According to the daughter, her mother had experienced severe pain in February and was sent to the general practitioner’s hospital for an injection. My doctor’s name and number had been misplaced. The mother got an injection from a pain doctor at the hospital, but there was only relief for seventy-two hours. The doctor (s) at the hospital recommended the woman take pain medicine and temporarily move to an assisted living complex so she could have rehabilitative therapy.

The daughter was calm and in control, but it was clear she was not pleased with her mother’s care in the A.L. facility. The mother, according to the daughter, was on her way to a hospital across the street from our office. She was diagnosed as depressed at her A.L.F. and was going to be admitted through the emergency room for a psychiatric work up. The daughter knew, felt in her heart, that if my doctor was able to give her mother an injection, the mother would feel much better. As the daughter said to me, “if you were in severe pain for almost three weeks straight, wouldn’t you be depressed too?”

We happened to have a cancellation for 11:30 this morning. The daughter said that she would tell the driver to bring her mother to our office before transporting her across the street to the hospital. The daughter hung up from me so she could call the A.L.F. and tell them to drop her mother off at our office before sending her to the hospital. The daughter felt that once the mother came into our office, the mother would feel much better because she would know that help was on the way for her pain.

We received a call from the ambulance company at about 11 a.m. stating that they would be late transporting the patient to her 11:30 appointment time. Would we still be able to see her? I told my coworker, who took the call, to tell them that we could see the patient if she was later than 11:30. I could juggle the schedule around a little to accommodate this woman. She would be arriving on a hospital bed, and I didn’t want her to wait in the reception area for too long and be made to feel that she was on display.

The schedule did a bit of a flip-flop, and we ended up having a cancellation at 12:30 as well. The ambulance company called again. My coworker took the call because I was on the phone with a case manager from the A.L.F. wanting to know what we were going to do to eliminate the patient’s pain. She also stated that she was very sorry that the drivers were running late, but they weren’t scheduled to pick our patient up and transport her anywhere. “Not even the hospital?” I asked. “Oh no. The patient and the patient’s daughter do not want her to go to the ER.” I transferred her to my doctor so she could get the scoop first hand. “Jen, the driver is running late. They won’t be here until around 12:30 or maybe later.” I looked at the clock. It was just around noon. I knew the doctor was going to want to spend a good 15 minutes talking to the patient before having her wheeled back to the treatment room. “She can still come, but tell them if they are much past 12:30, we will have to reschedule.”

My doctor came out of his office and said that the case worker at the A.L.F. was passed a note during the phone conversation saying that the ambulance was heading back to the facility. I picked up the line to speak to the case worker. “The ambulance was told to turn around because the doctor was refusing to see the patient. How can that be? I was just talking to the doctor about the procedure he planned to do.”

“We didn’t tell the ambulance to turn around. They called and said that they were going to be later than 12:00 and arrive closer to 12:30. We informed them that if they were later than 12:30, we could have to reschedule. It’s just about eight minutes past noon, so they have plenty of time to get here,” I explained.

“No, I see the ambulance pulling up in front of the building here. They brought her back.”

“We didn’t tell them to turn around, and the doctor would certainly not refuse to see her. That’s not how we operate around here,” I replied.

The doorbell chimed, and I looked up and saw someone I didn’t know, but I assumed it was the patient’s daughter. “Oh wow. You have my mother back there already?” “No. She’s back at her facility. The ambulance turned around before she got here,” I answered. “What?! Who did that? Why did they get sent back? I left the facility the same time the ambulance did and told them I would drive ahead and meet them here at the doctor’s office.

“I don’t understand why they didn’t think they could make it here by 12:30. It takes less than fifteen minutes to get here even driving the speed limit. Below the speed limit,” the daughter ranted. She told me she wasn’t upset with me, and I knew that. I had been working on trying to get our patient seen at the request of the daughter since about five past nine this morning.

The daughter got on the phone and called everyone. She called the powers that be at the facility; she called the ambulance service; she called her mother. I was trying not to overhear her conversations, but she did clearly state to someone, “No. I do not want her voice mail.” My coworker came up to me and asked if there was a problem with the ambulance service. I caught her up to date, and she said, “I told them if they were going to be later than 12:30 they would have to reschedule. Since it was only a couple minutes past twelve, I figured they would get here in time. I don’t know how they translated that to we wouldn’t see the patient.”

The daughter got off the phone and said, “well, the driver has the conversation on tape. Your office said that if they weren’t there by noon, my mother wouldn’t be seen by the doctor.” She then asked when we could see her mother next. We happened to have an opening at eight a.m. the next morning. “I’ll take it. But I am going to call everyone and make sure she is up, dressed, and out the door by seven. I will go over there, too. I will drive behind the ambulance and follow it here to make sure they don’t turn around. We’ll get to this building early, and we will wait outside until it is eight, and then we will come up.”

The daughter had a theory of her own about why the ambulance driver turned around. She thought the facility was so determined to take her mother to the ER of the local hospital to get a psych eval, that any other stop, even if it was directly across the street, would be too much trouble.

I don’t know if that is true. But this I do know. The daughter called us wanting help for her mother’s pain. The daughter set up the appointment with us and coordinated transportation. The daughter picked what she thought to be a very nice assisted living facility where her mother could get therapy and be treated kindly and with respect until the pain in her mother’s back dissipated. The daughter felt she had, in actuality, made  a terrible decision and was doing all the leg work for her mother to get her out of there and back home.

Before leaving our office, the daughter had set up a meeting with the ombudsman of the county department of aging. I gave her directions to that building from our office. It was only about a mile away. I will find out the results of whatever transpired from 12:45 today on tomorrow morning first thing.

Why can’t people just take a few minutes, sit back and relax and listen to what is being said?

The patient gets the MRI or scan done and the results are sent back to the surgeon who either determines surgery is an immediate necessity or could possibly be postponed until less interventional techniques have been exhausted. That’s where my doctor comes in to play. The surgeons are at a loss. The patient who doesn’t need surgery is not a good patient for a surgeon to have. So the orthopedist or neurosurgeon will write a prescription for the patient to find a pain management doctor.

What exactly is a pain management doctor? What does the surgeon tell the patient they are referring about one? I have a few ideas based on the phone calls I get from potential patients.

