I was sure this morning when I checked my face in my rear-view mirror one last time before entering the workplace, only to find that one of my basset hound’s squishy, gray eye boogers was plastered to my cheek, that it was going to be a bad day.
She is very pretty, though. And definitely worth the eye boogers.
It wasn’t really overall very bad. But there is one particular area of my day that was just usually awful.
I had a usually awful day dealing with very rude and unhelpful people who work in various doctor’s offices. Here’s the thing, if I take the time to call a doctor’s office, I am usually doing for the patient as a courtesy, and about 98% of the phone calls I make are either the patient’s or the doctor’s responsibility. But I generally like helping people and try hard to do that.
I am blogging about this issue to make myself feel better, but there are some outstanding problems with the way things currently work in the outpatient medical world. Here are some of the problems that I have outlined in my mind today with the current physician-patient-pharmacist relationship.
1. There is none
I feel as if there is a complete breakdown of communication between physicians and pharmacists. It is no one side’s fault. We are both guilty. We are both busy. The perfect example is the fact that the system that has been developed to renew a patient’s refills is a faxed form. Pharmacists like faxing for refills, because it takes much less time than calling. Doctor’s like it when we fax for refills, because all they have to do is check a box and enter the number of refills they would like the patient to have based on if the patient has kept appointments and, hopefully, the status of the patient’s disease state. Faxes are convenient for both parties. But a phone call gives opportunity for communication.
2. The Phone Answering System at the Doctor’s Office
Scenario: I have an 80-year-old woman turn in a prescription for nitrofurantion (an antibiotic commonly prescribed for the treatment of urinary tract infections). She is going to wait in the store, since she knows it will not take too long. My first reaction is, “This is not going to work for her. This medication is contraindicated in patients older than 65 because their kidneys are ‘worn out’, for lack of a better term, and no longer have the ability to concentrate enough of the antibiotic into the urine to kill the bacteria causing the infection.” But from my many experiences of calling doctors about this issue and having them refuse to change the medication, I go ahead and start to fill the prescription. Then my system alerts me that this particular patient is highly allergic to nitrofurantion. I have to call.
I pick up the phone, dial the number, and have to waste my time listening to a ridiculous number of options, none of which are appropriate for me to push. Usually it goes something like this: “Press ‘1’ for appointments, Press ‘2’ for lab results, Press ‘3’ if you are physician, Press ‘4’ for medication refills”, etc.
Out of those options, the one closest to what I am trying to accomplish would be ‘3’. But any pharmacist that has made this novice mistake knows that you should NOT PRESS ‘3’, unless you want a very hateful response and a complete waste of your time explaining that this line is for physicians only and you are not a physician.
If you are lucky enough to get an actual person on the phone instead of just a voicemail, as soon as the word pharmacist or prescription comes out of your mouth, the response is, “Hold on, I’ll get to the message line.” I DO NOT need to leave a message! I need to speak with someone right now about a serious issue. I mean, I guess I could tell the 80-year-old lady to come back later, but that is not easy for everyone. The patient only sees me as withholding medication from her and trying to give her a hard time. She doesn’t understand that I have possibly prevented a serious reaction for her that the prescriber missed.
The thing that gets me is that if a doctor or a nurse wants to speak with me, I am available almost immediately. I know that some of the chain pharmacies have a few options on their phones before you can talk to a human, but they are usually short and make sense. At my pharmacy, we have NO menu to sit and listen to.
Phones are a major problem and need to be completely re-worked!
3. Irresponsible Prescribing
A large portion of my job is to be the gatekeeper for narcotics entering the general population. I have to spend a great amount of collective time each day checking to see if a patient is getting too much of a controlled substance. If this does manage to slip by me, I am held accountable. I am fine with this fact. But the amount of responsiblity placed on me and the person who actually prescribed the medication is not proportional. Some doctors write for ridiculous amounts of controlled substances. It is almost as if no one has the power to regulate what a physician prescribes. Anyone with a brain knows that 360 oxycodone 30mg tablets and 240 Xanax 2mg tablets is not appropriate therapy for ANYONE! If you are prescribing absurd amounts of controlled substances, or if you are prescribing any amount of controlled substances without doing your homework to see if the patient is getting them from other prescribers, you are not prescribing responsibly, and you are contributing to the addiction epidemic in this country second only to obesity!
There. I said it. It is the prescriber’s responsibility to prescribe responsibly.
4. Prescribers Do Not Know Pharmacy Law
The practice of pharmacy has like a gazillion laws, so I would not expect all prescribers to know every detail of pharmacy law. But if you are going to write for a schedule II narcotic, than you need to know and understand the laws about schedule II narcotics. It goes back to responsibility.
Scenario 2: A man brings in a prescription for a powerful schedule II pain medication for his wife. She is not feeling well and is at home. They do not have prescription insurance, and need to pay cash for the several prescriptions they are bringing in. The man states that his wife has never had the medication before and is concerned that it will be too strong for her or make her sick (which I agree), so he does not want to pay for the entire quantity of 120 tablets that were prescribed. I explain to the patient that he may get filled as many of the tablets that he wishes, but the rest of the prescription will be voided, according to federal and state laws. He says that’s ok, he just wants 20, and I document that I told him about the law.
A few days later I answer the phone to a prescriber completely blessing me out for mis-filling the schedule II narcotic prescription she wrote for the patient. “Why would you withhold the medication I prescribed for my patient!?”, she frantically and somewhat abusively enquires, oblivious to before mentioned laws. When I patiently inform her that I did not mis-fill the prescription and of the federal laws surrounding the prescribing and filling of schedule II drugs, her response to me is, “Well I don’t feel like writing another one.”
The truth is, if she had really listened to her patient in the first place, she would have been aware of her concerns about the medication.
I did later get an apology for the accusation, but it never seemed to occur to her that it was her responsibility to know that law.
There are many problems on the pharmacy side as well, most of them having to do with governing laws which are beyond the local pharmacist’s control. I really think we should be working together to overcome these and other issues that stand in the way of patient care. The patient and their well-being should be at the top of our priorities. That may mean me making more calls and less faxes, or prescribers taking more time to communicate with their patients and us, but it needs to happen. We all make mistakes from time to time, ad we need to ban together to make it harder for mistakes to happen.