EP 12: Boundaries & Difficult Cases— Where Ethics, Emotion, and Practice Collide

What actions should clinicians take to maintain the delicate balance between patient comfort and provider safety? In this episode, our hosts discuss how to navigate sensitive exams, set boundaries within complex patient interactions, and protect yourself against potential litigation. You'll learn how to sharpen your instincts during difficult moments, advocate for your needs, and create an emotional forcefield to prevent burnout. 

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Transcript

Voiceover 0:01

Welcome to NP Launchpad, presented by Fitzgerald Health Education Associates, the podcast created for newly graduated nurse practitioners navigating the transition from school to clinical practice. Hosts Jason Gleason, Christopher Gleason, and Vanessa Pomarico-Denino deliver real talk, real experiences, and practical guidance to help you succeed from day one. So if you're ready, let's jump right in.

Vanessa Pomarico 0:32

Hi everyone, and welcome to NP Launchpad. Tonight we're going to talk about risk, boundaries, and difficult cases. My name is Dr. Vanessa Pomarico, and I'm so delighted to be with my co-host tonight, Dr. Jason Gleason, and soon to be Dr. Christopher Gleason. Hi guys.

Christopher Gleason 0:49

Hi, thank you.

Vanessa Pomarico 0:52

Nice to see you. Good to see you as well, Vanessa. How was your day? Thank you. My day was great. How about you?

Jason Gleason 0:58

Outstanding. Outstanding.

Vanessa Pomarico 1:00

Awesome. All right. So as a reminder to all of our listeners and our viewers, please remember to send your questions to nplaunchpad @fhea.com. That's nplaunchpad @fhea.com. And we might answer one of your questions on air. And I want to just make a quick disclaimer that these podcasts are really for education only. We're rarely we're really here as your friends and as your colleagues. So make sure that you're always verifying what your local uh state rules are applying to whatever topic it is that we're addressing today. So tonight, again, we're going to talk about boundaries that protect you, chaperones, documentation, and policy. So chaperones, you know, chaperones are a big thing. A few years ago, it was right around the time about the pandemic when uh the American Hospital Association made it a law that you had to have a chaperone in the room for sensitive exams. Um how how are how do you guys handle it, Christopher? How how is it what are what do you do at the VA that um regarding chaperones?

Christopher Gleason 2:04

So um so if I need to have a chaperone for for my visits, what I will do is I'll go out and get my LPN. They accompany me. Um my LPN happens to be a female, which works really well for me. But but you need to remember too, you can use you know medical assistance for your chaperones, your RN's on team for your chaperones, things of that nature. So what about you, Jason? What do you do?

Jason Gleason 2:23

You know, I I use chaperones obviously with any G U, G Y N exams, anything like that. On a male or a female, you know, either one, I always bring a chaperone in. You just want to protect yourself at all times. Plus, it makes the patient feel more comfortable, and that's paramount to me. I mean, yes, I want to protect myself, but their comfort level emotionally, physically, it's so important. It's so important that has to be paramount. But here's another time I use a chaperone. Whenever I have like a new patient, maybe they have a lot of mental health issues, maybe they have a use disorder. Something there, I bring my LPN that I work with or RN that I work with uh with me. And thankfully I've done that because in the in in hindsight, it's like thank goodness that they were there, because you might have a patient that just goes off on you, you know, and thank goodness you had a witness to witness the actual conversation of what happened. So yeah, so trust your dad on chaperones, and always during G-O-G-Y-N and then otherwise as needed, I would say.

Christopher Gleason 3:16

And one of the key things to remember too is when you have a chaperone, um, document that. Document, say, hey, you know, I was um was accompanied by whoever. But document it in your chart, because that is key, especially if you know, for litigation reasons, if it happened, God forbid it happens, but you have it documented and it says, Hey, I had this person accompanying me, and this person can definitely verify that you know nothing happened during that visit.

Jason Gleason 3:40

And this is key to that too. I would say not just the LPN or the RN came with me, but their specific name in the record, because some of this stuff doesn't come up maybe five years you know into the future. And you know, uh nurses go on to different jobs and you may have a hard time tracking that person down or couldn't even remember who that chaperone was. And if something happens, it's so important that that be accurately documented. So I would even document the name of the chaperone in the medical record so you're covered there. Yeah. Absolutely.

Vanessa Pomarico 4:07

So we actually have dot phrases that are mandatory when we have a chaperone. Oh no, and it it's a system wide, we all adopted the same dot phrase and it's automatically in there and it says chaperone, yes or no. And when you click on the yes, then you have to put in there, because it's a hard stop, your chaperone's name and their title.

Christopher Gleason 4:27

Yeah, I love it. I love it. I love that. That's awesome.

Vanessa Pomarico 4:31

Yeah. So let me ask you a question. If your patient declines, I and I we have signs in our exam rooms. I don't know if you have it, but we have signs in there and it says, you know, the reasons why that and we have it in different languages as well, so the patients know it's front and center right there. And before I start the sensitive exam, I usually will pick up the phone or go out in the hallway and grab, you know, one of the medical assistants who's free. And I'll always say to the patient, I have to just go get the chaperone. What do you guys do if the sh if your patient says, I don't want anybody in the room?

Jason Gleason 5:02

That's a tough one. You have to be sensitive to to what they're telling you, but I would not do any procedure exam without that. No, I don't know. And you also have to have your boundaries, right? Absolutely. Exactly. And I think it's a tough one though, because sometimes people they don't want somebody there because maybe they're embarrassed or you know, I mean, I don't think they just don't want somebody there just uh for no reason, right? There's a reason behind that. But it it's a tough one. Ultimately you gotta protect yourself.