1. The Pill Pusher~

Doctors have specialties. My own internist specializes in cardiology. My kids’ pediatrician’s specialty is cancer. Orthopedists are bone doctors. These specialty areas do not co-mingle. My doctor is not going to treat my child, and my boys’ pediatrician is not going to set a broken bone. Orthopedists and neurosurgeons do not prescribe medicine. That is not their job. When the patient has surgery, those docs will prescribe for post operative pain only; not pain management. If the patient is still in pain after the 5-7 days of pain meds wear off, oh well. If the patient has more pain, it is believed that telling a patient to seek a pain management doctor to get pain pills is the next logical step.

2. The toss a doc a bone~

These doctors are typically orthopedists who have had, for whatever reason, a back surgery gone wrong. There are so many reasons for this, and I am not here to bad mouth any doctor. There are risks involved with surgery, that’s why patients sign their lives away for everything anymore. But this tossing off a patient to another doctor is sometimes malicious. The surgeon will give the patient’s case to a group of fellows at a teaching hospital. Those docs will run the gamut of everything they can think of to help the patient, and the patient continues to suffer.

The other scenario is competition. In our particular area of Baltimore, there are FIVE pain management groups. One medical conglomerate has everything in one building. There are surgeons, pain management docs, physical therapists, and prothestic departments all working happily side by side. There’s a reason for this, and guess what? It’s not the patient. These doctors are looking out for themselves. If the patient gets better, that’s a bonus, but really it’s about the docs. So…why would a surgeon who has a group of pain management docs down the hall from them send a patient to another pain management group? Malice. The surgeon either hates a pain doctor and wants to send them “damaged goods” that no one can fix or the surgeon wants to save his own ass from the humiliation of his coworkers bagging on him for leaving the patient permanently scarred and/or disfigured.

3. If I can’t cut you open, I can’t vacation in the Mediteranean~

The orthopedic and neurosurgeons are not known for their bedside manner. Patients are seen every 10 minutes. I suppose it doesn’t take long to determine who does and does not need surgery after a while. Most patients are not even touched by the doctor; they are prodded. The surgeon does not use his hands to feel the area that is causing the problem, he uses a prod of some sort. Can you image going to a doctor, being in severe pain and feeling worn down and then having your doctor, the one who is supposed to make you better, poke at you with a rod? How awful would that be?

My feeling is the surgeon wants the “juicy” case. The one that is complex but not overwhelming; the case that is not done everyday. Some patients “pass” the test and others “fail.” The ones that pass get the opportunity to send the surgeon and his family on a very exotic vacation on a private island. If the patient fails, then the doc has already wasted 10 minutes; no sense in taking away any more precious time.

So the patient that fails and the patient that passed the surgical criterion but had only moderate relief (or worse, more pain and symptoms) gets sent for pain management.

As the secretary, I’m the one who typically answers the phone for my doctor’s office. A potential patient will call and say that they have been referred by their orthopedists for pain management. Our office has a wonderful working relationship with many orthopedists and neurosurgeons in the area. I will truthfully say that our offices need each other. The referring relationship can make or break a practice. Our office has been “thrown a couple of bones”, and we will not see any patients that have been referred by that huge network of surgeons. Word gets around and referrals stop. That is the minority of the time. It’s the patient that holds the referral slip for pain management in one hand and the computer mouse looking for doctors that accept their insurance in the other that calls for an appointment but doesn’t know why.

The person who called me today said her doctor referred her for pain management because she wasn’t a candidate for surgery. She called our office because her insurance book said that we participated with her insurance company. That’s not a bad reason to call, actually. It’s good to know that after all the pain, suffering, and anxiety, the patient won’t be stuck with an astronomical bill from our office. She, like so many others that have called before her, wanted to know what pain management was.

I’m really proud of the services my doctor provides. I think our office, as a whole is very warm and nurturing. The interventional pain techniques using steroids can truly eliminate chronic pain. The patient may have flare ups occasionally, but coming into our office for an injection that usually takes less than 10 minutes, is a really good thing for our patients. What my doctor does works. In the few patients where there is little to no relief, the injections pretty much point to surgery as the way to go.

Pain medications have their place. During the shoveling out process of the Blizzard of 2010, many people, myself included, were looking at their watches to see if it was time to take another dose of ibuprofen. Sometimes naproxen is needed to ease the sore and strained joints–the stomach pains associated with that drug are almost always worth it for the pain that gets relieved. That is considered acute pain. Acute pain is sharp and unrelenting and can take your breath away. It can come from slipping and falling hard on the ice, a sudden death sporting event, and breaking a bone. The pain eventually eases and then disappears for good.

Chronic pain does not get better with OTC meds. It doesn’t get better with strong prescriptions. It gets covered up. Masking the pain is not pain management; pain management is trying techniques that actually reduce the pain physically. Primary care doctors don’t usually give their patients correct information when referring to pain management. They say something like “well, there are pain doctors out there. Why don’t you see if you can find one for your pain.” When the patient calls, and I ask them why they are being referred, and they almost always say that they have pain. When I ask where the pain is, the answer is usually a broad “everywhere.”

My doctor doesn’t treat “everywhere;” he treats spines. The patient may respond that their back hurts, too, and I don’t doubt it, but we can’t help them. The often snippy retort is “what kind of pain management is this?” It’s the kind that treats chronic back pain with epidural steroid injections. “Needle? I’m afraid of needles. I don’t want a needle! I want a pill.” Sorry. Not here. I’m very sorry if your doctor has mislead you. I’m sorry that you will have to call your doctor and educate them on what a pain management doc typically does. I wish I had the time to call every doctor, P.A., CRPN, and RN in the Baltimore area and tell each and every one of them that we are not pill pushers. We are pain relievers. There is a huge difference.

Some patients we only saw once or twice; others we saw for months. Some patients would call us at the end of their valiant fight to say “thank you” and “goodbye.”  That  was a hard phone call to receive. Sometimes we found out about the loss of a patient because I have a strange fascination with the obituary column of our paper.

I sent flowers to the wife of a recently departed patient and enclosed a card that said something along the lines of ”We are so sorry for your loss. The office of  My Doctor.” I fell out of my chair when he called to thank me. Apparently his neighbor a few houses down from him had the same name. He was the one who died. That was a total shocker!

We had a patient that was absolutely wonderful. She worked at a community college and just loved the arts and culture and making culture available to kids. She was a patient of my doctor’s even before we moved into our pink shoebox of an office. Our  billing specialist sent her a bill, and we got the statement back with a copy of her death notice. She had breast cancer, and we never knew.

