Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Wednesday, July 18, 2007

Things I Won't Do; and Some That I Will

While reading Dr. Rob's post on what makes patients angry, I was struck by how similar our practice styles are. As a solo doc, ie, no partners to whom I can compare, I found this reassuring. Yes, I'm fairly confident that I'm practicing good medicine; still, validation is nice, however it comes.

So here is a brief list -- not exclusive by any means -- of things I won't do, even at the risk of angering a patient:

  • I won't call in antibiotics without a visit, with two exceptions: endocarditis prophylaxis, and the family member with documented strep scenario.
  • I won't prescribe narcotics without a visit.
  • I won't call in a prescription under someone else's name (if someone doesn't have insurance but a family member does.)
  • I won't treat "yeast infections" over the phone. Surprise: BV doesn't respond to antifungals. (Exception: if someone is already on antibiotics, though I usually ask and prescribe Diflucan concurrently.)
  • I won't treat UTIs over the phone (except MAYBE on weekends, and even then I don't like it.) The only time I really need the urine culture is when I didn't get it.
Here are some things I will do; I know some would disagree on some of them, but I've included my rationale:

  • I will write one controlled substance prescription for a new patient. No refills until I've seen your records, but you will get the benefit of the doubt once. Only once, though.
  • I will prescribe birth control pills without a pap. Contraception and cervical cancer screening have nothing to do with each other. Besides, even though gynecologists are not allowed to trust women (because every single one of them has been burned by someone who swears she's a virgin but turns up pregnant) if I've known you since you were five and you're asking for BCPs on your way to college, I believe you when you tell me you haven't had sex.
  • I will write for full pills even if you're splitting them. I didn't used to, thinking of it as insurance fraud, but given the obscenities that co-pays, pharmacy benefit managers, formularies and their profits have become, who's defrauding whom?
  • I will treat upper respiratory infections over the phone 'til the bovines are re-domiciled. Sore throat, stuffy nose, little cough for two days: go to bed and drink fluids for chrissakes. Don't call me unless something changes or you're not getting better after a week.
As I said, these lists are anything but exclusive. They're just the hot button issues that seem to come up most frequently.

Note to Clark re: Mr. Furious, "Close, but no cigar": Good thing I don't smoke.


At Wed Jul 18, 09:10:00 AM, Blogger MedStudentGod (MSG) said...

I really like the URI treatment. I've seen too many times a patient coming in to the office for a days worth of sore throat and "fever" that's clearly viral, but is still given Abx because the doc's too lazy to actually treat and educate appropriately.

As far as the controlled substance: fool me once, shame on you, fool me twice, ain't happening.

At Wed Jul 18, 11:00:00 AM, Anonymous Anonymous said...

. . . sounds reasonable. I'm amazed that patients actually expect some of the things you describe.

At Wed Jul 18, 12:38:00 PM, Anonymous Anonymous said...

Patients expect anything and everything out of a doctor. I have very similar "rules" but I have had very exasperating times on the phone on call trying to explain why "I just won't prescribe a narcotic" to someone I don't know, whom I can't examine over the phone, especially when it is 10 PM and no pharmacies are open in my town.

At Wed Jul 18, 07:32:00 PM, Blogger Dr. Smak said...

Fabulous list, Dr. Dino.

Question: logistically, how do you avoid having the URIs coming to the office to be seen? I can't develop any sort of phone triage system that the monkeys at the front desk can manage. So in they come.

Most patients who've been in for a couple of URIs get it, after the "education". But I'd love to catch them beforehand so as not to waste their time. I have to admit, I have some guilt about charging a $55 office visit to tell someone to take tylenol and sudafed. (Then again, we are so underreimbursed for other stuff that I suspect it all evens out...)

At Wed Jul 18, 08:19:00 PM, Blogger #1 Dinosaur said...

How do you avoid having the URIs coming to the office to be seen?

I can't always. All I said in the list is that "I will" treat them over the phone.

I don't feel guilty about the $55. They're the ones who wanted to come and "make sure that's all it was." Easy money (which only nets $35 from Aetna and $38 from the Blues anyway.)

At Wed Jul 18, 09:37:00 PM, Blogger Dr. Rob said...

I still can't get myself to write for the full pills, but that is just my conscience. I understand the flip side to it.

We do treat yeast infections over the phone x 1, but need to come in if not better with either OTC or diflucan.