Christopher Gleason 5:27

Yeah, absolutely. And I agree wholeheartedly, you have to protect yourself. And and if at that moment, you know, your patient is telling you, you know, I really don't feel comfortable with another person in here, then maybe it's a time to look at, you know, like Jason said, not doing the exam at that moment or having that frank discussion with your patient too. Well, I understand, you know, you're you're sensitive to this topic, what have you. I really need to have a chaperone in this, and even bringing up the guidelines uh V that you talked about earlier, the hospital guidelines, saying, you know, I really have to have a chaperone in here when I'm doing this exam on you. Yeah, and be super empathetic. Absolutely, absolutely.

Vanessa Pomarico 6:00

Absolutely. You know, and I always say it's a requirement. I I had a patient not too long ago. Uh, an older woman came in, happened to find a breast mass when she was taking a shower, and I said, I have to go get the chaperone, and she said, Why do you need to do that? And I pointed to the wall and I said, It's a requirement whenever we do a sensitive exam. I said, It's not only for my protection, but for your protection. And she said, But I've been your patient for so long. I trust you. And I said, It has nothing to do with trust. It has to do with the fact that it is a a rule, and I could, you know, get into trouble if I don't do this. So I called my medical assistant in who knows the patient. And she said to the pay, the patient said to her, Are you gonna turn around and put your back to just this guy? And I said, that kind of defeats the whole purpose with having someone here. Yeah. You know, so she wasn't happy about it. I said, Listen, I understand you're really upset about this mask, but I cannot do the exam if you don't allow my medical assistant to be in here. So uh and and then I just if the patient declines, I don't do the sensitive exam and I document patient refuse to have chaperone in the room. And that's all there is to it.

Christopher Gleason 7:06

Yeah. And that's documentation is key.

Vanessa Pomarico 7:10

The documentation is key because, like you said, five years from now, because the two of you are spoiled because you have nurses, um, you know, five years from now, if God forbid you get called into court, you need to have that name in the chart, and it's got to be documented because you're not gonna remember who was in the room with you.

Christopher Gleason 7:27

No.

Vanessa Pomarico 7:27

And that's a legal liability if you don't document the name and their title.

Christopher Gleason 7:32

Yeah, absolutely. Absolutely.

Vanessa Pomarico 7:33

Yeah. So how about boundaries? You know, I I have a an interesting story about boundaries. Um I don't carry my cell phone with me generally when I go into the exam room, uh, mainly because I don't really need it. Um, but I actually, when I was doing student health at the local university where I was teaching, the gynecologist who was there before me was actually fired because he was using his phone while he was doing an exam on a patient. Wow. And the phone, you know, on his shoulder.

Jason Gleason 8:03

You've got to be kidding me. Wow.

Vanessa Pomarico 8:04

I'm not kidding. I'm not kidding. And I remember when um the the dean had actually called, he actually called my husband because my husband was working at the school at the time, and he said, Your wife's a gynecologist, right? And he said, We need to find somebody. Is she available to come in two days a week? And I was the first nurse practitioner to work in the student health center, and I thought, why do they need somebody so quickly? And when I went in, and I had met him before, so when I went in for the formality of it, and I said, Do you mind if I ask you, like, what's the hurry here? And he said, We had to fire the gynecologist. He was on the phone while he was doing a pelvic exam, and the and the student complained, and he said, It's completely against our rules here. But how do you feel? Like, you know, I used to work with a doc that he would keep his cell phone on his waist at all times, and his wife would call, you know, a thousand times a day, and he would be in the middle of an exam and he'd say to the patient, wait a minute, and he'd pick up the phone and you could hear him talking, having personal conversations. What are your feelings about that?

Jason Gleason 9:00

Oh, I I don't bring my cell phone in the room. The one thing that drives me bananas, though, because I'm not going to take my watch off all the time, but you know, our smart watches. Yeah. And it'll buzz, even if it's on silent, it'll buzz and buzz. But here's something for our audience out there that's listening. Even when it's buzzing, I don't look at my wrist because you want to stay tuned in the patients will pick up on that. And what they'll think is, oh, you don't have time for me. They don't know that it's buzzing, right? Absolutely. They'll think, oh, right. You're behind schedule, you don't have time for me. Never ever look at your watch if you get a little notification. But yeah, I I never bring my cell phone in the room. Do you, Chris?

Christopher Gleason 9:33

No. Absolutely not.

Jason Gleason 9:34

Absolutely not.

Christopher Gleason 9:35

Yeah. And you know, can you ever?

Vanessa Pomarico 9:38

Go ahead, Chris.

Christopher Gleason 9:39

Uh, touching on what you're talking about earlier with boundaries, one of the things with boundaries is to look at too is social media. Oh.

Jason Gleason 9:44

Love me, social.

Christopher Gleason 9:46

Social media, yes. Because your your patients will find you on social media, trust me. They do. It happens. They do. Um, but they'll not only find you, but they will ask you medical questions and they or they'll find you, it'll be walking in the supermarket and they will come up and approach you and say, hey, I'm having, you know, I've got this rash. Would you want to look at it now? No, I really don't want to look at it.

Jason Gleason 10:05

And then they drop their pants right in front of you. Pretty much or line. I didn't want to see that.

Christopher Gleason 10:11

Please make an appointment. But on social media, I mean, I've and I've had it happen to me where patients have had uh sent me messages, you know, well, hey, could you refill this for me? Or hey, I have this and this these and these symptoms. You know, what do you recommend? And it's like, you really need to make an appointment. And that's a really hard boundary you should draw with your patients.

