This is the fifth article in a series of eight articles by Ilene Robeck, M.D. regarding difficult conversations a primary care provider may have when dealing with patients with chronic pain. This series is meant to be a guide for primary care providers facing these situations.
Difficult situation #5: A patient encounters an urgent problem or visits the office without an appointment.
Advice: All patients can have unexpected problems come up, so it is important to review with them, ahead of time, how your practice handles urgent patient calls, and how requests for early visits (before their next scheduled appointment) are handled. True emergencies will need to be dealt with and patients need to know what their options are before they just walk in, go to an Emergency Department, or look for an urgent care setting. It is especially important for this information to be conveyed to the patients you are treating for a chronic pain condition.
It is important to see your patients with chronic pain in a setting that affords you enough time to make an adequate assessment, each time you see them. The patient who comes to the office without an appointment, or requests an urgent appointment, still needs an appropriate assessment. Sometimes that means they have to wait until the next available appointment that is appropriate for their needs. Unscheduled visits or urgent phone calls should NOT be used as a way to increase opiate doses, unless there is an acute emergency, such as a broken bone or other injury that requires reassessment of their prescription pain medication regimen.
When you discuss with the patient the treatment plan you propose for their chronic pain, this should include a review of how your clinic or practice is structured for scheduled and unscheduled visits, when and if there is “call in” time, who in the practice can return calls, your policy about early refills, etc. It is best to explain to patients with chronic pain that they deserve a full visit; unscheduled visits will be taken care of according to their level of need at the time, but will always be followed up with a full scheduled visit.
Some patients will try to use unscheduled visits as a way to increase their opiate dose as they know the provider will be rushed. This is especially true when patients come in repeatedly for unscheduled visits at the end of the day. It is important to look for patterns here and address this issue fully, once such a negative pattern becomes apparent.