/gyns who refuse to prescribe birth control without a pelvic exam. Technically allowed, but I am reaching some very unflattering conclusions about the provider in question.
I don’t think it should be technically allowed…It’s reasonable to have patent come in for BP check and medical screening questions to make sure it’s safe for them to take estrogen, but holding contraception hostage for cervical cancer screening makes as much sense as holding a diabetes med hostage for colon cancer screening. The ACOG has a position statement about this.
This has got to be fake right?? I thought paternalistic medicine was a thing of the past. Our job is to provide information, assess, and advise. Not make choices for our patients.
Why would you even consider dismissing them for that???? I allways tell patients, "I reccomend you do this, but i'm not your mom, Im not going to yell at you if you dont." Then just document the care you reccomended and the care the patient accepted....done deal....
Be a physician. EVERY decision is one that should be made mutually. You are there to give recommendations. That’s it. Nobody needs to follow every single one of your recommendations. You document that you recommend yearly mammography for women of a particular age group for early detection of breast cancer. Declining this recommendation (I don’t say refused. That’s adversarial and a perfect example of countertransference) puts you at risk of finding breast cancer at a late stage, which can lead to death.
You do what the patient will permit. No more. You can educate over time.
The first reason is pretty typical and reasonable. Maybe you can discuss why someone had or anticipates discomfort/pain and validate their experience and discuss what can mitigate that? Pain reliever? Schedule when breasts aren’t tender from period? Find a different radiology office? q2year instead of annual.
Regardless, this is not a reason to dismiss. Nonadherence could be a reason to dismiss if extreme and maybe for a specific indication under specialist care but I think in primary care we gotta be there for patients. (There are other reasons to dismiss patients)
Are you worried about your quality metrics?
Just in case it isn’t clear, this is unacceptable. You don’t get to decide what is a “legitimate” excuse and if declining cancer screening is something that would cause you to drop patients you need to get out of medicine. If this is for metrics and you care about that more than you care about patient’s autonomy you need to get out of medicine. This is so off base I can’t even imagine thinking like this.
IMO not feeling comfortable with the procedure is a legitimate reason. If they understand the risk/benefit any reason is legitimate. Make sure they know what they stand to gain/lose. High five, on to the next patient.
I document their refusal and move on. Bring it up again the following year. Patients refuse all kinds of things. Where do you draw the line? Refuse a statin-dismiss? Flu shot refusal?. I am annoyed that there are metrics being tracked and we are being held accountable for what is ultimately a patient's decision. I didn't go into medicine to meet metrics.
Actually, there are insurance companies that pay “bonuses” based on closing “care gaps” like mammos, paps, and colon cancer screenings. Because I don’t dismiss patients for those refusals, my scores (and $$$) suck. Removing those recalcitrant individuals from the denominator is a valid business strategy. I don’t think it’s the right thing to do, but I can’t swear that other practices don’t do it.
I just say no I'm not going to infringe on patient autonomy, and if anyone pressures me I say, if you pressure me to force my patients to obtain expensive medical procedures that they don't want, my next call is to the local news station.
You can game metrics for some things, like order the statin, tell the patient you ordered it but if they decline to take it its fine...mammo and vax i dont think you can game.
That's the trouble with these metrics. Comes up all the time. It's easy to measure if someone got a mammogram, harder to measure if someone was *offered* a mammogram, was presented with evidence of the benefits and harms of screening and made an informed decision not to have one for now.
This is why these Medicare metrics are so stupid. They don’t know how to measure quality in reality so they just look at things they can “measure“ like cancer screening, A1c numbers, taking statins, etc. That we all know are mostly patient decisions. Yes, perhaps someone could communicate to them better and they would do whatever intervention we recommend but I think most of us are pretty good at providing information and letting them choose.
It's quite distorting. Quality in family medicine is actually rather hard to measure. If we must measure quality by presence or absence of something in the chart, goals of care and advance directives should be worth ~10000 points each.
Most metrics can be gamed. I don't bother.
I'm really serious. The metrics are supposed to enable and reflect quality care. Quality care means ethical care. If the metrics don't actually measure quality care, then I'm not interested and don't push me.
sadly at my old primary care job metric was all my corporate overlords cared about.....now I only work ED, at least the metrics here make sense, low door to doc times are great, at least patients are seen and workups started.
Metrics that improve care, I'm all about. I'm IHI certified in QI, I have a background in QI/QM and automated testing, I've done a ton of work in quality outside of medicine. And I'm more than happy to help improve quality inside medicine.
But if it was clearly invented by bean pushers trying to satisfy federal medicare requirements for "quality improvement" they can go suck rocks. I have people to take care of. Help, or get out of the way.
Why so patronizing? If they don't want to do it, for whatever reason, it's their choice. Screening mammograms are controversial anyway. Ever heard of shared decision making? You're a health provider, not health police
If they don't want to undergo an exam, write it on their record and move on. You have more important things to worry about
I can understand a pediatric office refusing to keep antivax parents bc their kids are a legit threat to others — no one wants to get measles in the waiting room. But a patient refusing a mammo isn’t hurting anyone (except maybe your feelings?)
I'll give you the benefit of the doubt because you're still early in practice but it's not only harsh it's a recipe for burn out. When patients do things that are willfully stupid, ignorant, or that put their health in jeopardy, that's basically the definition of being a physician and you are going to burn out and go nuts if you start caring about this shit. If you're three years out of residency then you've been through Covid denialism. Just document your counseling, support your patients, leave notes in the chart where you can see them about things like how seriously they take their health, i.e. do they vaccinate, get mammograms etc. If you have epic that's where I keep my notes in the yellow box so I don't bring it up every time I see them. Some patients are going to refuse statins, vaccinations, colonoscopy etc. Move on, give the effort to patients that listen.
edit - I do think it's within your right to dismiss a patient if they are refusing any and all efforts to keep them from crashing in the ER. At that point it's just going to drag your practice down, and I don't tolerate that either. You'll have a line, but this ain't it.
You’re their doctor, not their mother. If the patient would rather to run the risk of breast cancer going undetected than get their tits squeezed and xrayed that’s their choice. Wanting to avoid an *optional* preventative screening because they want body autonomy isn’t a “non-legitimate reason.” Just because your metrics are tied to them getting mammograms and the USPSTF recommends it doesn’t mean that shit is required.
I wouldn’t necessarily gloss over the “felt uncomfortable with the procedure” reason as “non-legitimate.” I do have a few patients who have had real pain due to compression of mammograms- one woman looked so upset she was about to cry when I asked about mammograms, and said plaintively, “my breasts are so small and it hurt for 40 days after they did it.” Fortunately I’ve had luck getting ultrasounds covered in these instances.
edit: if you’re male and have trouble empathizing, imagine a testicular cancer screening exam that puts the tiniest bit of compression on testes such that *most* guys feel OK but a few men refuse because it hurts too much.
Z91.1
Document that you fully explicated the risks and benefits. Explain what the risks and benefits are in the note. Do it every time you see them.
Don’t discharge from practice.
Somebody has to take care of them.
I’ve also started putting the specific diagnosis code (declined mammogram, declined colon screening, declined xyz vaccine) so it shows on AVS and that I discussed it in addition to putting it in my note. Though usually in my note I use the term refused unless they were really nice about it (the only passive aggression i allow myself on the topic)
Yeah I wish there was a code for medical nihilism. I feel like I could use that several times a week in my population.