Jason Gleason 10:29

It's so hard, especially when they're nice, like the nice older person, you know, that they're pretty benign, that they never like to have anything deviously devious plans for you or anything like that that you're worried about. But across the board, you have to set rules for yourself and boundaries. You know, I I've had a number of patients that search me out, and exactly like Chris said, you know, can you get me this or order this test, or their family member starts messaging you? But here's the key when you respond to these messages, because number one, don't respond at all. That's probably the best option. But if you respond to somebody, you would think, well, I'm just gonna let them know it's inappropriate, don't reach out to me on this platform like Facebook or Instagram or whatever. But even if you reply to them, Instagram and Facebook are not hyper protected, right? So even if you reply to them, you cannot, and you should absolutely never ever say, I'm your nurse practitioner, I'm your provider. You can't refer to anything in healthcare. A good way to say something to a patient if you're gonna reply to them on one of these platforms is say, you know, in my role in my professional role, I cannot interact with you on this platform. And that's just leave it at that. Simple. Because if you say that you're their provider or that you're their nurse practitioner, that leaves an opening for something to happen. They can actually go back legally and you know, you can lose your license, all that kind of stuff. So yeah, the best thing I would say is not to respond at all and maybe call them when you get to the office the next day or instant message them over secure messaging. But how about you, Vanessa? You got some stories.

Vanessa Pomarico 11:58

I have a lot of stories, but um I have to tell you, I don't even respond because once you respond, you're engaging. So I don't even respond. I've had patients that like would blow up my social media by sending me messages, especially on the weekend. Why are you not answering me? I sent this to you two hours ago and I'd get three, four, five, six messages, and I don't answer. And I don't even call them when I go into the office on the on Monday or whatever day it is, because if it's that bad, they can call on call provider or they can call my office when we first open, when we open up the following week. But I've actually had patients that were angry and they said, You didn't accept my friend requests. And I always say to them, I really appreciate the fact that you know you want to be friends with me. But to be honest with you, I am available to my patients 40 hours a week. I'm on call X number of hours. I said, you know, social media is the only place that I need to keep private. And I hope you understand that.

Christopher Gleason 12:55

Yeah.

Vanessa Pomarico 12:55

And for the vast majority of patients, they're okay with it. But I would advise anybody who's listening or watching, don't even respond. Because as soon as you respond, you're opening that door even just a little bit for them to kind of sneak in and just tell them, you know, again, my personal and professional life are completely separate. And we also have a um a policy in our health system that you cannot have patients on your social media.

Christopher Gleason 13:23

They actually that's a good policy.

Vanessa Pomarico 13:25

They actually it is a great policy. And when I first joined the practice, one of the first things our practice manager said to me was, I'm gonna friend you on Facebook. And I said, Go right ahead, I have nothing to hide. Um, and she said, We have, you know, we have this rule here. And I said, Great, because this weekend I had this person, this person, and this person. And she would then call them to say, you know, it's not appropriate for you to um contact Vanessa via social media. You always need to utilize the office. And may I remind you, we have we have somebody on call 24-7. So and that usually shuts them down. I think patients are probably a little bit more uh uh used to it now than when social media first came out. I think they thought, oh yeah, you know, I can I'll have 24-7 access to Vanessa. Right. Well, not gonna happen.

Jason Gleason 14:10

Right. Yeah. And on the patient, on the patient side, I can see where the again nobody does things on purpose to drive us bananas, right? But I can see where they would think it'd be easier because honestly, communicating in healthcare sucks. I'll be quite frank. Frank, when I call my provider, I get put on hold, I get transferred, I can never talk to a human. I leave a message that says, Oh, I'll call you back in 24 to 48 hours. That never happens, it's usually 72 hours or a week. It's because our healthcare system is just overrun, right? And we don't have enough resources. So I get it why they'd be tempted to reach out on social media. But yeah, like Vanessa said, don't even respond. That's your best option. And if you do, do not give any clues or hints at all whatsoever that you're their provider. You can't do that. Yeah. Yeah.

Vanessa Pomarico 14:55

So some of the other things you know that I always think about too is when we have to document, you know, now that we have the patients have the ability to see every single thing we write, we have to be so careful, right? We have to make sure that we're writing facts and not saying, this patient is such a bitch. You know, we can't write, you know, you can't. I'm sorry.

Jason Gleason 15:19

Or you can write it, but make sure you delete it.

Vanessa Pomarico 15:22

Right. So we can't really write feelings. I mean, I don't know about the two of you, but there have been times when I've had pain patients that have gotten angry and they've been inappropriate in how they've they've kind of, you know, things that they've said to me. And I've actually put in my plan, you know, patient was requesting X, Y, and Z, uh discussed with patient the rationale as to why that wasn't the appropriate medication. Patient was um uh not not entirely happy with this decision or or you know, some some wording like that. Um but how do you what do you do when it comes to things like that?

Jason Gleason 15:59

Well, what I do, I use AI actually. What I do on my notes, because what I'll do is not just for charting in the chart, but um because you do have those times where a patient, you know they're gonna read because it's the same patient when you prescribe a medication, they look at the package insert of the medication and read every stinking word, and it takes them three days, right? So they read every detail, they read into things that aren't even there, right? So we all all have those patients, and you will out there too if you're listening to this. But what I'll do is without any personal identifying information, that is key because even though AI in some of our office buildings and softwares and and uh electronic health records is secure, just to go an extra step, do not put any patient identifiable information when you copy your note and paste it into AI and say, AI, make this nice. You know, or even write. I have a patient that's very sensitive. Can you please word this the correct way where they won't be set off by this? And I'll do that. And it comes up with amazing, amazing things I wouldn't even have thought of. But you have to be super careful because you never want to put personal identifiable information in there, obviously. But absolutely that's what I usually do. Yeah. Or if I'm writing a letter to my boss, make it nice. AI works, right? Yeah.

Christopher Gleason 17:12

How about you, Christopher? So for my documentation, I am a little bit more, a little bit more blunt, I guess. So what I will put it, I won't, you know, obviously call my uh my patient a bitch or anything of the of that nature. You're such an asshole, Christopher. Yeah, exactly. Oh my god. But I will say, you know, I I had um provider had frank discussion with patient regarding XYZ. Patient became irritated or irritable with, you know, with discussion thing and things of that nature. And I don't think that's inappropriate. Because if if anything comes back later on, I want to be able to look back at my note and say, okay, you know, I did have this discussion with this patient, and this patient the conversation became heated. So there was a reason that I that I um did what I did.