Sometimes, and this just tears me to pieces, the spouse will call to cancel our patient’s appointment because of death. We know our patients really well, so when they die, my heart rips a bit. I stay professional and file away my sadness to be dealt with at a later time, but I have gone to a couple of memorial services. I have been told by other doctors’ offices that they never send flowers or go to services because it is an admission of guilt. Their logic is, if the doctor or staff do something comforting, the doctor must have done something to kill the patient, and they felt badly about it.

That is ludicrous! We are  going to these services and expressing our sadness because we care. Period.

There was the patient who was diagnosed with lung cancer and was given less than a year to live. Her medications were a mess. She was getting pain meds along with her injections, but the cancer pain was much worse than the pain she felt when she first came to us. What to do? Her primary care doctor had discharged her because he could not understand why she needed medicine for her cancer pain if she was taking it for her back pain. He thought she was drug seeking. Okay, so here’s the thing; she was! I mean, come on. She had cancer. She was dying. She was in excruciating pain. That is not the time to bail on your patient!

This woman had a tough life anyway. Her kids were in and out of jail and only spoke to her when they needed something. They couldn’t bother to help her when she got cancer. I overheard the patient talking to her sister about getting her estate in order. Apparently, the kids were available to tell her things of hers they wanted once she passed. She wondered to her sister if she was going to go to Hell because of her children. Was it her fault that her kids had no respect for the law? Was she a bad mother? What could she do differently if she was raising them today?

That was her last appointment with us. I really hope she went to heaven.

There are some patients that I adore (not professional, I know). One patient had been suffering from stomach pain and had lost a lot of weight. While he was pleased to be back in his “thin guy clothes”, he knew there was something wrong. The blood tests and exams proved he was right; he had stomach cancer. But, he didn’t let the cancer take over.

He went through the stages of emotion. After he stopped being angry, he made a “Bucket List” of things he wanted to do before he checked out. His list didn’t have things like skydiving or extensive travel. He wanted to spend the afternoon with his grandkids, one on one. He wanted to take his kids out for dinner and tell them how proud he was of them. He wanted to be able to actually eat a meal of real food and not “cancer food”. His list was attainable. How did I know all this? I asked him.

He and I both knew he was going to die. It was a fact and ignoring it and not talking about it wasn’t going to make it disappear. We talked a lot about him. He was a truly great man. I could see how he would have been gruff and strict as a parent. I could also see how proud he was of his kids. His generation wasn’t allowed to show a soft side.

Because of his chemo schedule, there were only certain days and times he could come in for his appointments. Because of the chemotherapy, he could no longer get steroid injections from our office because the chemo would eat that like it was everything else. He did take medicine, and was very concerned that our office would get  in trouble for sending him his meds without him being seen for an office visit. I thought even the DEA would understand what the situation was.

So, he scheduled appointments and I invented a spot for him. The last time we spoke, he asked to come in one last time because he wasn’t doing very well. He was losing a lot of weight and couldn’t keep anything down. He left a message on my voice mail. When I tried to call him back, no one answered the phone. Then there was a huge snow storm on the day he was thinking about coming in, so we didn’t see him.  The office closed for Christmas, and I went out of town for a few days. I had no access to our local paper to read the obituaries, but I knew he was gone.

Be good Mr. R., and save me a seat, would ya?

But, just a little while ago, I figured it out. It’s the atrocious manners some of our patients use when they speak to me on the telephone. I would love to post this list at work and give a copy to each patient as they leave, but I’m pretty sure that idea would get as far as calling patients dumbasses to their faces.

What not to do on the telephone:

1. Do not call me anything but my name. You can call me Jen or Jennifer. I call myself Jen, but the doctor often refers to me as Jennifer. No other name is acceptable.

The reason for this is simple; I have a professional relationship with the patient. I refer to the patient as Mr. or Mrs. or Ms Smith. I will only call you by your first name if you ask me to. I prefer to be called by my first name, too, but that is as chummy as you and I are going to get.

2. Do not call up and tell me “Hi Jen it’s me! When’s my next appointment?”

I am working with, on average, 25 of you a day, 5 days a week. So that makes 125 “me’s”. Some of you have recognizable voices or accents, but I have to ask with whom I am speaking if you don’t tell me because I don’t want your message going with someone else’s chart. Do not assume that because you can distinguish my voice, that I can distinguish yours. You have an unfair advantage since there are just the two of us who answer the phone, so even a random guess will be correct half the time.

3. When you call me and tell me you need something, I may or may not be able to help.

We ask that the patient give us 48 hours to process and take care of any paperwork such as prescriptions and work slips. A lot of the time the requests get expedited sooner than that, but not always. Do not call me and say that you have an appointment for an MRI in 20 minutes, and you left your prescription at home so I have to “fax another one over there right now.” Okay. First of all: Are you kidding me? You are a grown person who has a job, family, hobbies, and so forth. You can pay bills and balance your checkbook. If you forgot your prescription you have 2 options: 1) reschedule the appointment for another day, and 2) reschedule the appointment for a later time that day so you can run home and get the forgotten script. Second of all: I am not your secretary. I do not work for you. You are not my friend.  I do not owe you anything. See? You’re an adult and you can handle your own mistakes.

4. See # 3.

We see patients who are in pain. No one ever comes by to say “hello” on their way out to lunch or calls me and asks how I am. I am fine with that. I know you want to see the doctor as soon as possible, and that is fine. More often than not, I can get you in sooner. Sometimes I can’t. If I can’t get you in this week, and your appointment is next week, you’ll have to wait. Sorry. That’s just how it is sometimes. I do not dislike you. This is not personal. This is not rocket science, either. If no one cancels their appointment, I don’t have an opening. Period.  Do not ask me “are you sure?” Yes. I am sure. There is either a gap in the schedule or there’s not. It’s really easy for me to tell if I have a spot for you.

I also understand that inclement weather is a hassle. Many people do not feel comfortable driving in snow, sleet, heavy rain or gusting winds. We don’t want you coming in either. Stay home and be safe. Don’t worry. You see, you have chronic pain. That means you’ll keep having it. You will have that pain for the next time you come in; I promise. People with chronic back pain should not shovel, plow, or lift heavy containers of ice melt. That’s what the neighbor boy or girl down the street is for.

Stay inside, make yourself a cup of tea and feel thankful that you are smart enough to realize staying home is your best choice.