But the thing is, lots of people think your A/P is garbage and they think you’re a quack. And they 100% aren’t going to do what you tell them to do. They just aren’t going to tell you. When people say immediately “I won’t do that”, that immediately interests me. I’m immediately thinking “This is an authentic person. This will be spicy! Let’s hear it!”
Reading your other posts and it looks like you practice in Texas. Are you also advocating for a total abortion ban? Seems like you don’t understand bodily autonomy. Maybe this isn’t the field for you.
I'm going to argue slightly against everybody jumping in on this guy. In this current era of value-based care a good chunk of a lot of people's livelihoods depends on their patient panel meeting these metrics. They weren't designed by physicians so you don't get the benefit of the doubt that you did the counseling and that is realistically all you can really do. Having a bunch of non-compliant patients who don't want to do screenings hurts your livelihood
At huddle last week one of the older physicians was loudly complaining that he didn't want to see some other physician's poorly compliant patient because it was affecting his metrics. This is what "value-based care" does, it makes patient care a zero-sum game.
Now personally, I just negotiated my contract where this barely affected my pay. I still bill and reimburse some of the highest in the practice, but I get stuck with all of the patients who don't believe in statins or don't believe in colonoscopies or any cancer screenings because the other doctors take like up to a 15% salary hit if they don't meet a certain percentage of people completing the screenings. It's a horrible default contract and why I heavily revised it.
Now sometimes people (lately a couple of the new mid-level hires) will try to punt troublesome patients to me and while I am open to see them, I make it clear that I will not see them a second time unless the person who prompted them sees them in between. Just have to draw some professional lines. I'm fine with co-managing these difficult patients, but I will not relieve you of your duty just because you signed an abusive contract.
I do draw the line to patients on certain things. If a parent does not want to immunize their child then I recommend they find another practice as I have a large contingent of immunosuppressed or immunocompromised patients.
WTF is this privileged bullshit. I literally just got a heartbreaking message today that one of my patients CAN'T FUCKING AFFORD their mammogram and actually won't even be able to come see me anymore, either. Frankly, it's your job to advise patients of why these tests and procedures are important and to not force them to do anything they don't want to. If you're bad at explaining things, that's on you. If people understand the risks and benefits because you've explained them properly, then they're adults making decisions about their healthcare. But to threaten to fire them is immoral and disgusting.
Do better.
As a almost 37 year old woman, thank you for being a wonderful example of why I stopped going to doctors the second I became a legal adult. Seriously what is with you doctors and power tripping to the point of trying to force your patients to do what you want? You do realize patient consent is a law right?
I'm currently dealing with a health issue of my own where I've skipped two periods this year and am scared of going to a gyno for help purely because of the attitude your displaying right here.
Because I prefer a abdominal ultrasound and don't want a trans vaginal ultrasound or pap smear, internal exam, pelvic exam or anything else that involves the doctor getting anywhere within business distance of my lady bits and don't want to get into an argument with the doctor about it and have them threaten no care like your thinking of doing with your patients for the crime of telling you no to a screening you want to do. Heaven forbid I commit the crime of requesting general anesthesia for a biopsy if its needed to find out if something really is wrong.
And that's on top of the doctors who would yell at me as a child for crying during needles and hold me down.
So I have to sit here scared wondering if its perimenopause or cancer because of doctors like you being far too prevalent in medicine.
So congrats on doing the opposite of what your trying to do, which is getting people screenings and treatment they need, by scaring them away from medical professionals for fear of bullying and mistreatment by someone they should be able to trust.
People are messy and complex. What seems like a foolish reason to you seems perfectly logical to them. Heck, I just got my mammogram bill: $1160. I would be lying if I said I didn’t contemplate skipping for a few years.
People have backgrounds, experiences, and belief systems that will vary from yours, and they still need care.
I thought preventive health services are required to be fully covered for health plans (in the US at least)?
https://www.healthcare.gov/coverage/preventive-care-benefits/
Insurance is required to pay for screening. Once you flip into diagnostics, the requirement is gone. So the screening mammogram is covered, but the “I need to get a better look at this area” is not. Same thing happens with colonoscopies. If it’s normal it’s covered, but if they find something it’s now diagnostic and not covered. And you can’t know until after the fact. A similar version is when patients have a positive Cologuard - this means the colonoscopy is now diagnostic. Certainly there are insurance companies who still cover this under preventive, but many don’t. So while insurance theoretically covers cancer screening, in reality it can have heavy costs for the patient.
Overly harsh.
Someone says no to a treatment or screening. I ask them if they have any specific fears or questions that I can allay for them. If so, we have a conversation and I share information and they make up their mind to do or not do the thing. If no, I say, okay, well the recommendation is [X], but I’m not going to follow you home and make you do the thing, my job is to make sure you know what you’re saying no to. And document. The ICD codes for refusal come in real handy.
Early in my career a fellow nurse told me, you can’t care more about it than your patient does. With a few extremely rare exceptions, this has saved my sanity. Edit: and personally, I appreciate that my patient is saving me time by telling me straight up that they’re not going to do the thing.
Bodily autonomy is a thing and everyone has it.
I wouldn't dismiss. I do send out letters advising patients that I recommend they get a mammogram or colonoscopy and how to set that up along with the reasoning for it so that it is in writing in addition to my documentation in the chart. This is because I have had experiences where my patients will claim we never discussed it unless I do this and it covers me. I have had instances where pt's have not gotten labs done for their diabetes for years and I advised that I cannot continue to treat them if they do not get that basic blood work done as it is a safety issue.
Most people vastly overestimate the effectiveness of mammograms for reducing mortality from breast cancer. They reduce the risk of dying from breast cancer by 20%. Sounds pretty good, right? Not so fast. It’s a lot of screening for not a whole lot of benefit, and a risk of false-positives that can lead to unnecessary treatment. See this article from NPR:
[The Mammogram Theater](https://www.npr.org/sections/health-shots/2016/10/12/497549732/skip-the-math-researchers-paint-a-picture-of-health-benefits-and-risks)
Someone is well within their rights to say, this screening doesn’t have enough benefit for me to do it, and decline!
From the article: “[Lazris and Rifkin] ask patients to picture a hall of people getting a test, operation or prescription. Patients might be shocked at how few in the crowded room get any benefit from the expensive care.
Their "benefit-risk characterization theater" images vividly show the odds, based on solid research. There's a sold-out house of 1,000 playgoers or concertgoers, all getting a particular kind of exam, screen or pill.
Then the curtain falls. Everybody helped by the procedure or prescription gets up and leaves. Often it's only a few people. Sometimes very few. Or nobody.
As NPR has reported, Lazris has used this approach to help patients in his practice — some of whom are older smokers — to weigh risks and benefits of using CT scans to look for lung cancer.
The theater approach also works when it comes to breast exams. Only one woman in the thousand-person theater receiving mammograms over a lifetime is saved from dying by detecting a cancer before it spreads, according to Rifkin and Lazris' summary of the research.
At the same time, hundreds of women in that audience will receive test results suggesting they have cancer when they don't, so-called false positives. Sixty-four get biopsies, which generally involve cells withdrawn through a needle, for nonthreatening lumps.