Jason Gleason 17:57

You know, I have to say, I have to break in here and say, I think this is the first episode ever for any Fitzgerald podcast that is gonna get an E-rating on the podcast. This is adults only because we said two naughty words. We told you during our first episode. But we did say we're gonna be real with people, right? Yeah. So what healthcare provider at some point in their career did not say a naughty word? Yeah. That's right.

Vanessa Pomarico 18:21

So so while we're talking about, you know, kind of abusive behavior and that kind of thing, I know in a previous podcast we talked about managing angry patients and what to do when they're having unsafe behavior. You know, Chris, what do you do when you have a patient that starts to get really overheated and they start to escalate? What do you do to kind of bring them down a little bit?

Christopher Gleason 18:41

I think it's just really key to make sure that you yourself do not get agitated, and I know that's very, very difficult. Um but that is also it's key because they'll pick up on that agitation and it has the ability to amp them up even more. So just kind of trying to de-escalate the situation as much as possible, you know, using that calm voice, um terms of rein reassurance, things like that, I think that's key. However, if you get to the point where you you feel uncomfortable, and for myself, I if I'm in a patient room, I will always make sure that I have access to an exit. Because you know you you want to make sure that you have access to that exit to that exit. Because if it does get heated, if it does get if something does happen, then you want to be able to leave the room immediately. So I think you know, really it's it is just important to have to be able to kind of calm things down a little bit and de-escalate the situation as much as possible. What do you think, Jason?

Jason Gleason 19:32

I I agree a hundred percent. Your personal safety number one, right? That's paramount. So always have an exit plan. And you should have that in mind before you get into these situations. And most clinics have training on this, so you you are well prepared. But honestly, if I have an escalating issue with a patient, what I'll I'll do, like Christopher said, very calmly, don't escalate yourself, but uh really try to seek first to understand before being understood, right? Like, gosh, I'm so sorry. And and I'm not speaking as your provider here, but as your friend. Tell me why you're so upset today. How can I help you work through this? Because I really care about you. And be genuine and be real about that. I find that that approach is really helpful and it really diffuses the situation. But sometimes, let's say you have a patient on meth that's methed out in your clinic and out of control, there's no reason reasoning with them at all. And that's rare that that happens, but it will happen at some point in all of our careers. In that case, it's like you got to know your security button in the room, push it, you know, have the whole team show up, have the police called, whatever you need. Personal safety is paramount because in some situations you can't control those things, right? The patient's out of their mind, they they're not even thinking right. And in those cases, it's tough. Yeah, personal safety is paramount. How about you, Vanessa?

Vanessa Pomarico 20:41

So I I have an example, because when do I not have an example? Um but I had so I I had a young gentleman very early on in my career, and he was um bipolar and did not want to go on his medications. And in one of his manic episodes, he jumped off of a wall and fractured his ankle.

Christopher Gleason 20:59

Oh, wow. Oh wow.

Vanessa Pomarico 21:00

You know, went to the hospital, he got Percocet, and he said, Perco set, I need and he came to me and he said, I'm gonna be really honest with you. This is what I did. He said, It's the first medication that makes me feel good. And he said, I don't want to go on any of the other medications, I want you to prescribe the Percocet for me. And I said, I really can't do that. I went through the whole thing, and he was he was great until I said, I really cannot give you a narcotic to help with your bipolar disorder. Now, you know our exam room beds, I I have no idea how they must weigh about 500 pounds. I have no idea how much they weigh. This guy, and he was a big guy, flipped that bed over like a piece of paper.

Jason Gleason 21:40

Oh my gosh. Wow.

Vanessa Pomarico 21:41

And the way the room was set up, we ended up not using that room ever again, but the way the room was set up, I was lodged between the sink and the door. Now my staff, my my receptionists were right outside the door, so they heard the whole hearing they heard him escalating, they heard the bed flip over. And call the doc immediately is trying to open the door, and all I can see is his hand because that's how much the door could open. And he's he's trying to talk to the patient, and he kept saying, Vanessa, are you okay? And here I am, like in the corner, and that's when your whole fight or flight thing takes over. Oh, yeah. And you know, we were able to, and I said, No, no, we're okay, we're okay. And I said, you know, we're we're gonna come to an agreement with this. And then I said to the patient, All right, listen, I'll tell you what, I'm gonna give you enough to get you through the next couple of days, but you gotta let me get out of here so I can go get my prescription pad. And that was the only way I could sneak out of the office. And obviously the police were called and I didn't get, but I was, you know, I he could have hurt me. He really could have hurt me. So that so the thing I would say is that if you find somebody that's escalating, and you know, when you talk in that very calm voice, and remember their mind is going, when they start to escalate, their anxiety is making them think 15 steps ahead. When you think you're you're talking slow, you need to speak even more slowly because that's the only way it's gonna kind of de-escalate things, and then just really try to get them to just kind of speak in a calm voice. And again, listen, I'm here to help you, but you need to work with me right now. So let's talk a little bit about this and then get yourself out of the room where you are safety. Like you said, push your safety button, know what your safe words are, call somebody in the room, like I had mentioned in an earlier episode that you know, my buzzword is tell my next patient I'm running a little bit behind. Then my MA knows that means call 911 and get in here.

Jason Gleason 23:33

Nice.

Vanessa Pomarico 23:34

So you have to make sure you have your safety mechanisms in place. So um, all right, so let's move on to patient dismissal and termination. How do we do this safely, but how do we do it ethically as well? And and you know, uh I just had to dismiss a patient this week, and sadly she was a fellow nurse, but she was somebody that I've had multiple conversations with because she never comes in. She cancels if it's raining out, she cancels if it's too hot out, she cancels for no reason at all, she cancels because she overslept. I haven't seen her in two years, and she wants me to continue to prescribe her medication. And so I finally said, we've got to get these letters out, and and sadly we had to, you know, send the letter of termination. Um what is your dismissal process at the VA?

