On Flea
I don't often participate in blogosphere or Internet drama, but I do want to briefly add my comments to the general blogosphere reaction to the outcome of Flea's trial. If for no other reason than Flea was one of my favorite blogs, and its disappearance is a loss for medbloggers and the Internet community at large. I won't pontificate long. My thoughts boil down to this:
It saddens me when a case is settled not on the facts of the case, but rather on issues that are only tangentially related to the matter at hand, at best. That said, perhaps Flea was confident in his anonymity, but probably shouldn't have been. Being nearby, I considered going to the courthouse in Boston and asking a court clerk where and when "the malpractice case of the pediatrician" was being heard, simply because most of my days are free, and I would have liked to observe the trial. I wouldn't have revealed Flea's identity.
Unfortunately, hindsight is 20-20, and things that are obvious after the fact are often not so obvious while they are occurring. We've all done things that were dumb in hindsight — myself especially — so I will refrain from being an armchair jackassexpert and saying that Flea should have known better.
But ultimately we have a legal outcome wasn't about the truth. The truth — whatever it happens to be — is apparently irrelevant. Unimportant, even. I think that alone is poor commentary on our legal system.
[tags]Medical malpractice, malpractice[/tags]
Sorry, but we don't have a Batphone
There's a bizarre misconception that pharmacies have a Batphone that connects us with The Doctor at the push of a button. Anytime, anywhere.
The Batphone phenomenon generally rears its ugly head on the weekends or after hours when someone inevitably needs a refill on their Allegra, or their kid's fluoride prescription has run out of fills, or their Patanol copayment is higher than they'd like it to be. Eleventh Law stuff.
I've had people literally scream obscenities at me because I won't give out the doctor's special phone number. You know, the magic one that all you doctors have to every other doctor on the planet so you can have your secret conversations with one another and that pharmacies can use periodically when there's a medical emergency. Like that Patanol copayment. That super special phone that's never busy, and doesn't get answered by the front desk.
Why oh why are you holding out on us, doctors?? WHY???
And who might you be to be authorizing refills?
We've got this one doctor's office that refuses to accept prescription fax refill requests. This means we have to actually pick up the phone and call — but most of the time the phone is busy, so it takes 3 or 4 tries to actually get through. This is annoying, but not the end of the world — we fill a moderate number of prescriptions for him, but most of them seem to be antibiotics and such, with no refills.
What is disconcerting is that when we do get through to the office, a receptionist answers the phone, looks up the file while you wait, reads the prescription in question back to you, and then invariably authorizes it with two more refills. Every single time. I have no idea who this person is or what their qualifications are, but it makes me uncomfortable. Yeah, I have the refill "authorization" within 90 seconds which is nice and convenient… But who's doing the authorizing? Is she qualified to make the decision? Is the doctor being notified? Are the charts being updated? Who is doing the monitoring? When was Mr Smith last seen in the office?
Am I going to get a phonecall later asking me how the patient is taking the medication?
Call me old-fashioned, but I prefer the black box method of requesting a refill, where a request goes out electronically, via fax, or by leaving a voicemail, and then comes back some time later either authorized or denied. This delay lets me think that the prescriber is actually, you know, looking at the patient's chart to see what's going on before making a decision.
I like my comfortable delusion. Even if it is a fantasy and the med in question is "just" glyburide.
Shooting from the hip
I suspect a great many doctors shoot from the hip when it comes to refills. What makes me think this?
Well there's this weird little loophole in our automated refill request line where someone can request a refill and trigger an auto-fax to the doctor if the script has expired or run out of refills. It's all automatic — no pharmacy personnel even see the refill request before it gets sent. Our computer systems aren't typically smart enough to check and see if there's a replacement prescription in patient's profile already.*
What's amusing is that often this second prescription differs from the first. Not significantly, but where the first might have 5 refills, the second has 3. Or 11. Or maybe zero. Often we'll get two scripts with the old refill number on it sent back on the same day, each with a different number of refills, usually in the same handwriting. This makes me wonder… how are you guys charting this stuff?
Is this why we get phonecalls asking what strength of a drug a patient is taking? And how are they taking it? And please give them six months worth of refills?
Not to beat the EMR drum — because I don't think they're perfect either — but I have never seen this happen with an EMR.
