Blog | Tuesday, November 18, 2014

Why I won't refill your prescription

Giving prescription refills is not quite as fun as it used to be. Years ago, we doctors would whip out our prescription pads, often sooner than we should have, and we'd scribble some coded language that pharmacists were trained to decipher. I'm surprised there were not more errors owing to doctors' horrendous penmanship. On occasion, the Food and Drug Administration (FDA) would require a pharmaceutical company to change the name of a drug so it wouldn't be confused with another medicine with a similar name. The name of the heartburn drug Losec was too similar to congestive heart failure drug Lasix, so the former drug name was changed to the familiar Prilosec.

Nowadays, we physicians refill medicines with point and click techniques within our electronic medical record (EMR) system. When this works, it's a breeze. Three clicks and the refill has been transmitted to the patient's pharmacy. Alerts notify the physician of any potential drug interactions with a patient's other medicines. A record of all prescriptions and refills becomes a part of the EMR system for all time.

Often, the drug interaction alerts are too sensitive. More than once, an alert has appeared warning me that if I hit the ‘prescribe’ button, that my patient will suffer the same fate as did the Wicked Witch of the West when Dorothy doused her with water. When I can't verify this doomsday scenario using old fashioned techniques, I call the pharmacist directly who may reassure me that the drug is safe to use. So, I prescribe the drug knowing that my EMR system will document that I have been duly warned and have chosen to cavalierly override the admonition. Guess which profession likes this EMR function?

Patients contact us nearly every day for prescription refills. Of course, we beg them to do so when they are in the office, but life doesn't work this way and I understand this. Here are some instances when I will not refill the requested medicine.
• One of my partner's patients calls after hours for a refill on narcotics
• A patient wants a refill beyond my expertise. I won't be refilling your cardiac medicines as this should be done by the prescribing physician for several self-evident reasons.
• I haven't seen the patient recently.

It is a common scenario for a patient whom I have not seen for a year or two to request a refill on their GERD or heartburn medicine. When this occurs, I politely request that the patient see me in the office first. The patient may not grasp any urgency as he is feeling well and only wants another year's worth of acid-busting pills. However, the moment I refill it, I am in effect accepting responsibility for this action and any resultant consequences. Here are some pitfalls with refilling a patient's heartburn medicine who has been AWOL.
• Does this specific drug still make sense?
• Can the dosage be lowered?
• Have any new symptoms developed that might require diagnostic investigation? Suppose the patient has been losing weight, for example? What if the ‘hearturn’ has worsened and a new disease is responsible?
• Is the patient experiencing side-effects from the medicine that he or his primary care physician might not appreciate?
• Could the heartburn medicine interfere with new drugs that the patient is now taking?
• Is the patient up to date on other issues within a gastroenterologist's responsibility such as colon cancer screening?

Refilling routine medicines may not be routine and should be done with care and caution. The patient from 2 years back who has GERD might think he needs Nexium for his ‘heartburn’. What if his symptom is actually angina? Get my point?

So, when we ask you to stop in for a brief visit, it's not because we delight in hassling you or are hungry for your copay. We're trying to protect you and to keep you well. Doesn't this seem like the right prescription?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.