Christopher Gleason 24:23

Yeah, Christopher, go ahead. Um so for for the VA, I mean, we we have the ability to quote unquote fire our patients. It it takes a lot to to do it. It does not be able to do that. And only for the providers, I think, you know, it it's not only a process, it's not nothing that we really want to do. But if you have patients that are non-compliant, like I have patients that are, you know, I prescribe them medications and you know they they don't take them appropriately, they're you know, they're asking for early refills, things like that, or just you know, in general non-compliant with their care, then it comes to a point where you you have to say, you know, I have done as much as I can w for you. Yeah um you're not meeting me halfway. This is this is a partnership. You know, the provider-patient relationship is a partnership and you're not meeting me halfway. So, you know, at this at this point, I feel it it's important that it let you go so that maybe you can find a provider that will work with you and that will you will have that that rapport with.

Jason Gleason 25:17

Yeah, and you you know veterans are a special population because there's a lot of mental health um things that you have to consider, I would say. And some of that is non-compliance, right? And so if we put in we call it a change of provider request. On our side, if we put in a change of provider request, it goes up to like a medical director and they look at the file and the chart and the notes and all that stuff and determine you know what would be best for the patient. But that's pretty rare that we can do that, right? So we we are stuck with those patients that are sometimes really complex to work with. Um so on the other side of that though, our patients they can put in a change of provider requests. Like if they're not getting their opiates, we see this all the time. It's like mom and dad, who or dad and dad, daddy mom, who are you gonna go to? Who's gonna give you the answer you want, right? So we've had patients that have actually gone through like multiple providers in our little pot of five providers, multiple teams, like in a short duration of time, to the point where now there's a policy they can only change once a year, which is nice, right? But but I agree with with every comment that both you and Christopher made, Vanessa. You know, if I do have to uh not terminate a patient, but you know, just do a change of provider for them on my part, you know, being empathetic with them, explaining the reasons why. And what I'll usually do is I'll I'll tell them something like this you know, we have come to the point where it's not therapeutic for you. Like I I don't find that I can help you. And there's probably a provider out there that you can connect better with that has maybe more resources or training or knowledge that is not my niche, so to speak, that could be really helpful to you. So let's get you to somebody that that you would gel with. And that approach is pretty helpful. I think it diffuses a lot of the negativity around it. And I've also had patients that you know you don't gel with and they're afraid to tell you, like, but they they really want to see somebody else or that you think they should see somebody else because you're just not making any headway with them. And just, you know, from a human standpoint, just recognize that those situations happen and and how can we make the best of the situation. But if you do dismiss a patient, absolutely every time you've ha whether you're writing a letter and talking to them about it directly, make sure you cover them for at least 30 days of continuous medical care. Because if you just drop them on day one when you're gonna dismiss them, then that that leaves it open for lawsuits and you know patient issues with medications. So at least continue to provide them with 30 days of care, you know, so they can transition to a different provider.

Vanessa Pomarico 27:41

So one of the things that we actually do in our practice, which is a little bit different than the VA, let's face it, the veterans, you know, they can go in to the VA. It's a little different when you're in a different system. And so what we do is we actually give them, if so, if they do a same-day cancellation or a no-show, they get a letter. If they do a same-day cancellation or a no-show, they get a second letter. And in that letter, it says very nicely, but I'm gonna kind of summarize it, you know, you didn't show up or you had a same-day cancellation. Um, we're giving you notice that if this behavior continues, you will be asked to leave the practice and be reassigned to someone else. We do have a policy in our offices that if let's face it, I'm not everybody's cup of tea, and I get that. Um, and and like you said, you're just not gelling with the patient. They can't switch and go see one of my colleagues within the same practice. And the reason why we do that is because what happens if that person is on a maternity leave or paternity leave or on vacation or out sick, and I'm the only one, now they have to see me. And so we do that as a backup mechanism to say, you can't switch to somebody else within the practice, but you can go to one of our other offices. Um, and so but they get it, everything is in writing, it's all in the patient's medical record, so the patient can see every single letter. And and we send it not only registered, but we send it through the patient portal so that the patient can't say, I never received anything. Well, it's in the patient portal. And we can tell that you read it because it says red.

Jason Gleason 29:10

Red. Absolutely. Absolutely.

Vanessa Pomarico 29:12

Yeah. So, and again, it has all the the the all of the policies in there, and like you said, about giving the 30 days. And I have to tell you, some days I would be counting the days until those 30 days were over just to get some of the really, really difficult patients. I had somebody very recently, she's been my patient for a long time. I've had a lot of tolerance with her, never showed up on time, never. And would always throw me behind. And the last time, I I think I had just reached, and we have talked to her about it. You show up 15 minutes late for a 15-minute appointment, you've missed your visit, you know. And so she showed up 16 minutes late for her physical. I was fully booked for the whole day. I didn't have time to squeeze her in or even run behind. And they said you're, you know, you're we called her at 10 after. We called her and said, Are you on your way? And she said, you know, I worked until 3 o'clock this morning and I'm trying to get there as fast as I can. Well, I can't help it that you worked until 3 o'clock in the morning. Who told you to make an eight o'clock physical? And so, of course, she showed up, I was fully booked, and they said, We're I'm sorry, we're gonna have to reschedule you. And she dropped a litany of swear words, slammed the door so hard that I thought the glass was gonna break, um, and then wrote an incredibly nasty letter, you know, about how horrible I was. Well, I fortunately had it documented every single time that the patient had showed up late. So, you know, when we had when we were dismissing her, there was absolutely you know no discussion there. But we have a mechanism in place too that if I want to dismiss a patient for whatever reason, it actually has to go to a committee. And then the committee will actually look at the patient's, you know, medical record and then they'll they'll ask, you know, the questions. And so we at least have mechanisms in place. So it's not again, I don't want our our people out here watching or listening. Again, we're not gonna gel with every single patient, and it's okay if they want to go see someone else.