Many patients don’t care about driving in inclement weather. For every one cancellation we get because the local weatherman whispered the snow word, there are 2 people who will take it. It makes the day fun and busy.

There are a few patients who try to charm me in accordance with the weather. Let’s use this example: “My appointment is at 1:00 tomorrow. Is there anyway I can move it up? I hear bad weather is coming in the afternoon, and I don’t want to drive.” Here’s the thing with that; you are not the only one with that little nugget of meteorological information. Lots of people listen to the weather. Lots of people even have the Weather Channel application on their smart phones to keep abreast of the  latest threat from Mother Nature. So, as it is 99% of the time with me, no means no.

Do not bat your little ole eyelashes over the phone: “I really need my shot, and I’m not going to cancel, but the blizzard of the century is going to start at the exact moment I pull my car into your parking lot. Are you sure you don’t have anything earlier?” I am positive.

“Okay, I guess I see you tomorrow at 1:00 unless you call me to tell me I can come in earlier. Before the snow.” Don’t wait by the phone mister/sister. I know my schedule in bad weather, and trust me on this: everyone is going to try to come in earlier than snow o’clock. 

The worst offense I can think of for me personally is to call me some dumb nickname that you’ve made up just for me and treat me like an idiot. “Okay, Jen Jen (heavy sigh of sadness for not getting your way). I’ll see you tomorrow at 10:00.” Your appointment is at 1:00. I will see you then. “See you at 11:00.” No, we will see you at 1:00. “Unless you call me to come in sooner?” I. Will. See. You. At. 1:00. Click.

Sorry, but sometimes I’ve just got to hang up. Maybe your spouse or S.O. thinks that you’re adorable, but, and I mean this is the most professional way, I want to reach my hand through the telephone and strangle you.

5. Do not leave multiple messages on my voicemail

I feel like I have covered this item in earlier posts, but it’s worth reiterating.  It goes hand and hand with this one:

6. Do not leave me a message telling me that you will call me in the morning.

See, here’s the thing. The voicemail message I have left for my option gives the hours the office is open. If you call me when the office is closed, fine. Leave a message. I will get it. Do not call me when the office is closed and leave a message that is long winded and then at the end of it say that you’ll call me tomorrow when the office reopens. Do you see? Do you get how much time that wastes for me? Do you understand how counter productive that is for you?

7. Do not call me in tears saying that you need an appointment right away.

I understand that you hurt. I don’t want you to be in pain any more than you do. We really do try our best to help you feel better. Calling me in tears is incredibly stressful for me. I feel even worse that I can’t schedule you sooner or that I refuse to interrupt the doctor mid procedure to listen to you cry over the phone to him. Please. Pull yourself together. Breathe deeply. Take a warm bath. Find a fairly comfortable position to sit or lie in. When the tears stop, and you are coherent again, call me. If you are a new patient trying to get an appointment, do not burst into tears when I say that we schedule new patient visits six weeks out from the day you call. This is not psychological warfare; this is the schedule. You will not hurt my feelings if you call your referring physician and ask them to give you the name of a pain specialist that can see you sooner. I like that, actually. You are taking control of your pain, and I think that is something that probably doesn’t happen enough. By all means, get several numbers for several doctors.

8. Do not call me and ask me to do something, and then call right back to see if I have done it.

Look it. I’m not your child. I don’t need verbal prompts from you to get something accomplished. If you have called me to say that I must cover your heinie because you did something dumb and need my help bailing you out (which I don’t enjoy doing in the first place), don’t call me 15 minutes later and ask if your heinie is covered yet. Don’t call me 10 minutes after that to say that the recipient’s fax machine was out of paper and to fax something again. It’s a fax machine not your parents’ mimeographer. If the fax I send doesn’t go through, my fax machine sends me a notice.

9. When you call and ask if I have a minute, I do…but not many.

When you call, I am there for you. I will listen to your concerns and questions and offer reassurance. I realize I’m not a doctor, but I am a mother. A lot of the things patients ask me is common sense stuff; “I just had an injection, and the doctor told me to put ice on the injection site. Can I use heat?” Well, no. And there’s a reason for that. Ice reduces swelling. Heat does not.

Or, “I just had an injection, and tonight’s my bowling night. Can I still go?” Of course! You come to us so you can live your life. We don’t want you to sit in your living room all alone in the dark and have a pity party. Go bowling! But, and here’s the Mom thing: if the pain creeps back or feels worse than when you started, stop. Your body is telling you that enough is enough.

100% of the time patients know all this. They just want a little hand holding, and I am happy to do my share.

But if you ask me if I have a minute and then ramble on about your Aunt Tessie’s varicose veins, I tune out. Yes, I am nice and helpful to you when you call about you, but I don’t care a bit about Aunt Tessie. (Sorry.)

If you are calling about your spouse or parent who is a patient of ours, I can only answer questions in the general sense. All patients are given a sheet of paper after the injection with a list of possible side effects and reactions along with the doctor’s after hours number. A “what to expect” cheat sheet, if you will. If your question cannot be answered by the information on that sheet, I can’t tell you. It’s the law. However, if you have questions, you are more than welcome to come to the patient’s next appointment and express your concerns if the patient will allow it.

10. Have all your information ready.

If you call and say you need a refill of a certain medication, that’s no problem. I get your chart, follow the prescription orders and make sure that 1) you are not requesting a refill too early and 2) that we are talking about the same medication. If I put the request in the doctor’s office, and he has a question or concern, I will call you back on the doctor’s behalf to make sure I took the message properly. Some medications can be called in and some have to be picked up by you.

Do not call me and say “I need you to send away my medicines like you did the last time.” Say what? What are you talking about? Do you have a mail away prescription plan? Do you have a phone number and fax number? Do you have an address? How about your prescription plan number or a refill number?

Do not take for granted that I know what you want. This is medication we’re talking about. Do not say you want what the doctor gave you the last time or talk in milligram amounts : ” I was taking 5′s but the 7.5 works better. I actually like the 10s the best. They don’t have any acetaminophen.” Tell me what you are being prescribed. If the medication is not working, you need to mention that at your next appointment. The doctor will not change your medication without an office visit.

If you do not have your pharmacy’s phone number, I can probably look it up, but I need some help from you. What’s the address? Don’t sigh into the phone and indignantly whine “I don’t know. Don’t you have all that stuff? Isn’t that your job?” In a nutshell: no. If I am going to go through the trouble of finding out the name, address and phone number of your pharmacy and then mail away, fax or call in the prescription, I may as well be taking the meds myself. You seem pretty incompetent.