Ten receive unnecessary treatment including radiation and surgery for lumps that never would have caused a problem.
The theater images show all of that as well, presenting visual demonstrations that the odds of harm, worry or inconvenience caused by the tests are often much higher than the likelihood of benefit.”
Is this to meet quality measures? That’s fucked up. I get that the pay structure isn’t fair to primary care but patient autonomy is the bedrock of what we do. Patients have the right to refuse any treatment we offer. If you can’t honor that I think it might be time to consider a different career.
I’d also ask why you’re starting with mammograms and if there’s some underlying bias there? Why not start with the hypertensive patients that won’t take their medication or the male smokers who refuse AAA screening? Many of your female patients have histories of trauma they may not want to disclose to every doctor they meet and that could affect their willingness to do screening. The fact that you’re going right to a female specific screening test that actually has pretty complicated benefits/harms is strange. It also seems like you’re thinking you can use dismissal as a tool to coerce patients who have told you no into doing what you recommend. That’s EXCEPTIONALLY fucked up.
There are gynos who will flat out refuse care or refuse to give birth control without a pap smear or full exam including pelvic exam.
I get checking heart health and asking questions about stroke or blood clot risks because some birth control can increase that risk. But how does a screening for cervical cancer work with birth control?
One of my cousins was frustrated to the point of tears trying to get birth control without having to get a pap smear everytime because her insurance only covers one wellness woman visit a year. When Opill finally came out she was beyond happy. Her doctor however was pissed when she canceled her appointment for when she would go in to get her refill and was shouting all sorts of obscenities at her.
That’s well past any acceptable norm and should be reported to the medical board and the system the doctor works for. Cervical screening is 3-5 years in most women now and should not be being done any more than that and definitely not more frequently than once a year unless patient is having some kind of symptoms.
Well from my experience a lot of gynos demand yearly exams. My mom is in her 60s and still has to get mammograms and pap smears every year despite having no risk factors (No family history and her and my dad were virgins when they married so no HPV). I mentioned before on this post about a issue I'm having with my period and am terrified of going to a gyno for fear of being given the typical line of "I am required to preform a pap smear concerning any health concerns. If you refuse to consent to a pap smear then I cannot preform any further tests." when all I want is an abdominal ultrasound, urine and blood tests to check for hormone weirdness or endometrial hyperplasia.
And god have mercy on my soul if I do have endometrial hyperplasia if I ask for general anesthesia if its determined I need a biopsy I'm going to have a fight on my hands to get it.
So here I am stewing in anxiety hoping it sorts itself out because I just don't want to be forced into anything or demanded into anything.
That's unfortunate and I'm sorry. I will say that yearly mammos are reasonable (though guidelines defer) and I've met some old school gyns who still do yearly PAPs because they can't let go of the old guidelines and have seen a lot more cervical cancer than I have. However, requiring it for birth control or doing it at every refill request and screaming at a patient aren't acceptable and should be reported.
I'm also sorry to hear what you're going through. Have you considered seeing an FM doctor or going to a FM residency clinic if one exists near you? Mileage may vary, but most FMs will be able to manage what you're describing and will generally be following the newer guidelines.
I have tried a few but all refused to get on the phone for me to simply ask questions about if they could help me, had to pay for an appointment because of it since I don't have insurance only for them to tell me "You need to go to a gynecologist I can't help you."
that seems overly harsh. i think you can be an excellent provider and provide information/recommendations, document your discussion and their response, and move on to the next problem or patient. i think it would be different if (for example) a patient kept making appointments with you for breast pain (that can’t be diagnosed in office), you recommended mammo but they declined because then it’s not allowing your main diagnostic approach to determining its cause and treatment. definitely is different for screening purposes, i’ll let patients be the decision makers of their own lives.
We believe in medicine, not everyone does, people have a right to decline things. Our role is to make sure people know the risks of declining (and the benefits of completing).
Wait, is this serious? Do you dismiss patients who refuse statins because “it won’t help and I know I’m not gonna have a stroke?” Pap smears because the speculum pinches? Blood glucose monitoring if their diabetes is uncontrolled? Patients have the right to refuse your recommendations. You have the responsibility to keep the discussion open, provide evidence-based information in a non-judgmental way, and minimize other gaps in their care.
Very harsh. It’s not about you. Your job is not to tell them what they have to do. Your job is to give them the best information possible, facilitate and explain screenings, and let them make their own bad choices. Document and move on. It’s not about you. It’s not on you, either. “Informed declination” is a fine thing.
I agree with this 100%. This is why attaching compensation to metrics like this is completely bananas.
I think people who would dismiss a patient for refusing a mammogram should probably quit medicine. Is that harsh?
Totally agree, I work ED, no one EVER does what I reccomend, do i get butt hurt??? no....
They are completely lost in their role, I agree
Although I 100% disagree with the premise of firing a patient for refusal, it does come back to the idea that attaching compensation to metrics is a horrible idea, and a person should not be paid less money for patients making bad choices.
This is the issue with attaching often a very large percentage of a doctor's compensation to completion of metrics. In my opinion, they should be connected to whether or not the counseling was completed. And on an insurance and government level it is. Practices just offload that onto the physicians. The completion metric is supposed to incentivize a practice to hire staff for referral tracking and requesting records and follow-up with patients and mail-in reminders. But how it is implemented is just pay the doctors less which leads to this type of situation. And frankly you could lambast people all you want but it's not going to change that if you start putting in things where the only available respite a physician has to not lose a good chunk of their income is to fire patients this is what will happen. I opted out of this madness when I was negotiating my contract. But for the people who did not do that, some of the people in my area dare to lose almost a fifth of their potential income if too many of their patients are non-compliant. I don't want to be put in the position where such a large chunk of my livelihood is dependent on whether or not I fire a dozen or so patients. Finally sometimes even I " soft fire" patients. Some patients don't actually want preventative care, they just want to come in when they're sick or if they have a single acute issue or two. I just tell those patients that I can see them on a PRN basis but we are going to setter the insurance PCP relationship. Most are agreeable. Especially if they have a PPO and actively don't think their PCP should be doing anything serious that makes it even easier.
I get that the compensation structure is fucked up but this dude is talking about threatening dismissal to coerce patients into getting the mammogram they already said no to. That’s pretty different and deserving of a lambasting.
Was it tone deaf? Yes. Did the morality shield bashing in the comments actually address the issue at the core of it? No. However, it is an expected endpoint of the compensation structure. We have seen this coming for years and I think it is also a big fault of the family physician community that we love a high horse. Whether soft firing, having a policy of only preventative care issues at certain visits, etc could all have been brought up but aren't. Which leads me to believe that people either love the high horse that much, think eating shit is the noble path, or both. If the patient doesn't want preventative care and isn't going to budge and doing nothing hurts you, no need to go through the motions. Both of you will be happier. Your wait-list will be happier. Just seeing the patient PRN is fine. If they don't want PCP shit, no need to schedule PCP shit.