Jason Gleason 31:10

It is, absolutely. And don't take it personally. Don't take it personally.

Vanessa Pomarico 31:13

Right, you can't take it personally. Yeah, exactly.

Jason Gleason 31:16

The other time I think we should talk about is when you are leaving a practice. Let's say you got a job somewhere else. You it would be very unprofessional for you to leave a practice and give them two weeks' notice, and here's why. Because you should at least give them, I would say, a month's notice, 30 days, if even not longer, and you gotta look at your contract with them and everything, because it might spill it out in there as well. But but at least 30 days, because here's what you want to do when you leave a practice to go somewhere else, make sure that the practice is sending out a letter to all your patients. And what I do is I would recommend that you proofread the letter that they're gonna send out, ask for it. Because if you just leave a practice and you think, well, administration is gonna take care of sending out letters, sometimes that doesn't happen. But guess who's on the hook if something happens to a patient, you know, and you haven't given that 30-day kind of transition time for them? Yeah, it it can be bad news for you. So make sure that whatever your practice you're in, that they send out that letter, proofread the letter first, and say, Yep, you can mail this out to all my patients, and make sure there's language in there that there's a plan in place to care for them for the next 30 days as they're trying to get set up with another provider. Uh myself, my provider left town. I I didn't get any notice. It's like, oh, that's that's news to me that they left. That's great. You know, so yeah, you'd never want to put your patients in that in that spot.

Vanessa Pomarico 32:31

So you don't want to be sued for abandonment either. No, absolutely.

Jason Gleason 32:34

That's what it is. That's what it would be. That's what it would be.

Christopher Gleason 32:36

So, V, kind of touching back on what you're what we're uh saying about boundaries and in time frames uh with appointments, I think it's really important to have a boundary with patients that if they show up that 10 minute, 15 minutes late, that they need to understand their appointment's going to be rescheduled. Because, you know, at that point, they're not only affecting their care, they're affecting the patient's care that's coming that comes after them. You know, and like you said, if you have, if you're allotted like a half an hour for a physical, and more often than not, those half an hour for physicals take a half an hour, if not more, and you have a patient that shows up ten minutes late, then that, like you said, you know, it puts you behind for the whole day. So I think you know, drawing that boundary line and saying after this cutoff point, you know, whether it be 10 minutes, 15 minutes, what have you, you know, you're gonna have to be reset or you're gonna have to be rescheduled.

Jason Gleason 33:21

Respect the time of your other patients. Yep. Exactly. The other thing to balance that out though is you don't want to be a hard ass, right? I I've had patients that let's say they're 85 years old, they're driving through a blizzard. I mean, every every individual case, you gotta consider that as well. But even then, if they're like 20 minutes late, it's like, well, I can't see right now, I got these other two patients, and if I have time this morning, I'll I'll sure fit in. So you always have to, you know, have some leeway. Don't be a hard ass on things, but but also don't give in all the time because your patient will be trained for that and then they'll show up late all the time and and expect that that that's gonna be the thing you do for them every time. But you know, there's instances where you kind of have to be a little easy on patients, depending on the circumstance. But but I would never Yeah, if I was booked all day though, tight and I had no other openings, there's no way I could fit them in. But if I can fit them in, or if somebody doesn't show up, you know, work with your patient. But that's pretty unusual and pretty rare when that does happen. Yeah.

Vanessa Pomarico 34:15

Right. You have to have that understanding. And again, like you said, you have an elderly patient, you know, maybe it takes them a little bit longer in the parking lot. I totally get that. But when people are chronically late because they don't leave their house on time, and like you said, it's all on how you how you approach it with the patient. And so I'll usually go in the room and sometimes depending on the patient, I'll say, Oh, I didn't think you were gonna come today. And they'll say, Why? And I said, Well, you know, you were you were so late for the appointment. Your appointment was at nine o'clock, you know, you didn't show up until 9.15. Or another time, like if the patient, like this one that was chronically late. And when I tell you, we're talking 10 years of chronic lateness, you know, that I I've been very forgiving of. And one of the last conversations with her, I said, you know, listen, I understand that, you know, you live a little bit farther away, but I'm gonna ask if you could just please try to leave earlier for your appointments, because I have patients of mine that have to get, you know, a babysitter, or they have a family member that they have to get someone else to have to watch them, or maybe they had to leave work and they're using PTO time, or you know, or whatever the the case is. But I'm not just saying and so those are the patients that, you know, they've had to take time out of their day to get here on time. And when you show up late, it's now gonna make them late, and it's not fair to them. There's just some people that cannot get out of their own way, and they're just chronically late.

Christopher Gleason 35:34

Yeah.

Vanessa Pomarico 35:34

You know, and there's just not that that shouldn't impact me and how my other patients have some empathy. Um, but you know, you do have to have some understanding, but also know that you, you know, you have to set some boundaries because otherwise they'll run all over you.

Jason Gleason 35:48

They will be and be friendly with them, you know. Right. Right.

Vanessa Pomarico 35:52

You know, be kind about it because they can't get anywhere.

