American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, July 8, 2015

The hold over

The first thing I saw when I entered that clinic room was a worn and tattered Air Jordan sneaker hanging off of the edge of the examining table. It was the only thing peeking out from under the mound of sheets and blankets that he'd piled on top of him before curling up into a fetal position. He'd purposely turned his body to face the wall; that blanket tucked tightly between his chin and shoulder like some kind of angry spouse determined to prove that this wasn't an “in the mood” kind of evening.

And see, all of this was super awkward-appearing considering we were in a regular clinic room and not on the inpatient service. I hadn't snuck up on him in the wee hours of the morning for some quick post op assessment on rounds. No. This man wasn't in a bed so this was weirdly indulgent and a bit odd, particularly since that short little table was no match for a 6-foot, 4-inch man. I paused with my hand on the door knob the moment I stepped into the room and squinted my eyes, a gesture I knew he couldn't see. Instinctively I began to coach myself to be patient.

Instead of perking up or turning to face the door when I came in with the resident, he didn't flinch. “Good morning, Mr. Ashby,” I said to his back. “My name is Dr. Manning and I'm one of the senior doctors working in the clinic today. I've been putting my head together with your primary doctor and wanted to come by to see you, too.” He didn't move.


Now. I'd already been briefed on the details of his clinical concern. He had some very treatable medical problems that warranted taking medications and keeping appointments. They were the kind of medical problems that could become life threatening over time without specific interventions and lifestyle modifications. But, in addition to missing appointments, he never wanted to talk about any of that.


Mr. Ashby wanted to talk about the fact that his back hurt. He'd been in a fender bender 2 or 3 years before and had complained of back pain ever since. MRI films, orthopedics consults, and visits to physical therapy were arranged for him which never came to much. No acute findings on those magnetic images, not even a slipped disk or so much as a degenerative change. He missed the ortho appointments and PT discharged him after he skipped the first 3 sessions and then cursed out the therapist on the other 1.


See, Mr. Ashby had a fairly clear agenda on each visit. And that was to get some kind of narcotic pain medication. He was pretty much about as uninterested as anyone could get when it came to discussing anything else.

I'd looked through his chart already. I'd spoken to the resident doctor and we truly looked to see if there was any indication for narcotics or high-level pain management. There wasn't. That said, he'd been to several emergency departments and clinics and somehow got narcotics every single time. That is, enough to “hold him over” until he saw the next provider.

This. This is what I'm thinking about this morning. The easy wrong versus the hard right. And “hold over” prescriptions for patients who try your … well … patience? That's one of the world's easiest wrongs.


It starts with the body language. Strange contortions that aren't commensurate with the problem or situation. A lady lying on her back on the floor in the waiting area with her feet up on the wall moaning out loud and saying that this is the only comfortable position. A gentleman crying and pacing the moment you get close to him. And on this day? Mr. Ashby tucked under a pile of blankets that he'd likely dug from 1 of the supply drawers coupled with the very definition of making oneself at home. All of it off putting and usually the first thing that pops the valve on the patience reserve.

Now. I'm sure this reads like a lack of empathy, but I swear I don't mean for it to sound that way. I don't. In these situations, I coach myself to find the indication for, say, hydromorphone or oxycodone. I mean, I really do. And sometimes there is a patient who has truly been misunderstood and who absolutely has been getting their pain undertreated. But then there are the others who've regrettably encountered enough irresponsible or burnt out providers and received such liberal amounts of habit forming medications that now they feel sick without them.


And so. A while ago I made up my mind not to participate in the “hold over.” I made this decision after repeatedly feeling the pain of seeing the patient who'd been held over. Being unable to arrange some follow up with the treat ‘em-and-street ‘em provider they'd seen before and tired of feeling bullied into doing something that didn't make me feel good.

So now? I look at the chart and the patient. Then I make an assessment. If, in my medical opinion, Percocet or Dilaudid or Vicodin or whatever isn't indicated? It's a no. A firm, unwavering no. But in the kindest way.

Here's what that means, though: sticky, prickly encounters sometimes. That's what makes hard rights hard, you know? That feeling like you're rubbing a dog's fur in the wrong direction. Nothing about it is ever smooth. And since it is human nature to not like such a feeling, the most natural thing to do is to avoid it at all costs.


So. A man treating a clinic exam table like a California King bed and who is trying to negotiate with me on how “if I give him something for pain, he'll let me treat his high blood pressure” might wear a lot of folks down. But not me.

No, sir. No, ma’am.

See, it isn't a pride thing with me either. It's just that giving someone things that they don't need, especially medications that have consequences to health, isn't okay. And I'm thankful that I've been at Grady long enough to see how awesome it is when people get providers who are willing to fight for them. Even when it is uncomfortable to do so.

So yeah. I guess this is just a way to fight for the patient. Though I doubt Mr. Ashby saw it that way.

He told me to go to hell and walked out of the room without even being discharged. His blood pressure was too high and his cholesterol was, too. The cigarettes in his front shirt pocket rattled as he pointed at us and called us names. Mean names. And all of that happened after he'd been lying like Eeyore on that table barely moving.

I'd asked him to sit up and he said he couldn't. I told him I thought that he could and that I couldn't talk to him that way. So when he finally was upright, he pulled the covers over his shoulders and hunched down like Yoda. And yeah, I'm sorry for all of the comparisons but I need you to see what I was seeing. So amidst all of his psychomotor hypo-activity somewhere in there a light switched on to “Now I'm going to try to scare you” mode. I cracked the door open and positioned myself in front of my resident.


And he yelled and cussed and paced all around. Calling Grady names and me names and all sorts of things. And yes, I listen to my spirit and respond when my fight or flight instinct button gets pushed but most of these times, the ones like this one, it doesn't. I wasn't afraid. Instead I was just sad. For my patient.

He wasn't going to wear me down into a hold over. And I know for certain that this was exactly the way it had happened before.

“I really want to take good care of you, Mr. Ashby. These medications aren't good for you. I can't prescribe you Percocet, sir. But please, let's talk about another way we can address your pain, okay? I think we can come up with something. It won't work exactly like Percocet but you'll start to feel better when your body isn't used to Percocet.”

“None of that shit works! Can't you understand? NONE OF THAT SHIT TOUCHES ME!”

“I understand, sir. And part of the problem is that you've been getting Percocet. We have to get you off of it. Away from it. It's habit forming.”

“Not for me it ain't. It ain't! I need something that WORK. Can I at least get like a 7-day supply until I see my doctor?”

And that's where it happens. The hold over. The chart told it all. Nearly 17 encounters in the last 4 months. Most ending in just that. A few more. To hold him over.

“We won't be prescribing you any form of narcotic pain medication today. We won't administer it here and we can't give you a prescription for it. Do you want to talk about some other options we've thought of?”

And that was the end of it. Him telling us to go to hell. Which is a much nicer way of describing what he really said which involved an F-bomb and a recommendation that I do just that to myself.


But you know what? I looked myself in the mirror that afternoon and felt fine with my decision. I did and do think of him but not in the way I think of those I've done wrong. I hope in my heart he someday realizes that we were trying to care and do right by him. So that's what I think about. Just as much, I think of those other providers he'll see and hope that he doesn't push them into easy wrongs that will hurt his body more.

My job is hard sometimes. It is. Loving people and trying to do right by them is tough, but especially so if it isn't something a person is used to experiencing.


Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

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Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

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Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

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Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

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Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
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American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

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One of the most popular anonymous blogs written by an emergency room physician.

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