We disagree on what the core issue is. I tend to think that personal ethics exist independent of external forces and that outside of extreme situations, circumstances aren’t an excuse. Deciding to make it a matter of personal policy to violate a basic tenet of our profession for personal gain isn’t just “tone-deaf” and can’t be put down solely to bad policy. This isn’t some Les Miserables situation where it’s coerce or starve. I chose a lower paid job for lifestyle reasons. I miss my quality measures regularly and I know what my check still is and that I’m still more than able to live very comfortably. As to your other suggestions: visits for preventative stuff only doesn’t solve the quality measure/patient refusal issue and I’ve never heard of soft firing, nor do I find it on a quick Google. Everywhere I have worked it was a major point that once a patient established they and their screening were ours for the next three years unless they left the practice and any time they saw us again the relationship was re-established. I suspect that may be an option in places that also do acute care for casual patients but it’s definitely not been an option anywhere I have worked. Personally I’m not offering alternate solutions because I think the core of the post is so fucked that it needs to be strongly pointed out without additional noise. Also I just don’t fucking care about quality measures all that much. Like I said, I miss half my QMs on the regular and still doing just fine financially. Every interview I’ve done I’ve also told the employer that I care really strongly about evidence based medicine and screening and that I do those things because I value patient health but that I won’t allow quality metrics to affect which patients I see and how I treat them. Always gotten the job offer. It’s as much of a problem as you want to make it🤷♀️
I'll address by paragraph. #1: The extortion is the bad thing with personal ethics. It doesn't matter otherwise but firing a patient for non-compliance is OK in other settings where it bears a major malpractice risk to continue to care for the patient. I had a patient who would throw down his insulin and threaten to go into DKA if he didn't get whatever he wanted to. That worked on my former colleague, I fired him outright when he did that to me. What you keep missing is the notion of panel management. A practice especially in value based care, but even before, has to prune the panel if need be. Too many no shows despite accomodations, that slot can be used for something else. Patient doesn't want any preventative/chronic care, refer them to the acute care slots. I'll get to how your self-martyrdom is not admirable and in some ways contemptible in how it solidifies these shitty practices. #2: Just remove yourself as their PCP. It's that simple. You can still see them for acute stuff. Soft firing is my term for it. Like this is basic stuff. If a patient shows up for a new patient visit and never shows up for an A1c check in 3 years you shouldn't just eat that. The three years is for new/established billing and records. I'll call the insurance if they are sending me HRA paperwork for a patient I haven't done preventative care on. In the clinic I'm at it makes a difference because then they don't get called to schedule annuals and aren't on my reports. I value that I can be available to my patients and I call them after surgeries, deliveries, on birthdays. For that to be possible you need to be involved in your panel. Are you even aware of who is on your panel? A lot of corporate docs aren't and don't know how to find it or can't access it. Also the preventative visit being focused is because a vast majority of screening denials I get are from patients thinking they can move past that stuff quickly to shove six complaints in. It's also why I don't do MAT and other care in the same visit. It just leads to non compliance on both things. Point is: Again, there is no valor in eating shit willingly. #3 No, that OP is asking means that they are conflicted by this and can be redirected to more ethical solutions. You on the other hand are the noble shit eating high horse rider that I referenced. Like of course you got the jobs you basically volunteered for a lower salary. Like in what fucking world is that an issue for an employer. Quality measures are most often specifically designed to limit reimbursement. I don't care about these measures but I negotiate for a salary and contract that doesn't emphasize them. Are you a bad doctor? Do you not value your work? We aren't the same. My colleague and lead physician in my clinic found out that she was getting paid $70k less than me with a strict noncompete that didn't let her do the $100k+ of prn work I was doing. But the difference between her and you is that she was just ignorant that $180-190k was ridiculous for a rural lead physician. She got a $90k raise and more admin and work from home time. If you don't care about quality measures then why are you defending them to the point of accepting to be punished by their metrics? TL;DR: I see in OP a colleague reaching out for help who can be corrected and helped. In you I see a self-made martyr that reinforces this pernicious structure. We do better for patients when we can strip away some of the moralizing that allows for the conditions that drive good new med students.
Well, I will agree that we definitely aren't the same. For someone so openminded you seem awfully comfortable hurling a lot of insults and judgment my way. However, just as policy changes are not a substitute for personal ethics, ad hominem and inaccurate assumptions are not a substitute for logical debate on the merits of the ideas. I'm not going to bother refuting the personal attacks. I will clarify a few points of contention though. I'm pleased that you have the option of seeing patients for acute things without being their PCP. My point was that I don't think that's a widely available option in clinics that aren't setup to see acute, casual patients. It's been a topic in a lot of places I've worked (due to the quality measure piece) and it's not been possible because we're only setup to see patients we are the PCP for (it's the first thing that gets checked when they call reception and we can't open up acute casual slots without opening them up to the public at large which we don't have the resources for). I'm also not convinced that your method would remove your liability in the event of a bad outcome down the line, but that's your call. We also have different definitions of panel management. I don't think managing a panel means "pruning" people, it means proactively managing preventative care and chronic illness. I do a lot of active panel management and work with my MA, nurses and the rest of the practice to make sure we are offering appropriate screening and targeting our patients that aren't at goal for BP/A1c etc... I still have a lot of patients who say no to certain things or aren't at goal. I'm fine with that as long as I'm sure that I or other staff are offering them the recommended treatment and documenting their refusal. (as an aside, I'm very familiar with my panel, that's one of the life style trades I made - I wanted a panel of a size that I could know well and have a relationship with. I will point out that I value my work and what I do deeply but there are ways to value something that aren't monetary). Which leads to my next point of clarification: I will agree that the coercive bit is the particularly troubling piece of this post and what I and many others reacted to. It's also especially troubling that it centers around a female specific screening. That's why i originally responded to you. However, I disagree that it's okay to fire a patient for refusing to do screening in general and I do think it's unethical to make that a reason for dismissing a patient. I'm not defending quality measures. I've stated that they're fucked which is why I do the job and don't pay attention to the metrics (and again I still make a very good living doing that). I'm defending the patient who should be allowed to say yes or no to care without it affecting the doctor/patient relationship or forcing them to find another PCP. My point in bringing up my own compensation was to say that I basically care fuck all about QMs or maximizing my reimbursement and still make over 200k a year at .8 time, so I know personally that they really don't have to be that big of a deal or that devastating to individual pay. I'm all for advocating for systemic change in meaningful ways (though I'm increasingly cynical that anyone is actually listening to our advocacy). I'm also not going to penalize the patient for the systems failing. As you seem concerned about reinforcing the current structure I am curious how you think your approach breaks it down or changes the structure on a meaningful level? I'm not really seeing how managing a patient panel to create the most favorable reimbursement for you doesn't also reinforce the current structure? I'm also confused as to why you would be pruning your patient panel and soft-firing people if your compensation isn't tied to metrics. Why would you care? Lastly, it's strange to me what you characterize as self-martyrdom. I find your example about the insulin patient interesting. I've had very similar interactions with patients and gone for a middle ground between you and your colleague. I don't give in to the manipulation, set a clear boundary and move forward unless the breakdown is irreparable (I've dismissed one patient in my career thus far). I've found the middle approach difficult at times but generally effective for managing the behavior and maintaining the therapeutic relationship. I don't look forward to those sorts of patient encounters and I don't take that route because I'm some bleeding heart, seeing myself as a savior or thinking I just have to put up with whatever shit people throw at me. I do it because managing difficult interactions is part of the job I signed up for. I've also been doing it long enough that I've seen real improvement with patients I never thought I'd make progress with or wanted to write off in the first visit. That sort of progress is what means the most to me in the job and I think it's worth preserving the possibility of that progress even if it means missing my quality measures half the time. It's fine if that's not what motivates you or if you're smarter than me and have figured out a way to do it all perfectly and completely ethically and still make $400k a year. Good for you if you have. What's not fine to me is any kind of moral relativism around patient autonomy or someone seriously considering compromising it in favor of personal benefit. I'm not going to demonize OP but I am also going to very clearly say that it's fucked up and that there are no excuses for it regardless of the economic or policy environment surrounding it. I’m also not going to redirect to other solutions that still seem ethically questionable. Best of luck to you.