So, to summarize: no crying, whining, begging, pleading, yelling, cajoling, or thinking the rules do not apply to you. Treat me the way you like to be treated. There really is a Golden Rule. Be kind, concise, clear, pleasant and able to be told the NO word. Also, you can say thank you, too.

Patients fill out a pain questionnaire that asks them to describe their pain. There are more adjectives listed than I have thought to count. The words, in part, range from intermittent to constant when describing duration of pain, and tingling, stabbing, and throbbing when describing the kind of pain.

Patients are also asked to rate their pain on a scale from 1-10 with 1 being the least and 10 being the worst pain ever. The doctor wants to have a starting point for pain, so he and the patients can compare and contrast levels, types and durations after a series of injections.

Sometimes pain medicine is prescribed during the series of injections. Pain is flaring up, and the steroids are doing its job attacking the pain. It’s a process that almost always is successful once the area being addressed calms down. The patient completes the set of injections, is slowly taken off the meds, and Voila! They are done.

Some patients come in periodically for a “tune up”; but then there are the others; the ones who won’t give up the meds. They come back in complaining of a new pain. Their back hurts, and it hurts more than it did before the injections even began. The doctor will prescribe a new MRI to see if a new disc has degenerated or if there is another problem. The new MRI very rarely shows anything significant. This is good news and bad news. It’s good because, the patient is not getting any worse. It’s bad because they feel worse and have no reason to, according to the report.

So the doctor will lend a sympathetic ear and tell the patient that there are other injections that can be tried. “It’s a process”, he tells them. A different set of injections in scheduled and a new prescription is written. The cycle has begun. With the patient being the only one who can state where the pain is and how badly it hurts, the doctor has to figure out what the problem may be.

The patient will come back in, or call, saying the injection did no good and the pain in 10 times worse than it was before the injection and 100 times worse than it was when they first came in. At some point, the injections must stop for a period of time. Sometimes it’s 3 months and sometimes it’s 6. It depends on a variety of factors such as patient’s age, overall health, activity level, sedentary level and so on.

My phone is not quiet while these patients are in remission. “Tell the doctor that I hurt.” This is often followed by a call an hour later, “Did you tell the doctor I hurt? Why hasn’t he called me?” The doctor returns calls at the end of the day unless there is a fairly significant break in the schedule. The patient calls again. “I have to run out for a minute. I want to leave my cell phone number.” I take the number. Between other calls, this particular patient will leave me at least 10 messages to give the doctor; and God forbid, I have to go to the bathroom and do not pick up the phone, the patient will leave me a voice message saying that they are home and the doctor can call them at the original number again. As I retrieve this message, the patient calls wondering if I got the message.

This is harrassment.The patient that demands this much attention needs a live in medical staff. I have even said to patients that they only need to call me once. These patients NEVER get the hint. They are so wrapped up in their pain and in the desire to be prescribed something much stronger than what they are currently taking because they have to wait  for the next set of injections. These people become the addicted; not the dependent. There is a huge difference.

Someone who is dependent on medication takes it so they can be the best person they can be. They are busy professionals, mothers of younger children, volunteers in their community, and so on. With the help of periodic injections and a stable dose of pain meds, they are living their best life. Yes, they have bad days. Yes, their body has become an accurate barometer for any changes in the weather, but at the end of the day, they can sit back and feel they’ve accomplished something worthwhile.

The addicted are not dependent. The addicted are strictly drug seeking. There is almost a hyperness to their endless calls. Each message I take ends with the patient saying that they have never felt this much pain, ever. They will beg, borrow and steal to get pain meds. They will stop following the directions on the bottle and run out of meds earlier than they should “well, I hurt, real bad” they’ll say defensively.

The addicted leave more and more hostile or threatening messages. They come into the office without an appointment begging for anything that will make them feel better (that’s available in pill form.) Finally, I have to state my concerns to the doctor.

My concerns are legitimate. These patients are taking time away from other patients. Also, though, I get a little paranoid. Are these guys going to jump me in the parking lot? Are they going to follow me home? I begin to freak out, and I worry for my own well being. The doctor will take a variety of things into consideration, and if the concerns add up, the patient will be weaned from their pain meds.

This is not a punishment by any means. These patients can be a royal pain, but the doctor is above board in every way, and will not take a patient off of meds for the soul purpose of making them feel worse. (“Haha! You thought you felt bad before? Wait till you’re not taking anything!! Bwahahahahahaha!”) The doctor has sensed something that the patient probably thought of way early in the game. Their body craves the medicine. They are listening to very small pain impulses and enlarging them to get more, stronger medication. Once the patient gets off all of the medication, their pain goes away.

That’s right. Once the body stops “needing” the medication, the body stops misinterpreting what the brain is signaling. The pain goes back to how it was when the patient first came to see us, and the injections work again.

As a post script, though, if the patient really wants to feel better, they will agree to go on the weaning schedule. It is a very slow process, and we keep a copy of it in the chart so the patient can check in and make sure they’re “doing it right.” Some patients “get stuck.” They are weaning down and then, they have to stay at the point where they are a few days  longer than the schedule states. That’s okay, though. The weaning schedule is a guideline. The patient makes it work to their ability.

The other side to this, the patient who say they want to get off the meds and have absolutely no desire to do it. They resist every step of the way, but they say they want to stop taking “this junk.” The weaning schedule is far less successful if the patient is resistant. Sometimes, the patient will discharge himself from our care in order to get different, stronger, more meds. There are very few doctors in this area that will prescribe any medication at all. The patient, unless they go to a clinic somewhere, will have discharged us and end up without any doctor at all.

I, for one, used to be a huge pain wimp. I could feel my eyes sting as I willed myself not to cry over a hangnail pain. I knew that about myself and wondered how in the world I was going to deliver children. When it did come time for me to deliver my boys, I practically begged my anesthesiologist to hit me over the head with a sledge hammer so I wouldn’t feel the epidural. I guess having kids raised my pain threshhold, although it is true what they say, you forget the pain associated with childbirth.