Jason Gleason 35:55

I get the real story where I where I screwed up big time because we're we're this is about being real with our audience, right, and our friends out there. You know, I did 20 years in the military, and as a young lieutenant, I would have to drive over 150 miles to get my to get to my guard drill once a month. And I remember working as a registered nurse on the floor, working the evening shift because that was the shift I had. That was my job, that was my reality. I didn't have any way to get out of that. So I get off at work at 11 and I'd have to drive all the way 150 miles to my guard unit to be there at 7 a.m. for roll call. And and roll call in the military, as our military folks out there understand, you know, the whole group is there, like 50 people, and they're they're reading off names as they go down, and here I'd be showing up five, ten minutes late. And it was it was a habit of mine. But in my mind, I thought, well, gosh, I just got off at 11 o'clock the night before. I'm exhausted. You know, I'm trying my hardest to be here. And my commander pulled me aside and it changed my entire outlook and my behavior, and I made things work because she told me, she said, you know what, I understand totally where you're coming from and the reason why you're late. You're not purposely on late late, it's life. It gets in the way, right? But to those 50 other people out there that are serving with you, they don't know your circumstance, nor should they care. They don't need they don't need to know that, right? But what they see is that you're coming through that door late. And and it's disrespectful for all of them that have showed up on time. And I thought, wow. And I have to put a disclaimer in here that I was a very, very young lieutenant. I I didn't ever do that for like years afterwards, but it's a lesson learned, right? And so I use that same of my approach to my patients, like you said, Vanessa, and explain to them, I'd love to get you in, but here's the deal. And just be real with them and be their friend. You know, it's disrespectful to them. And I know you have good reasons to be late and everything, but we need to change something here because it's not working. Yeah, right. So just be real with them. Absolutely. That's my lesson learned. Don't hate it.

Vanessa Pomarico 37:44

Thank you for sharing that.

Jason Gleason 37:45

And I and I've been on time ever since.

Vanessa Pomarico 37:47

Very good. I'm happy to hear that. Because you know, you know me, I I'm always I'm I'm early. I hate to be that late one because just for that reason, it's that ripple effect. It is. So I just want to talk a little bit about some safety planning and when we need to get like our leadership or security in place. And you know, if there's one thing we talked already about is you know, what is your escalation ladder? You know, who do you go to? You know, who are those supervisors? Is your supervisor even in the office? You know, what are the your emergency services? We touched upon using our panic buttons, making our staff aware of what's happening in a room. Um, I have a patient that's coming in this week, and I've already said to my medical assistant, I'm not to be alone in the room with them. Somebody needs to be in with me and somebody needs to be outside because the patient can be that volatile. Um, so I have that staff awareness. But we I want to talk a little bit about how you document the threats and you know what do you what do you document and how do you document it, you know, kind of clearly and concisely. Do either one of you have any suggestions?

Jason Gleason 38:48

We have we have such a good program at the VA. I would say it's it's really a lead for the rest of the country to follow. Because if we have a patient that is disruptive, that's the term we use. If they're disruptive, we actually have a process for reporting that up. There's a committee that meets, that looks at the entire record, and then depending on the level of disruption, like if they're making a physical threat or if they were just talking loud, right? Or they're just causing damage to a facility or making physical threats, it escalates, right? So some of our patients like that are very disruptive where safety is a big issue, they have to actually go to our headquarters VA in Montana, which may be, you know, a hundred miles away from where they're at. But they have to go there for all their visits. It has to be with one of the police officers on the campus that accompanies them to the visit because safety is paramount. But in most cases, you know, they get a little flag on their chart if they're disruptive, and then we know ahead of time, you know, if it's not the extreme case, like they have to have an escort. But like you said, Vanessa, be prepared, know who those patients are. So the VA really does a great job at that, I would say. Yeah, in and being very very responsive to protect staff and to protect the patient.

Vanessa Pomarico 39:53

I I do you do any debriefing after those types of incidents?

Christopher Gleason 39:57

Oh, totally. Yeah. More often than not, it it happens with the clinic manager. But sometimes, like our supervisor will will um kind of contact us and say, hey, what was what happened with this patient? And then you kind of have to do a debrief with them as far as what went on during the visit that that led to the uh the disruptive disruptive report.

Jason Gleason 40:16

And I I I would say one key thing with disruptive patients, because it might be that patient that annoys the crap out of you because they just say insulting things or the derogatory or they're raising their voice all the time. Make sure you document any little thing because if you don't document the little things and then something big happens and it goes to that committee, they're like, Well, this is the first instance that this has happened. We don't have any other documentation, and that's all they can go by when they're doing remedies for these things, like getting an escort or whatever. So make sure, like, if I have a patient that's yelling at me on the other side of the phone, I get it, they had a bad day, whatever. Still report those things. Find out what system you have in place in your clinic and report it up the chain so that it's documented somewhere. And at a minimum, if you don't have a system, make sure it's documented in the chart. Absolutely. Every time though, don't blow it off. Even though it takes time to do, don't blow it off. Because when you need that documentation, it's gonna be very, very useful.

Vanessa Pomarico 41:08

So one of the things I I want to just mention about debriefing, and again, this isn't to scare anybody who's listening or watching, but um, you know, if you ever do, if a patient ever gets physical with you, or even, you know, like the patient that had flipped the table over and kind of pinned me in the room, I remember getting out of the room and thinking, okay, I gotta go see my next patient. And the doc was there and he said, wait a minute, you need to go home. Like you need to just, you've had a really bad incident here. And I was like, nope, I'm fine, I can see my patients, because we get into that fight or flight, and it's it's not good psychologically because I have to tell you, I went through the day, I worked, and then when I came home, I fell apart. And, you know, my husband is a therapist, and I told him what had happened, and he's like, Did anybody debrief you? And I said, No, I was fine, I was fine, but I think the enormity of everything hit me when I got home. Um, and you know, you have to report these things because you know, I've had I've been physically assaulted by patients, and again, that you know, that adrenaline rush comes in and you don't feel anything, but then I ended up with a concussion and I ended up with whiplash, and you know, you don't realize it until after the fact. So you've got to document everything. And like you said, it takes a little bit longer time, but even with the phone calls, if it's the patients escalate in the phone calls, there's a way of of writing it that will have it documented that if you have to go up the chain of command, they will be able to read through the lines to say, okay, that this was more than just a patient being angry. This was a patient who was being abusive. So I would just tell you, make sure that you that you get the help that you need if you are a victim, but also too, that you make sure that your supervisors and anybody up the chain knows what's going on with a patient because it's not appropriate. We are there to provide good, sound health care. We are there for our patients 100, 1,000 percent of the time. And if they're having a bad day, that's one thing, but don't take it out on the provider.

Christopher Gleason 43:07

Absolutely. Absolutely.