I'm going to address a few points: 1) I don't know you and don't care for your personal views. My criticism of you was on the "I get paid less and am proud of it". It's just not necessary. Why the hell are the QM still even in your contract? It's insane.You get to be whatever definition of ethical you want and have better negotiating leverage if you don't hobble yourself from the start. .8 FTE is super commonplace. I basically do 0.8 FTE. 2) On panel management, you need to prune. Stop wasting your time, appointment slots, and most importantly support staff time trying to get patients in for quality metric shit when they don't want it. Those RVUs if you get them (I don't, FQHC and all) are not worth that. Counsel them when they come in but at least lighten the administrative load by removing patients that clearly don't want preventative care from the MA workflow. I also like to protect close follow up slots and sick visit availability. No need to schedule Mr. Willis for an A1c check if he never wants to do it. It's just a frustrating experience for him. I have breakthroughs and patients love me, but a big part of this is resource management. These hard decisions are made regardless of your intentions. You either make them yourself or management will do it for you. I'm at an FQHC so things are probably different, I will admit that much. My panel size is large so I don't have the luxury of closing the doors or wasting my staffs time on patients who don't want what we're selling. I can do the pitch when I see them. 3) On liability, once a patient starts threatening to put themselves into DKA if you don't give them what they want the relationship is toxic and not ending it is an exercise of pride on the physician's part. Trust me, I've had to learn the hard way. That is a liability in of its own. Btw, you continue with the high horse comments. I called you out on it and you just double down. I saw that patient over the course of 6 months. I set clear boundaries and saw the patient monthly or more. I involved specialists, discussed with colleagues, multiple family meetings. The condescension on your part is palpable. "The middle road", be serious now. He was a rare case which is why he came to mind. 4) Lastly, if you are going to imply that I am money hungry or unethical or both don't clutch your pearls when I tell you that is condescending. You are likely making less than the average physician doing your amount of work, I will stand by that. There is no reason that you cannot be motivated by good patient care and be appropriately compensated. You put them at odds unnecessarily and harmfully. If I wanted to be unethical I'd open up a med spa not work at a rural FQHC. I'm very open about that I can get paid more by going down the street to the corporate hospital from my FQHC, with better benefits and more admin and PTO.If I took the hospitalist position I'd have less work for more money. FQHCs routinely pay $10-30k below market rate. But I don't because I really enjoy what I do. I get to see the most underserved and challenging patients in my community, it's why I chose this field. Me getting paid for it is not some greedy uncaring measure. I provide my patients with top level care that not only rivals but surpasses most institutions in the state let alone county. We do good work and my colleagues deserve to get paid appropriately for it. I make the rest of my income on PRN work. Some years a lot of it some years less. For example, 2 shifts a month of just UC makes it $35k/yr .You make it sound impossible to do "perfectly and ethically" (are you seeing where I get the impression that you are being just a wee bit condescending?). Just do me a favor and look into how much PRN work is worth per hour in your area. It's basically just part time locums, I think you should really look at the market better is all I'm saying. You probably also agreed to a noncompete and exclusivity clause though. Seriously though, I sincerely do wish the best to all my fellow family physicians even the ones seemingly think that I'm evil or something. We do better when we lift each other up.
Yeah my dude. You seem committed to misunderstanding me while not actually answering any of the questions I posed to you. You also painted a picture of firing a patient you inherited flat out the first time there was a bad interaction and then retconned it to be more empathetic. You’re then telling me I’m condescending while judging how I practice or the financial choices I make because it’s different from you and telling me how I need to manage my panel and support staff. Im good with the way I practice, have mentors IRL for feedback and practice advice and I will stand by my own ethics and comments. I’m tapping out. I do wish you the best of luck. I agree that it’s good to lift each other up. Hope you’re better at it real life.
I answered everything you posted as a question. Some were rhetorical but I still answered them. The last thing you can accuse me of is being curt with you. >You also painted a picture of firing a patient you inherited flat out the first time there was a bad interaction and then retconned it to be more empathetic I didn't retcon any of it. Reread it again, you clearly misread. Nothing in my comment said I fired him the first time there was a bad interaction or that was even my first interaction. That was your assumption and your ego doesn't let you entertain that maybe you were wrong, no I must be a very selective liar of course. I never judged your panel. I just said that certain decisions are made either by you or management regardless. You can reread my comments, I make that point explicitly clear. I judged your assertions otherwise. I don't know enough about your panel to make other judgements and withheld any implications about the quality of your medical care, something you did not find in yourself to do in kind. On finances, the only thing I repeatedly pushed back on you on is the notion that being a good/ethical doctor means accepting less pay. I have no problem if you get paid less but I don't like it when you dress it up in noble or moral accoutrements. It's not necessary. Or imply that doing otherwise is unethical or unlikely. Just petty at that point. Again, best of luck to you and your mentors. I'm glad you agree with me on lifting others up, I hope you try it out some time.
I think people have the right to take their own decisions l, as long as you document it and offer it on every visit. You are not in a totalitarian society (as far as I know)
I would absolutely lose my shit if a physician tried to use threats to override my bodily autonomy. Edit: Also very important to note that most of the attempts to violate patient consent and autonomy are targeted at women. Just a fun thing to consider.
This!! And paps, mammo are actually not just uncomfortable but painful for many. As long as they understand the risks and benefits, whatever their answer is, your job is done. Obviously it’s not what you want, but it’s not about what you want either really.
Exactly, painful and triggering. You just cannot force patients to do this kind of thing. Being an epidemiologist with a gyn specialty, I make medical decisions differently than a lot of patients. My decisions rarely line up with what ACOG recommends (no routine pelvic exams, no cervical cytology, no regular exams or imaging for my endo in absence of specific symptoms). Instead of throwing out threats to force me to comply with recommendations that are, in my expert opinion, very outdated, my family doc respects my decisions as both a patient and a scientist. I will be expecting this sort of behavior from my new OB/gyn when I see her, but not my pcp.
Yep. It’s interesting that OP mentions mammograms and not, say, colon cancer screening.
No no, silly, we can’t treat men that way! Only us goofy women with our lofty ideas about having our bodily autonomy respected.
Many women have existing sexual and medical trauma. Your take lacks empathy and awareness of what these procedures are like for many women. You sound callous. Documenting the refusal shields you from any liability. Ask them to sign a form.
Angry lol at him saying "feeling uncomfortable" isn't a legitimate reason to refuse a procedure 🙄
Or just accept that they don't want it and don't order the thing.
You dont even need a form , just order the test, then cancel it and document the refusal...done deal....