In 2003, I had an ovarian cyst removed.  As crazy as this may sound, I felt instantly better. Even the post op pain was nothing compared to the months and months of pain I had experienced before surgery. I’m not great with anesthesia and sometimes will throw up as a result (TMI, I know). For the first few days after surgery, I didn’t eat or drink much because I didn’t want to barf and pull my stitches. It was late at night, and I let my dog outside. My shoes were untied, and I remember thinking “I’d better tie my shoes so I don’t trip and hurt myself.” Ironically, I was so dehydrated from not eating or drinking enough that I got dizzy when I stood up and lost my balance. I fell into the corner of our kitchen table and broke my rib. I found my new pain level.

Now I compare any pain I have to the broken rib, and honestly, I haven’t felt pain that excruciating since. I have broken my toe twice, and even breaking a different bone did not cause the intensity to equal or rise above my rib pain. Why is that? Well for me, personally, I’m not one to complain too much if there is something physically wrong with me. I just don’t for whatever reason. The pain I had with the broken rib was debilitating. I could not pick things up off the floor. I could not reach any higher than elbow level to grab charts at work. I could barely breathe for the first two weeks. I could not sleep because I couldn’t get comfortable. If I coughed or sneezed, or tried to stifle it, the pain would be so intense I would literally have tears pouring out of my eyes. I didn’t sob, though, because sniffling and blowing my nose was also immensely painful. I needed help from family and friends, and that was really hard for me to ask for. My rib pain was that, but it was also a psychological blow because I’m the helper, not the helpee; so for me, that has been the worst pain I have ever felt, thus far.

I work in a medical office that treats chronic pain. I have seen all types of patients and their various stages of determination. We’ll get the patient that will come in once a year for their annual “tune up.” We have patients that will come in every six weeks whether the doctor has asked them to or not. There is also the patient that will cancel their appointment because they feel so much better. “I don’t want to waste the injection”, they’ll say. The last type of patient we have is not the majority, but they are certainly the most exhausting. These patients are the ones that are controlled by their pain. They are so mindful of what hurts, that they are never without pain.

We have one patient who is morbidly obese and can only get around in a wheelchair. His wheelchair is called the “super wide” so it doesn’t fit though regular doorways. He can manage to walk the 25′ to the consultation area, but he struggles. This man knows nothing but pain. He can’t sleep; he can’t function; he can’t live. He just exists. That’s depressing; so, he also eats. He calls me at least 3 times a week to let me know that the injections don’t work and he needs to take medicine – strong medicine. Here’s the thing, though; he is taking strong medicine, and it’s not working. The answer to this situation is not to take more medicine because the body wants to feel pain so the brain can feel the effects of the medicine. The patient’s  brain is making him drug seeking.

This is a man that years before we met him was a big, strapping manly man who called women “little lady” and would often offer to lift something heavy for the damsal in distress. His now wife fell for his chivalry hook, line, and sinker. They got married, he got a little older, and his pain intensified. In a little over a decade, he has gone from manly man to completely dependent on others for everything – even hygiene. The wife feels like she got a bum deal.

This patient is depressed and very overweight. It’s not pain medicine he needs, it’s a weight loss plan. He is at least 150 lbs heavier than he should be. His back can’t take the strain. Think about this: when we carry groceries from the car, our arms get tired. If we lift a piece of furniture, even with help, our arms and back are relieved when we put the furniture down. Imagine walking for miles with 150 excess pounds on. We can’t. The man gained weight because he was in pain and depressed, and now he is depressed because he is overweight and in pain. It is an awful cycle, but it’s not one he will give up anytime soon.

We have a woman patient who felt fine until a year ago. She ran in marathons, swam in the ocean, and lifted weights. Her personal life was going through some stressors. She was dealing with sick family members and her spouse’s high pressure job stress. She dealt with all of these things until,one day, she couldn’t. She woke up in severe pain and was barely able to walk much less run or swim. No one knew where her pain was coming from, and no one could diagnose why, after all these years, she was having pain now.

 I believe that she hurts. I can see it in her eyes. I can see it in the way she gingerly sits down and slowly walks to the consultation room. Medicines and injections only seem to help for a day or two. She is miserable. She is also lonely and afraid. She has to stay strong for her family, but her brain is now sending impulses to her body and is telling her she needs to take care of herself. She doesn’t listen to her brain’s subliminal message that she needs to do something nice for herself; she hears her brain scream that if she’s not going to rest on her own, pain impulses will be sent like hot daggers through her body. She hears the screaming pain loud and clear. She is focused on it. She calls this office everyday to leave updates for the doctor. This patient knows where her pain was, where it it going, and where she thinks it may end up. She is ruled by pain.

No injection or medicine is going to provide what she really needs which is a do-over. She needs a healthy, stress free family, and that’s not likely to happen any time soon. The next best thing for her would be to realize that illnesses in the family will still happen whether she is there or not. Same with her husband’s job stress. If she is there at the dinner table listening to him unload about the heinousness of his job, she’s not doing anything more for him than providing a sounding board. She could put a cardboard cutout of herself, and the husband could rant to that. What she is doing, however, is hurting herself.

Unfortunately, this patient has no idea why she feels as badly as she does. She looks at her pain and thinks that her situation could be much worse; as bad as her family members. If she could get a nurse, therapist, anger management professional – anyone to take her place for just a little while, she would feel much better. Period.

Next up…why getting off all pain medications may end pain.

When a medical office and an insurance company choose to participate with one another, contracts are signed on both sides. A lot of the fine print has to do with payments. An insurance company will agree to pay a certain percentage of the fees as long as we agree to bill the patient for the balance.

Because in this country, having medical insurance is a privilege and not a right, subscribers pay a monthly premium, a copay, and the balance that the insurance company doesn’t pay. In most cases patients also have to pay a deductible. This means that at the beginning of every year (calendar or fiscal), depending on the sort of coverage a patient has, they will have to pay 80-100% of the office fee until the deductible is met. Only then will the insurance company pay what it has agreed to pay in the contract.

This is insanity. Insurance is expensive and keeps getting more so. Benefits are not always great and getting worse. Patients end up paying more and getting less.

And here’s the thing: it gets worse. Our office specializes in chronic back pain. Stress exacerbates back pain. Think about it. How do you sit when you are worried? Do you shrug your shoulders? Do you slump forward with the weight of it all instead of standing up straight? Does worrying make you tighten up your whole body, so that when and if you can relax even muscles you didn’t know you had hurt? The financial burden placed on the patient by their own insurance company, makes their pain worse! The patient comes in for an injection, gets the Explanation of Benefits from the insurance company saying how much the company will not pay (for various reasons) and calls us in a state of despair. “How can I pay for this?” they wonder, and with good reason, too. Didn’t they just shell out a huge monthly sum for the insurance that’s not paying?