We actually don't do the OCP, but I see your point. I feel that women may just avoid getting a pap if we don't hold the OCP hostage. Plus, being Med/Peds, I really avoid anything to do with GYN if at all possible.

There are differences, but the fact is that we are trying to do what is right. We all have our priorities in practice, but know good medicine when we see it.


At Thu Jul 19, 01:43:00 AM, Blogger Dr. K said...

Good on you for stating that birth control pills should have nothing to do with cervical cancer screening.

At Thu Jul 19, 11:44:00 AM, Blogger The Tundra PA said...

I will almost never hold contraception hostage to a Pap smear. If she doesn't want to be pregnant, I don't want her to be pregnant. If she is more than 2 years behind on Paps, or has a history of not-always-normal Paps, I may only give a month of OCPs, or one Depo shot and tell her she has to get in before the next refill. Most of the women in my practice seem able to manage it; of course, we do have a federal grant to provide travel expenses for women to receive routine cancer screenings (Paps and mammograms).

At Thu Jul 19, 02:40:00 PM, Anonymous Anonymous said...

Holding OCP hostage. I've never heard it put that way, but from the wrong end of the speculum, it sounds oddly true.

I get spam on spam offering to sell me viagra, cialis, and what not. But if I saw ONE spam offering me my OCP for some pseudointerview over the internet, I'd be sorely tempted!

At Fri Jul 20, 04:35:00 PM, Anonymous Anonymous said...

If she is more than 2 years behind on Paps
Aren't current guidelines say every 3 years after several years of normal paps? So when you say more than 2 years behind, do you mean over 5 years since the last one?

Out of curiousity, why do you make one dependent on the other. If a woman for whatever reason decides not to be screened, isn't it her choice even if you don't agree with it? Why should she then get pregnant?

At Mon Jul 23, 08:57:00 PM, Anonymous Anonymous said...

There is a medicolegal reason to hold the OCP "hostage".

The mere fact my name is on the prescription makes me legally liable for ANY harm caused by them, real or imagined. I would be liable whether or not she wants to get cervical screening.

Would you like to be in front of a jury and be asked by the Plaintiff's (the patient's) attorney-"Doctor, we just heard from my expert witness that good medical care for someone on birth control is a good faith exam on a regular basis. When did you last perform such an examination?"

If you answer more than one year, you'll (at least in CA) be guilty of violating the prescription writing law for which the lawyer will point out to the jury.

They will also point out the fact that you did not document "Informed Refusal" of cervical screening, breast cancer risk associated with OCP, risk of blood clots in the leg or lungs, etc., etc. Just like getting Informed Consent for any procedure, we as providers are to give face to face risk vs. benefit DISCUSSION of NOT doing something medically recommended.

The mere fact the patient refused to come in for the exam is NOT an excuse under the courts to have provided the Informed Refusal!!!

That why I will hold those pills hostage for an office visit. I have to pay for malpractice. That is part of the overhead that only gets paid when patients see me. Even capitated patients pay a Co-pay to see me, that is the only real "profit" that I make a living on. The monthly cap only pays the overhead.

At Tue Jul 24, 09:30:00 AM, Anonymous Anonymous said...

So you're saying that the hostage holding has nothing to do with the patient's medical needs and everything to do with the doctor's money?

At Thu Jul 26, 10:24:00 AM, Anonymous Anonymous said...

until you're a woman who is suffering with a horrible UTI (especially one who is prone to them, either because of a short urethra or some other reason, and absolutely knows for sure when she has one), i don't think it's remotely fair of you to refuse to treat UTIs over the phone. nobody's getting high off of antibiotics. nobody's abusing them. just phone the darn prescription in! UTIs are terrible, and your refusing to simply phone in an Rx for an antibiotic, and instead making the patient come in and pee for you when she knows FULL WELL what her problem is and how it can be solved, is just cruel.

At Thu Jul 26, 03:54:00 PM, Blogger #1 Dinosaur said...

Anon: If someone is prone to UTIs I'll usually have given her a scrip for post-coital prophylaxis.

Besides, isn't it more cruel to give her an antibiotic, have it not work because this time she has a resistant organism and then have to get the culture off antibiotics? Much greater total suffering overall.

I've also offered to call in a scrip if they'll pee first and bring in the sample so I can send it for culture. Then again, I've been burned when they've gotten the scrip without leaving the specimen.


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