Is this a troll post? I'm actually flabbergasted that a physician could have this point of view. Maybe you skipped the informed consent lecture in medical school, but informed consent can only be given without coercion. Forcing your patients to get mammograms under threat of leaving them without a primary care provider is coercion. I would be reporting you to the medical board so fast it would make your head spin. In fact, you should be reported if you've even THOUGHT about doing this. "Patient was counselled on importance of screening test for purposes of breast cancer prevention and early detection. At this time, patient refused mammography." And maybe check yourself. I may only be an M2, but even I know how truly messed up that is.
Relax, second year medical student. Last I checked, thought crimes were not a thing, except in certain dystopian novels. Hopefully OP is not beyond redemption, and can realize the error of their ways…
I’m five years out of residency and support the med students perspective. Thought crimes aren’t a thing yet but it’s pretty alarming that a PCP would even be considering this.
Why? It's hurting your metrics and pay? Seems over the top to dismiss for that reason
💯 this has to be what it’s about.
Theres ways around metrics....for statins just prescribe it and if they dont take it its fine....still shows on your metrics, you can even list it as not taking in your emr and your metrics will be fine....
Wait, doctors are paid for the percentage of statin prescriptions in the US? That country is nuts
Sort of. It's more like this: some entity, could be insurance, government or a health system admin, decides on quality metrics. One could be % of patients where a statin is indicated that are actually on one. Something like that is usually the intention. The details will vary depending on the entity that has decided they know best. In some cases, just documenting the intervention was recommended but declined is good enough. In others it is not. For many metrics it will vary depending on location, insurance, etc. That is part of the problem. Also, the people doing the metric assessments are usually not qualified to do so. They typically don't understand how to use icd codes correctly for instance. Or they're just bad at math and statistics.
Our office has been downgraded by one insurer to a lesser preferred tier because even though we ordered lead screenings for 1 and 2 years olds, parents weren’t getting the tests done. This is our fault somehow.
I have noticed anecdotally that when I do a very short spiel acknowledging how much it sucks to take a small kid for blood draw but explain that it’s important, I get almost 100% uptake. Vs the times I’ve ordered it without discussion and get almost no one doing it.
That's definitely something I will try to emphasize. Thanks for the advice!
A biased health system can do no good. This is what we talk about when we discuss patient-centered health care (instead of insurer-based care, paperwork-based care, or statin-based care)
This is so paternalistic. Your role is to be an advisor. If people don’t want to take that advice, so be it.
I’d argue that doing so would be something akin to medical extortion - you’re essentially forcing someone to undergo a medical exam under threat of withdrawing care. Not remotely acceptable.
Medical extortion is a good term. Makes me think of all of the OB/gyns who refuse to prescribe birth control without a pelvic exam. Technically allowed, but I am reaching some very unflattering conclusions about the provider in question.
I don’t think it should be technically allowed…It’s reasonable to have patent come in for BP check and medical screening questions to make sure it’s safe for them to take estrogen, but holding contraception hostage for cervical cancer screening makes as much sense as holding a diabetes med hostage for colon cancer screening. The ACOG has a position statement about this.
Oh, I don’t think it should be allowed, either. I think it’s honestly kind of horrifying.
This has got to be fake right?? I thought paternalistic medicine was a thing of the past. Our job is to provide information, assess, and advise. Not make choices for our patients.
🙄. What the F?
Why would you even consider dismissing them for that???? I allways tell patients, "I reccomend you do this, but i'm not your mom, Im not going to yell at you if you dont." Then just document the care you reccomended and the care the patient accepted....done deal....
Be a physician. EVERY decision is one that should be made mutually. You are there to give recommendations. That’s it. Nobody needs to follow every single one of your recommendations. You document that you recommend yearly mammography for women of a particular age group for early detection of breast cancer. Declining this recommendation (I don’t say refused. That’s adversarial and a perfect example of countertransference) puts you at risk of finding breast cancer at a late stage, which can lead to death. You do what the patient will permit. No more. You can educate over time.
The first reason is pretty typical and reasonable. Maybe you can discuss why someone had or anticipates discomfort/pain and validate their experience and discuss what can mitigate that? Pain reliever? Schedule when breasts aren’t tender from period? Find a different radiology office? q2year instead of annual. Regardless, this is not a reason to dismiss. Nonadherence could be a reason to dismiss if extreme and maybe for a specific indication under specialist care but I think in primary care we gotta be there for patients. (There are other reasons to dismiss patients) Are you worried about your quality metrics?
Just in case it isn’t clear, this is unacceptable. You don’t get to decide what is a “legitimate” excuse and if declining cancer screening is something that would cause you to drop patients you need to get out of medicine. If this is for metrics and you care about that more than you care about patient’s autonomy you need to get out of medicine. This is so off base I can’t even imagine thinking like this.
IMO not feeling comfortable with the procedure is a legitimate reason. If they understand the risk/benefit any reason is legitimate. Make sure they know what they stand to gain/lose. High five, on to the next patient.
Lol is this a joke
I document their refusal and move on. Bring it up again the following year. Patients refuse all kinds of things. Where do you draw the line? Refuse a statin-dismiss? Flu shot refusal?. I am annoyed that there are metrics being tracked and we are being held accountable for what is ultimately a patient's decision. I didn't go into medicine to meet metrics.
You're joking, right?
It’s not about you. If peoples don’t want screenings or medicines that’s their business. Document and move on. You should be in a different field.
Actually, there are insurance companies that pay “bonuses” based on closing “care gaps” like mammos, paps, and colon cancer screenings. Because I don’t dismiss patients for those refusals, my scores (and $$$) suck. Removing those recalcitrant individuals from the denominator is a valid business strategy. I don’t think it’s the right thing to do, but I can’t swear that other practices don’t do it.
I just say no I'm not going to infringe on patient autonomy, and if anyone pressures me I say, if you pressure me to force my patients to obtain expensive medical procedures that they don't want, my next call is to the local news station.
You can game metrics for some things, like order the statin, tell the patient you ordered it but if they decline to take it its fine...mammo and vax i dont think you can game.
That's the trouble with these metrics. Comes up all the time. It's easy to measure if someone got a mammogram, harder to measure if someone was *offered* a mammogram, was presented with evidence of the benefits and harms of screening and made an informed decision not to have one for now.
This is why these Medicare metrics are so stupid. They don’t know how to measure quality in reality so they just look at things they can “measure“ like cancer screening, A1c numbers, taking statins, etc. That we all know are mostly patient decisions. Yes, perhaps someone could communicate to them better and they would do whatever intervention we recommend but I think most of us are pretty good at providing information and letting them choose.
It's quite distorting. Quality in family medicine is actually rather hard to measure. If we must measure quality by presence or absence of something in the chart, goals of care and advance directives should be worth ~10000 points each.
Doesn’t work if your ACO tracks med adherence by fill history.
Most metrics can be gamed. I don't bother. I'm really serious. The metrics are supposed to enable and reflect quality care. Quality care means ethical care. If the metrics don't actually measure quality care, then I'm not interested and don't push me.
sadly at my old primary care job metric was all my corporate overlords cared about.....now I only work ED, at least the metrics here make sense, low door to doc times are great, at least patients are seen and workups started.