More often than not, the patient has received his statement from the insurance company before we’ve received our; so we don’t know what it is the patient has to pay. The billing specialist will tell the patient that our office will not be sending them a bill until we receive notification from the insurance company telling us what amount to bill and why.

By law, our office must collect the payment transferred to the patient by the insurance company. If the patient has a $1200 deductible, and our procedure cost $500, the patient must pay us $500. They have $700 more that they need to pay before the insurance kicks in. So, the vicious cycle is this: the patient has chronic pain and sees us. The insurance does not pay for the procedures until the patient pays a certain amount out of pocket (the deductible). The patient cannot afford to keep seeing us until after the out of pocket expenses are paid in full. We will try to help the patient by setting up a payment plan for them, but, obviously, we want them to pay off the current debt, and not add to it.

The patient ends up cancelling or rescheduling appointments until they no longer have a balance with us, and the procedure the patient had has long worn off. It is an awful situation that is getting worse.

As an office manager, I have a week of needs. Monday, I need to close out the previous week and copy checks from the weekend. Tuesday, I need to organize bills and start writing checks. Wednesday, I need to make a deposit at the bank and treat the office to lunch. It is important for us to be able to sit back for a couple of minutes with something tasty and fairly nutritious once a week since we don’t close the office for lunch. Thursday I need to look to the upcoming week and see if I need to get approval from workers’ comp or insurance companies so that the patient’s appointment will be paid for. Friday, I need to suppress the urge to get out of of my swanky pleather chair and do the Happy Dance because it’s the weekend!!

So…my work needs are already established. As a secretary, I need to be patient, courteous, kind, thoughtful, a good listener, an efficient message taker and a problem solver. My needs are taken care of there, too. So, here’s the thing; I do not need a patient to call me up and tell me what I need to to for them. I’ve got it covered.

You see, patients don’t need me to be kind, courteous, thoughtful, blah, blah, blah. They get that anyway. They have different needs for me. “Jennifer, I need you to do something for me. I need you to call my prescription plan and tell them I am allergic to generic brands of medicine.” “Um…Are you allergic?” “Well, no, not really, but who knows what is in the generic, and I want the name brand, but I don’t want to have to pay for it out of pocket. My insurance company will only charge me the copay amount if you call them and tell them I’m allergic.” “So, to be clear, you want me to lie for you?” “No, not exactly. I mean sometimes I do get really itchy when I take some kinds of medicine, so that would be an allergy.”

Ah yes…see? We can all be doctors. Who needs that pesky degree?

“I am not willing to call your insurance company and tell them that you are allergic to a medication because you don’t want to take the generic form. You do not have an allergy, for one thing. For the second thing, insurance companies are run by very greedy people who are not stupid.” They will ask the doctor to fill out 3 pages of paperwork to go along with your so called reason for needing name brand scripts. I will fill out what I can, give the rest to the doctor, and then I will fax it back to the insurance company. Then, I have the pleasure of waiting 48 hours for them to receive the fax. I don’t mind. I have other things to do, but I do mind your calling me every hour on the hour to see if I’ve heard anything. See, here’s the thing; you need to be patient and let me call you when I hear something.

But, because I’ve done this so many times for legitimate reasons, I know that the response I’ll get from the insurance company is a denial. As I mentioned before, insurance companies are very greedy. Why should they lose some of their profit in order to help a patient? They will deny the request because it buys the insurance companies time. They send us a list of medicines that have to be prescribed before they will approve the request. They figure if they saturate offices with senseless paperwork, the offices will throw their hands up in the air, and say I can’t take this bureaucratic doo doo any longer! Nevermind! Who cares if the patient dies because of an allergy to generics. We all have to go sometime!!

But, being the patient soul that I am, I get the information together so the doctor can write his appeal and send it off. By then a week or more has passed, and the patient might not have any medication. Without medication, they may go into withdrawal. If they do into withdrawal, they may have to go to the hospital. If they go to the hospital, that is more expensive than approving the name brand medication. In the end, it’s almost always worth it for me to say a silent apology to all the trees being killed for this senselessness, because I am an advocate for the patient.

That being said: don’t make me lie on your behalf and waste time and paper. You’ll have to discuss with the doctor, on your next visit what you don’t like about a certain generic and what may work for you instead.

The other thing patients think I need to do for them is lie with them about insurance coverage. Are they insane? Here’s the thing. I like my job. More importantly, I like my freedom (read here: I am not, nor will I EVER go to jail for you or anyone else.)

I am not your friend. I am not your accomplice. I am a secretary who works in a busy medical office. If you have the stupidity to tell me that the insurance information you gave me is bogus, but for me to “try billing them anyway”, you will be discharged. Because you are trying to involve us in illegal activity, our office also reserves the right to let your future medical office know why you were discharged.

That’s the theory, anyway. In actuality, there would be that one couple who have nothing else to do but sit at that table and drink endless cups of coffee. The server could have asked for the bajillionth time if the table needed anything else and then bring over the check, only to have it sit, ignored, for 30 minutes or more. Except for asking them to lift their feet as you vacuumed around them, I honestly didn’t know how to get rid of them. Some couples were cool. They’d tell their server at the very beginning of the evening that they weren’t planning on going anywhere, but that they would leave an extra tip to make up for the fact that the table wouldn’t get turned again anytime soon.

Getting to know people helps to gauge where the wiggle room is in the schedule. I learned that hostessing, and I have perfected it as a secretary. We have some patients that require extra time. By that I mean that the 30 minutes we give each patient will be used up on those particular patients. Other patients, it seems, take longer to walk to the consultation room than it does for them to have the procedure.

There are times when we have to squeeze in patients per the doctor. I prefer doing it over my coworker, but that is because her specialty is billing. I have a better feel of which patient will take less time than she does. Conversely, she knows which patient pays their bill the same week the statement arrives.

I’m so good at my job, that our patients feel that they can do it too. I’m guessing the thought process is “if Jen can do it, anyone can.” Patients will call and say that they need to be seen right away for their pain and that they don’t take long so I can fit them in anywhere. Thank you for that. Patients with siblings or spouses that are also seen in this office will call to tell me that they aren’t going to keep their appointment, but they are giving it to their sister.

