Patient-Clinic Policy Form: Fill & Download for Free

Ok, here’s what happened: in the early 1990’s, when I began my clinical rotations, opioids were generally reserved for fractures, post-surgical pain, and cancer pain. Around that time, two things occurred: there was a movement to address undertreatment of pain by patient advocate groups, later sponsored largely by companies that provided newer opioid analgesics - specifically Purdue Pharmaceuticals w/oxycontin; and the Press-Ganey patient satisfaction surveys were introduced as a way for hospitals to be responsive to patient concerns and complaints. Patients, at least in the ED, who were hell bent on scoring opioids had only to fill out a negative PG survey to hurt a doctor who wasn’t taking their pain seriously - valid in some cases, but in other cases, a form of revenge that actually impacted careers and income for doctors.In my residency, which lasted from 1995–1999, we were told to take the patient’s complaint of pain at face value. Even today, texts state that self-report, using a visual analog scale, is the most reliable indicator of pain. So doctors, most of whom practice in good faith, tend to treat reported pain. Still, I know from personal experience that it is an uncomfortable situation for a patient to be in - I would probably have to be near death from pain before I would ask for a pain med, since I am afraid to be labeled as a “drug seeker.” That is a result of my experience personally as a physician and from listening to colleagues - it is a real song and dance between doctor and patient when it comes to prescribing pain meds. Who leads? Who follows? Etc.And there’s this: the increasing shift in medicine from a profession to a profit center for a few corporations led to cuts in staff and time pressures that shred the ability of doctors to fully evaluate and counsel patients on their pain. My ED implemented an annoying system, after getting rid of things like our stat lab and ED pharmacy - they put a red blinker on the computer to alert us when a patient had been in the waiting room—something we had no control over—for longer than 30 minutes. The message: move them in and out. Fast.Purdue Pharmaceutical should get a lot of the blame for the current crisis, as they almost single-handedly brought about this revolution in prescribing opioids for chronic non-cancer pain. They addressed the earlier fear that patients would get addicted by quoting (with the suggestion that they were quoting an actual RCT) a letter to the editor of a journal, which stated that a small sample of patients treated for pain with opioids in the author’s practice had not become addicted, therefore patients treated for pain with opioids could not become addicted. In other words, Purdue promoted anecdote as evidence and they managed, through intensive marketing, to convince the world of something that simply wasn’t true. Keep in mind, one of the three Sackler brothers who owned Purdue Pharma was an advertising genius, who had achieved a significant accomplishment a couple of decades earlier: he managed to make Valium the first “blockbuster” drug by marketing it as a benign aid to mitigate the stress of modern life, particularly for housewives.Purdue then proceeded to hire a bunch of doctors to speak to their colleagues, convincing them to try Oxycontin as a solution to troublesome patients with chronic pain. They managed to use these doctors to promote their non-evidence. Those troublesome patients, in many cases, became addicted. Some of those patients had real pain. Others had existential pain. Have you ever tried opioids? They tend to smooth out the rough edges of the moment. That might seem helpful, until you realize that a tolerance develops rapidly and dependence means eventual withdrawal.Purdue also shipped massive quantities - dumped them, really - of oxycontin into warehouses that distributed massive quantities into communities throughout the US, even after the DEA and their own executives pointed out red flags. Pill mills sprouted up all over the landscape. People spent all of their time moving from clinic to clinic, pharmacy to pharmacy - obtaining massive amounts of opioids with relative ease - and becoming, often fatally, dependent.When communities started to realize what was happening, it still took several years before they were able to shut it down - and then the drug supply dried up in terms of “legal” prescription drugs. But people were still addicted. And the Mexican cartels moved in, supplying heroin through a decentralized supply network that was efficient and profitable. And our government really failed to punish corporate malfeasance - the living Sacklers of Purdue Pharma are comfortable in their Stamford mansions, after paying trivial fines on their billion dollar drug dealing spree.There’s also this: the recovery industry is largely geared towards 12-step programs that can be cheaply run for maximum reimbursement but have less efficacy than medication assisted treatment for addicts and even alcoholics. This is the industry that fails to offer heroin addicts opioid maintenance therapy on discharge from a largely useless and overpriced stay in a residential treatment center, resulting in many unnecessary deaths, at the cost of broken families, relationships, and lives.Abstinence only programs like AA or NA “frown on” opioid maintenance therapy, yet it is the gold standard for treatment and, in terms of cost, it is much, much lower than the cost of ineffective residential treatment by untrained, non-medical personnel. I personally think these centers should be sued by families who lose their loved ones to overdose, particularly those many cases that occur shortly after discharge. Most of these centers do not provide outcome studies, something that is unacceptable in any other field of medicine. Here’s the other part of the abstinence-only paradigm: without it, the drug-testing industry, worth billions annually, would go bust.This is a societal problem—a problem of profit over people, a problem of easy money and a scheme in which too many beneficiaries can buy a place at the policy table. The recovery industry was largely behind passage of mental health parity. Ask yourself why there are more treatment facilities than mental health facilities in this country and, while you are at it, ask yourself why we spend trillions to reimburse the 17,000 plus facilities in this country while the problem gets worse and has actually lowered life expectancy in the US for the second year in a row.

We don’t. We have a system that is free at the point of delivery but is paid for through taxation. It is basically the same concept as insurance, except that no one can opt out of paying into the fund. Essentially it is compulsory medical insurance with a single provider.This does the same as any other form of insurance, it spreads the cost between every taxpayer just as insurance spreads the cost between every insured person.This means that you don’t shop around for policies, and the pool of contributors to pay for the system is very large, which can drive down costs. It also means hospitals, clinics and other health services don’t need any staffing or depts to deal with billing and liaison with insurance providers which saves on overheads, and as there are no insurance companies with their own running costs between the patient and the hospital this reduces costs further.There are other factors that affect the costs but these are the ones that most people understand.

Think about the problem. EMR likely can be there with physician notes from about 2005 when these began to be used .Problem: The emails sent back and forth between providers may provide useful data but may or may not be saved.Imaging both the dictated physician reports and the copy of the actual image may be electronic and may be related and may be together.But: Records that were from outside the system may have been in analog or old school images and paper documents not yet put into electronic form.Paper letters between providers may exist but be separate from the electronic medical records.Ancient records recorded in paper in hand writing are often illegible and messed up.Paper and hand written records were the norm till about 2003–2005Old records greater than 20 years may simply no longer exist because of different hospital policies or clinic policies. Fires do destroy buildings and records.Even today the details of interdepartmental notes say for requesting a consult date time of calls to the patient back and forth may or ay not exist.These records may be needed in a legal case to prove say that a consult was called in to a patient at this date , but the patient may have never received it or refused to comply or simply ignored it. And how many attempts were made to recontact the patient. These records may exist in some other local computer or not.So “medical records” do not show everything. They are mainly for the use of providers to communicate medically useful data. They rarely are so detailed as to include some medical or legal information that lawyers may need to use to confirm some legal question. But they may…..