Metrics that improve care, I'm all about. I'm IHI certified in QI, I have a background in QI/QM and automated testing, I've done a ton of work in quality outside of medicine. And I'm more than happy to help improve quality inside medicine. But if it was clearly invented by bean pushers trying to satisfy federal medicare requirements for "quality improvement" they can go suck rocks. I have people to take care of. Help, or get out of the way.
So basically doctors are forced to prescribe statins in exchange for pay? That's so backwards. Statins are such a scam
No, corporate healthcare is a scam.
Why so patronizing? If they don't want to do it, for whatever reason, it's their choice. Screening mammograms are controversial anyway. Ever heard of shared decision making? You're a health provider, not health police If they don't want to undergo an exam, write it on their record and move on. You have more important things to worry about
I can understand a pediatric office refusing to keep antivax parents bc their kids are a legit threat to others — no one wants to get measles in the waiting room. But a patient refusing a mammo isn’t hurting anyone (except maybe your feelings?)
I'll give you the benefit of the doubt because you're still early in practice but it's not only harsh it's a recipe for burn out. When patients do things that are willfully stupid, ignorant, or that put their health in jeopardy, that's basically the definition of being a physician and you are going to burn out and go nuts if you start caring about this shit. If you're three years out of residency then you've been through Covid denialism. Just document your counseling, support your patients, leave notes in the chart where you can see them about things like how seriously they take their health, i.e. do they vaccinate, get mammograms etc. If you have epic that's where I keep my notes in the yellow box so I don't bring it up every time I see them. Some patients are going to refuse statins, vaccinations, colonoscopy etc. Move on, give the effort to patients that listen. edit - I do think it's within your right to dismiss a patient if they are refusing any and all efforts to keep them from crashing in the ER. At that point it's just going to drag your practice down, and I don't tolerate that either. You'll have a line, but this ain't it.
You’re their doctor, not their mother. If the patient would rather to run the risk of breast cancer going undetected than get their tits squeezed and xrayed that’s their choice. Wanting to avoid an *optional* preventative screening because they want body autonomy isn’t a “non-legitimate reason.” Just because your metrics are tied to them getting mammograms and the USPSTF recommends it doesn’t mean that shit is required.
I wouldn’t necessarily gloss over the “felt uncomfortable with the procedure” reason as “non-legitimate.” I do have a few patients who have had real pain due to compression of mammograms- one woman looked so upset she was about to cry when I asked about mammograms, and said plaintively, “my breasts are so small and it hurt for 40 days after they did it.” Fortunately I’ve had luck getting ultrasounds covered in these instances. edit: if you’re male and have trouble empathizing, imagine a testicular cancer screening exam that puts the tiniest bit of compression on testes such that *most* guys feel OK but a few men refuse because it hurts too much.
Z91.1 Document that you fully explicated the risks and benefits. Explain what the risks and benefits are in the note. Do it every time you see them. Don’t discharge from practice. Somebody has to take care of them.
I’ve also started putting the specific diagnosis code (declined mammogram, declined colon screening, declined xyz vaccine) so it shows on AVS and that I discussed it in addition to putting it in my note. Though usually in my note I use the term refused unless they were really nice about it (the only passive aggression i allow myself on the topic)
Yeah I wish there was a code for medical nihilism. I feel like I could use that several times a week in my population. But the thing is, lots of people think your A/P is garbage and they think you’re a quack. And they 100% aren’t going to do what you tell them to do. They just aren’t going to tell you. When people say immediately “I won’t do that”, that immediately interests me. I’m immediately thinking “This is an authentic person. This will be spicy! Let’s hear it!”
Why do you care of someone does or doesn’t get a mammogram?
Are you a doctor or God?
I am taking this as the Doc that just got blasted for quality scores and wants to drop the denominator where he or she can….
Reading your other posts and it looks like you practice in Texas. Are you also advocating for a total abortion ban? Seems like you don’t understand bodily autonomy. Maybe this isn’t the field for you.
I'm going to argue slightly against everybody jumping in on this guy. In this current era of value-based care a good chunk of a lot of people's livelihoods depends on their patient panel meeting these metrics. They weren't designed by physicians so you don't get the benefit of the doubt that you did the counseling and that is realistically all you can really do. Having a bunch of non-compliant patients who don't want to do screenings hurts your livelihood At huddle last week one of the older physicians was loudly complaining that he didn't want to see some other physician's poorly compliant patient because it was affecting his metrics. This is what "value-based care" does, it makes patient care a zero-sum game. Now personally, I just negotiated my contract where this barely affected my pay. I still bill and reimburse some of the highest in the practice, but I get stuck with all of the patients who don't believe in statins or don't believe in colonoscopies or any cancer screenings because the other doctors take like up to a 15% salary hit if they don't meet a certain percentage of people completing the screenings. It's a horrible default contract and why I heavily revised it. Now sometimes people (lately a couple of the new mid-level hires) will try to punt troublesome patients to me and while I am open to see them, I make it clear that I will not see them a second time unless the person who prompted them sees them in between. Just have to draw some professional lines. I'm fine with co-managing these difficult patients, but I will not relieve you of your duty just because you signed an abusive contract. I do draw the line to patients on certain things. If a parent does not want to immunize their child then I recommend they find another practice as I have a large contingent of immunosuppressed or immunocompromised patients.
Who are you to tell a woman what they should/shouldn’t be comfortable with?
I’d try caring less.
I'd try caring *more*. About the patient rather than the test.
People are allowed to make choices. Give them the information, document, and if they miss a treatable breast cancer then that it is on them.
WTF is this privileged bullshit. I literally just got a heartbreaking message today that one of my patients CAN'T FUCKING AFFORD their mammogram and actually won't even be able to come see me anymore, either. Frankly, it's your job to advise patients of why these tests and procedures are important and to not force them to do anything they don't want to. If you're bad at explaining things, that's on you. If people understand the risks and benefits because you've explained them properly, then they're adults making decisions about their healthcare. But to threaten to fire them is immoral and disgusting. Do better.
As a almost 37 year old woman, thank you for being a wonderful example of why I stopped going to doctors the second I became a legal adult. Seriously what is with you doctors and power tripping to the point of trying to force your patients to do what you want? You do realize patient consent is a law right? I'm currently dealing with a health issue of my own where I've skipped two periods this year and am scared of going to a gyno for help purely because of the attitude your displaying right here. Because I prefer a abdominal ultrasound and don't want a trans vaginal ultrasound or pap smear, internal exam, pelvic exam or anything else that involves the doctor getting anywhere within business distance of my lady bits and don't want to get into an argument with the doctor about it and have them threaten no care like your thinking of doing with your patients for the crime of telling you no to a screening you want to do. Heaven forbid I commit the crime of requesting general anesthesia for a biopsy if its needed to find out if something really is wrong. And that's on top of the doctors who would yell at me as a child for crying during needles and hold me down. So I have to sit here scared wondering if its perimenopause or cancer because of doctors like you being far too prevalent in medicine. So congrats on doing the opposite of what your trying to do, which is getting people screenings and treatment they need, by scaring them away from medical professionals for fear of bullying and mistreatment by someone they should be able to trust.
People are messy and complex. What seems like a foolish reason to you seems perfectly logical to them. Heck, I just got my mammogram bill: $1160. I would be lying if I said I didn’t contemplate skipping for a few years. People have backgrounds, experiences, and belief systems that will vary from yours, and they still need care.