It makes me scratch my head. Shouldn't the order of operations be something like:
- Request comes in and is put aside for later perusal.
- Patient's file is checked
- A determination of the appropriateness of a refill is determined.
- The number of refills is written on the request AND the patients chart — along with any changes.
- Chart is closed, request form is faxed back to the pharmacy and then thrown away or placed in the patient's files once you get the confirmation that the fax has gone through successfully.** If not, re-fax periodically until it does go through, or if it's a constant problem, just CALL it in. That's what we do when we can't get a fax through.
Just askin'.
* This seems a good time for a digression. This little loophole, I suspect, is where the aggravation on a prescriber's part that a prescription refill request has already been responded to, comes from. "I already took care of this, dammit! Why am I seeing it again?" Well now you know that patients can trigger second (and third, and fourth) requests all on their own, with no human intervention. This seems to be popular with elderly people who will often try to call in the same refill four days in a row before they actually come down to the pharmacy "just to make sure it's there" — and our system isn't smart enough to catch it and weed it out. It sucks. I hope this loophole is closed, too, because some pharmacy personnel aren't smart enough to throw those second and third redundant prescriptions away when they come off the fax machine. They're not real, people. Just toss 'em.
** Another digression: when irate patients come in demanding to know why the pharmacy doesn't have a prescription because Goddammit-I-spoke-to-Jane-at-DrBob's-office-this-morning-and-she-said-it-was-faxed-last-Thursday- what-the-fuck-is-wrong-with-you-people and we call the office, and get a sheepish "Oh, it was faxed but it says the line was busy. Sorry. We'll do it now." — it really tends to piss us off.
Can you read these prescriptions? (Round 2)
Update: Thanks to Kevin, MD, The Consumerist, and The Wall Street Journal Health blog, this entry is getting a lot of traffic. If you enjoy it, please take the time to Digg it. 
The first round was popular, so I thought I would share another round of Bad Prescriptions. Answers will be posted tomorrow (Thursday) night around midnight.
Remember there's more to a prescription than the drug. You need to get:
- Drug name
- strength
- directions
- quantity
- number of refills
The last prescription is totally legible. I have included it so you can cringe along with me. It was for a 6 year old child. And the folks in the Ivory Tower think MinuteClinics are bad…
Exhibit A:
Exhibit B:
Exhibit C:
(Standard disclaimer about electronic prescribing not being the perfect answer applies.)
[tags]Medicine, pharmacy, prescriptions, bad handwriting, doctor's handwriting[/tags]
OK so it's expensive but would you really rather go without it?
Generally little things cost small amounts of money. Unless it's a diamond. Or some medications. And this was brought to my attention most recently by a comment left on an old Plavix post. My premise is that the public thinks about the cost of medical intervention the wrong way. (Duh!)
It's not uncommon to hear people complain about the cost of Ambien (with apologies to Dr Dino ). Until recently, Ambien was one of the most expensive, yet most common medications. And also widely complained about. Patients don't like the fact that it's costing them $45/month to take some tablets to help them sleep.
But this anger is the result of a flawed perception. Instead of valuing the tablets as something that you hold in your hand and swallow, you should be valuing the quality of life that they afford you. Is it worth $1-1.50 per night to sleep well? If you asked a person with insomnia if they would pay $1.50 to enjoy a full night's sleep just before they're about to go to bed, most would pay without complaint.
It would be foolish NOT to.
It amuses me that people pay the high cost of Viagra without any problems. And that they'll throw down $10-15,000 on plastic surgery, or $75/month for Propecia, but they complain about a medication that is keeping them alive. Honestly, if having high cholesterol was a cosmetic issue, and relative attractiveness correlated with your LDL levels, there would be NO complaining about the cost of a given statin.
The Ambien CR reps must be out in force…
This whole week, I've seen probably double the number of Ambien CR scripts as usual. Cutting into the usual volume of new Ambien prescriptions. This makes sense, of course. What with generic Ambien now available, we must educate those docs on the benefits of a controlled release zolpidem formulation!
What a crock of shit.
Also of note is that generic zolpidem is less than half the price of it's name-brand counterpart — startling, given that new generic drugs typically run around 80% of the price of its brand competition for that first six months. I'm sure insurance companies are lovin' it.