Okay, here’s the thing, I am possessive of my schedule. Only I or my coworker do the scheduling. Sometimes the doctor schedules appointments, but that is almost always a recipe for disaster. Do not tell me that I can squeeze you in anywhere. I can’t. You see, you may be super fast, but some of our other patients are not. Plus, I’m not thrilled for you to tell me how to do my job. I am a trained professional, and although my job may seem as complicated as putting charts away in alphabetical order, it is only because I am very good at what I do, and everything tends to run smoothly on my watch.

You want to give your appointment to your sister? That’s fine…sometimes. You see privacy laws make it very difficult to explain to you that your sister can only be seen at certain times because of varying issues. I don’t care if you’re related and you know everything about her; I am not about to give any information for why your sister may not be able to be seen at the time you want to give her. HIPAA and its thousands of rules, hundreds of pages and multiple workbooks with examples has figured out a way to fine office staff who violate the laws thousands and thousands of dollars. Even if I had a spare $25K sitting around, do you think I want to spend it because I let it slip out that your sister has a STD and the medicine she is taking will not react well with the medicine the doctor gives her?

So, ask. Say “hey Jen, my sister is in much more pain than I am. Can I give her my appointment?” I will tell you that, yes, that is no problem or no, I’m unable to give your sister that time. If I can’t, I’m not being mean and heartless, I am looking at the whole day and all the patients to see if a change in the schedule is doable without being disruptive. You may be the only one on God’s green earth to not recognize that your sister has diarrhea of the mouth and getting her to stop talking long enough for the doctor to ask his questions is time consuming and exhausting. That’s why she gets the last appointment of the day. You never got a chance to say a thing growing up, so you only give yes or no answers. You are a perfect person to schedule at noon. I give your sister that spot and we’ll be running 30 minutes behind for the rest of the day. No thank you.

So, your job is to be the patient, okay? I’ll take care of my job.

I have never, ever said “don’t you know who I am?” Because, depending on the network, the answer is just as likely to be a blank stare as it is to be a welcoming smile of recognition. But, let’s face it; if we’re in the same network, I wouldn’t have to ask about me anyway.

Our medical office has the pleasure of treating  patients with varying degrees, various income levels, and different levels of public familiarity. We treat all of our patients the same. The little grandmother who has a very limited income and is on Medicare gets the exact same treatment as our patient with very obvious name recognition. We schedule new patients as quickly as the schedule allows. Period. The exception to that is if a neurosurgeon or orthopaedic doctor has scheduled surgery for the patient and our doctor can give interventional pain techniques as a last ditch effort before going under the knife. In that case, I usually hear from the doctor directly, and we’ve been known to see these patients well before the office opens for the day.

When a potential new patient calls to schedule an appointment, they have to have certain information before we can schedule them. Since we are a specialty office, the patient must be referred by a neurologist or orthopaedist. Those two surgeons have usually ordered the MRI’s or CT scans and have diagnosed the problem. The procedures my doctor does is the last attempt at eliminating chronic spine pain before surgery.

We very rarely schedule new patients who are being referred by their primary care docs because those patients are typically being referred for pain relief through medication or to take over the prescribing of pain medicine that a family physician isn’t comfortable writing.

We also do not schedule new patients that are being referred by current patients. As I said before, the patient must be referred by a specialist who has diagnosed the chronic pain condition so it can be treated interventionally and not solely with medication.

We didn’t set out to be choosy, but the DEA makes it necessary for us to only schedule patients who, on paper at least, seem as though they would benefit from our services.

The criterion for accepting patients has not changed too much for us over the last seven years or so, but some people who want to become patients seem to think the rules do not apply to them. One woman called me, and when I told her I could have her seen in 6 weeks (which is typically an average wait for new patients in many specialty offices), she asked me if I could schedule her sooner because her son is a very well known anesthesiologist in Palm Beach, Florida. Um, no.

The doctor will occasionally tell me that he has scheduled patients outside of regular hours as a favor to them. That’s fine. As long as my coworker or myself are not required to stay, he can schedule how he wants. Maybe once, twice max has the doctor taken the initiative to schedule a new patient visit on his own. It is not an ideal situation because the doctor specializes in doctoring, not secretarying. He knows that each new patient comes with a spanking new chart with all of the required information from our office filled out and placed in the correct sections. He just doesn’t know how. That’s okay though, because there is no way I could ever know what he does. I have to do a last minute scramble to get the new patient to fill out all 8 pages of our paperwork before being seen. “Ken, do you have Mr. Jones’ phone number? I have to call him to get his information.” “No. I don’t have his number. Isn’t it in the paperwork?” “Well, it will be once he fills it out, but I have to see how to go about getting it to him.” “Oh. Okay. Thanks. He’s an aquaintance of mine, and we got to talking, so I suggested he come in.” “Oh. Can I give you the packet to give to him to fill out before he comes?” “I’ll give it to him before he leaves the appointment.”

In other words, this new patient isn’t just a new patient, but “A Friend of Ken’s” also known as a FoK or FoKker. FoKker’s screw with my organizational skills. Paperwork gets filled out before the appointment, not after. I am a big fan of methodology. It makes sense to me. There are two types of FoKkers: The ones that Ken schedules himself, and the ones he tells to call the office and speak to me so I can get them in ASAP. “Make sure you tell Jen that you are a friend of mine.”

As far as I am concerned, all patients are FoKkers. We schedule each new or return patient as quickly as the schedule allows. Period. No exceptions. No squeeze ins. No per the doctor. We make accommodations for all of our patients whenever possible. Going on a cruise this month? We will schedule you to be seen before you go. Not because you are a friend, but because we want you to be comfortable and relatively pain free for your vacation.

There is a third type of FoK; the ones that are told by legitimate FoKs to say that they are FoKs. These people wouldn’t know what the doctor looked like if they fell over him. I’m pretty good at figuring out these people. They’ll call and say, “hi. I’m a FoK, and I need to be seen as soon as possible for my low back pain.” “You are, huh? How do you know the doctor?” “Well I work for someone who sends a lot of patients to see him, and they have a good rapport.” “Oh? And who is that?” “Jane. Jane Smith.” “The same Jane Smith that does the scheduling for the ABC adult community?” “Yes.” “Jane and the doctor would not speak because he does the procedures and I do the scheduling. What you’re saying really is that you are a friend of mine.” “Okay.” (Pause for infinity…) “so can I get scheduled or what?” “Of course. I have an opening in 6 weeks. Who is your referring physician?”…and on it goes.