Vanessa Pomarico 43:09

All right, so I've got some um in your show notes will be some resources to share online. So there's the Occupational Safety and Health Administration, OSHO Workplace Violence and Health Care, with a great website. Take a look at that. The CDC also has um the National Institute for Occupational Safety and Health Workplace Violence Prevention with some great um suggestions in there. And the Joint Commission Workplace Violence Resources, again, these are all in your show notes. So now we come to the my favorite part of the program is our factor fiction. Are you ready, guys?

Jason Gleason 43:41

We are ready. We're waiting for the conveyor. Yes, waiting for the conveyor.

Vanessa Pomarico 43:45

All right, Christopher, having a chaperone policy can protect both patients and clinicians. Fact or fiction.

Christopher Gleason 43:51

That is absolute fact, and it is key to some patients. Absolutely. Protection.

Vanessa Pomarico 43:57

All right, Jason, firing a patient is Always illegal.

Jason Gleason 44:01

That would be fiction.

Vanessa Pomarico 44:03

That's right. That's right.

Jason Gleason 44:04

Sometimes those are easy questions this time. What the heck?

Vanessa Pomarico 44:08

I wonder who made them up. All right. Christopher, documenting threats or unsafe behavior helps your clinic respond appropriately.

Christopher Gleason 44:18

Absolutely, absolutely. You know, and Lisa, as we touched on earlier, when you have those disruptive patients, you if you need to, you know, quote quote unquote fire the patient or file that disruptive report, that is what's going to be key. That documentation is what's going to be key when you need to file those reports and does it.

Vanessa Pomarico 44:36

And not only that, but if it goes to uh illegal and you press charges, you need to have all of that in there as well.

Christopher Gleason 44:44

Absolutely.

Vanessa Pomarico 44:44

All right, Jason, de-escalation is mostly about having the perfect words, factor fiction.

Jason Gleason 44:50

Fiction.

Vanessa Pomarico 44:51

Absolutely. Absolutely. We never have the perfect words. And you know what? No matter what we say, sometimes our patients are going to twist what we say anyway.

Jason Gleason 45:00

They'll hear what they want to hear. Yeah. Right. Yeah.

Vanessa Pomarico 45:03

All right. So now we're going to do a little bit of an orbit check. We want you to email your questions to npaunchpad at fhea.com. Again, that's npwaunchpad at fhea.com. We do have a couple of questions here. Um so Christopher, what boundary is hardest for you to hold, like late arrivals, opioids, hostile behavior, or the oh, I have one more thing I want to talk to you about.

Christopher Gleason 45:29

I will say it's the one more thing. Yeah. I I am very much the the provider that wants to do, you know, provide the best care for their there for their patient. And oftentimes, you know, my LPN will room, room my patient. They will tell tell her one thing, I will go into the room, and it will be a completely different scenario. And I'm I'm heading for the door, my my hand is on that handle, and then you hear the inevitable, oh, one more thing. One more thing. Inside, a little bit of you dies. No, I'm just kidding. That's right. That's right. You know your lunch has died. Your lunch break has died, that's for sure, right? Exactly. But yeah, I think that would be my hardest.

Vanessa Pomarico 46:12

All right, Jason, when should you involve leadership or security and how do you document it clearly?

Jason Gleason 46:17

Oh, I would say most clinics, you know, if if they're a good clinic and you have good leadership there involved from day one when you start employment there, right? And they make you very aware of the policies, they give you the support you need and the training if that's required as well. So from day one, and then how do you document it clearly? I would say by consistency, right? Even those subtle things that that are a little disruptive, make sure you document all of that because you know you may need it down the road somewhere. You need to get that trail of information. So consistency.

Vanessa Pomarico 46:46

So true. Yeah. Yeah. You know, I know that this this episode might be a little bit depressing. We're God. But but so so I want to just share with all of you that we do appreciate what our listeners are doing for us. And so we want to share some special savings with you. Uh, if you go to the FHEA.com website and you use the code LAUNCHPAD20, you will get 20% off all of our continuing ed library and memberships as our way of thanking you for supporting the show. Um, so I have some uh take-home tips for you before we wrap up. Uh so your three take-home tips know your clinic chaperone and dismissal policies and where to find them quickly. Uh create a short de-escalation and boundary script that you can use verbatim. And if your clinics don't have these things, create them. You might be able to, you know, start something new. You better. Um and also use chaperones, boundaries, and documentation as your seatbelt, not a vibe check. Your safety is of the utmost importance. So your homework this week is to write a difficult patient boundary script that you can read verbatim if needed. So that's your homework for this week. Yeah, isn't that great?

Jason Gleason 47:57

That's really good.

Vanessa Pomarico 47:58

Good. So, one more thing before we close out, if you wouldn't mind, we would ask if you would please drop five stars if you're enjoying our podcast, so we can continue bringing some of these amazing podcasts. Hit follow, tap subscribe, and more importantly, share this podcast with your NP colleagues, your friends, and your family. We would really appreciate that. And make sure you stay in touch, send us your comments, send us your if you have a uh particular content that you want to see on a future podcast, we would be happy and open to that. And you can email all of us at nplaunchpad@fhea.com. So, guys, that's a wrap. I know this was a really heavy podcast, but that's a wrap for tonight. You are amazing, and I'm always so glad to work with all of you. So until next time, everybody, thanks for joining.

Christopher Gleason 48:47

And we will be available to prescribe your prozac after the show. That's right. Give me my prozac. I want to double dose. Maybe some cyprexa while we're at it.

Jason Gleason 48:54

Oh my gosh, what an episode. Come back, please.

Christopher Gleason 48:59

Thank you all.

Jason Gleason 49:00

See you later, everyone. Take care.

Christopher Gleason 49:06

You've been listening to NP Launchpad, presented by Fitzgerald Health Education Associates. Like, subscribe, and share. And for more tools to power your NP career, visit FHEA.com.