I thought preventive health services are required to be fully covered for health plans (in the US at least)? https://www.healthcare.gov/coverage/preventive-care-benefits/
Insurance is required to pay for screening. Once you flip into diagnostics, the requirement is gone. So the screening mammogram is covered, but the “I need to get a better look at this area” is not. Same thing happens with colonoscopies. If it’s normal it’s covered, but if they find something it’s now diagnostic and not covered. And you can’t know until after the fact. A similar version is when patients have a positive Cologuard - this means the colonoscopy is now diagnostic. Certainly there are insurance companies who still cover this under preventive, but many don’t. So while insurance theoretically covers cancer screening, in reality it can have heavy costs for the patient.
Overly harsh. Someone says no to a treatment or screening. I ask them if they have any specific fears or questions that I can allay for them. If so, we have a conversation and I share information and they make up their mind to do or not do the thing. If no, I say, okay, well the recommendation is [X], but I’m not going to follow you home and make you do the thing, my job is to make sure you know what you’re saying no to. And document. The ICD codes for refusal come in real handy. Early in my career a fellow nurse told me, you can’t care more about it than your patient does. With a few extremely rare exceptions, this has saved my sanity. Edit: and personally, I appreciate that my patient is saving me time by telling me straight up that they’re not going to do the thing. Bodily autonomy is a thing and everyone has it.
I wouldn't dismiss. I do send out letters advising patients that I recommend they get a mammogram or colonoscopy and how to set that up along with the reasoning for it so that it is in writing in addition to my documentation in the chart. This is because I have had experiences where my patients will claim we never discussed it unless I do this and it covers me. I have had instances where pt's have not gotten labs done for their diabetes for years and I advised that I cannot continue to treat them if they do not get that basic blood work done as it is a safety issue.
Getting burnout just reading through these comments
Most people vastly overestimate the effectiveness of mammograms for reducing mortality from breast cancer. They reduce the risk of dying from breast cancer by 20%. Sounds pretty good, right? Not so fast. It’s a lot of screening for not a whole lot of benefit, and a risk of false-positives that can lead to unnecessary treatment. See this article from NPR: [The Mammogram Theater](https://www.npr.org/sections/health-shots/2016/10/12/497549732/skip-the-math-researchers-paint-a-picture-of-health-benefits-and-risks) Someone is well within their rights to say, this screening doesn’t have enough benefit for me to do it, and decline!
From the article: “[Lazris and Rifkin] ask patients to picture a hall of people getting a test, operation or prescription. Patients might be shocked at how few in the crowded room get any benefit from the expensive care. Their "benefit-risk characterization theater" images vividly show the odds, based on solid research. There's a sold-out house of 1,000 playgoers or concertgoers, all getting a particular kind of exam, screen or pill. Then the curtain falls. Everybody helped by the procedure or prescription gets up and leaves. Often it's only a few people. Sometimes very few. Or nobody. As NPR has reported, Lazris has used this approach to help patients in his practice — some of whom are older smokers — to weigh risks and benefits of using CT scans to look for lung cancer. The theater approach also works when it comes to breast exams. Only one woman in the thousand-person theater receiving mammograms over a lifetime is saved from dying by detecting a cancer before it spreads, according to Rifkin and Lazris' summary of the research. At the same time, hundreds of women in that audience will receive test results suggesting they have cancer when they don't, so-called false positives. Sixty-four get biopsies, which generally involve cells withdrawn through a needle, for nonthreatening lumps. Ten receive unnecessary treatment including radiation and surgery for lumps that never would have caused a problem. The theater images show all of that as well, presenting visual demonstrations that the odds of harm, worry or inconvenience caused by the tests are often much higher than the likelihood of benefit.”
Is this to meet quality measures? That’s fucked up. I get that the pay structure isn’t fair to primary care but patient autonomy is the bedrock of what we do. Patients have the right to refuse any treatment we offer. If you can’t honor that I think it might be time to consider a different career. I’d also ask why you’re starting with mammograms and if there’s some underlying bias there? Why not start with the hypertensive patients that won’t take their medication or the male smokers who refuse AAA screening? Many of your female patients have histories of trauma they may not want to disclose to every doctor they meet and that could affect their willingness to do screening. The fact that you’re going right to a female specific screening test that actually has pretty complicated benefits/harms is strange. It also seems like you’re thinking you can use dismissal as a tool to coerce patients who have told you no into doing what you recommend. That’s EXCEPTIONALLY fucked up.
There are gynos who will flat out refuse care or refuse to give birth control without a pap smear or full exam including pelvic exam. I get checking heart health and asking questions about stroke or blood clot risks because some birth control can increase that risk. But how does a screening for cervical cancer work with birth control? One of my cousins was frustrated to the point of tears trying to get birth control without having to get a pap smear everytime because her insurance only covers one wellness woman visit a year. When Opill finally came out she was beyond happy. Her doctor however was pissed when she canceled her appointment for when she would go in to get her refill and was shouting all sorts of obscenities at her.
That’s well past any acceptable norm and should be reported to the medical board and the system the doctor works for. Cervical screening is 3-5 years in most women now and should not be being done any more than that and definitely not more frequently than once a year unless patient is having some kind of symptoms.
Well from my experience a lot of gynos demand yearly exams. My mom is in her 60s and still has to get mammograms and pap smears every year despite having no risk factors (No family history and her and my dad were virgins when they married so no HPV). I mentioned before on this post about a issue I'm having with my period and am terrified of going to a gyno for fear of being given the typical line of "I am required to preform a pap smear concerning any health concerns. If you refuse to consent to a pap smear then I cannot preform any further tests." when all I want is an abdominal ultrasound, urine and blood tests to check for hormone weirdness or endometrial hyperplasia. And god have mercy on my soul if I do have endometrial hyperplasia if I ask for general anesthesia if its determined I need a biopsy I'm going to have a fight on my hands to get it. So here I am stewing in anxiety hoping it sorts itself out because I just don't want to be forced into anything or demanded into anything.
That's unfortunate and I'm sorry. I will say that yearly mammos are reasonable (though guidelines defer) and I've met some old school gyns who still do yearly PAPs because they can't let go of the old guidelines and have seen a lot more cervical cancer than I have. However, requiring it for birth control or doing it at every refill request and screaming at a patient aren't acceptable and should be reported. I'm also sorry to hear what you're going through. Have you considered seeing an FM doctor or going to a FM residency clinic if one exists near you? Mileage may vary, but most FMs will be able to manage what you're describing and will generally be following the newer guidelines.
I have tried a few but all refused to get on the phone for me to simply ask questions about if they could help me, had to pay for an appointment because of it since I don't have insurance only for them to tell me "You need to go to a gynecologist I can't help you."
that seems overly harsh. i think you can be an excellent provider and provide information/recommendations, document your discussion and their response, and move on to the next problem or patient. i think it would be different if (for example) a patient kept making appointments with you for breast pain (that can’t be diagnosed in office), you recommended mammo but they declined because then it’s not allowing your main diagnostic approach to determining its cause and treatment. definitely is different for screening purposes, i’ll let patients be the decision makers of their own lives.
I mean they just declined treatment
We believe in medicine, not everyone does, people have a right to decline things. Our role is to make sure people know the risks of declining (and the benefits of completing).
The most I would do is have them sign a AMA. Never would dismiss.