Sunday, November 17, 2019

Why I Won't Prescribe You Antibiotics

At least a few times a year I am asked to prescribe antibiotics to people who are not my patients.  From my point of view, there is only one answer that makes sense here – no.   I have the same reaction when patients call me for a refill or advice when I have not seen them in a year or two.  The patient may feel that I will refill their heartburn medicine indefinitely without an office visit, but I won’t.  Once I hit the refill button, I am now totally responsible as the doctor. 

Patient Gets Medication Refill in 14th Century

The Patient’s Perspective
  • I’ve been on the same medicine for 10 years and all I need is a refill.  I feel fine.
  • I do not want to take time off work for an unnecessary appointment.
  • Why should pay a copay when all I need is a refill?  Sounds like a rip off.

The Physician’s Perspective
  • No refill until I verify that there are no concerning symptoms. A routine ‘heartburn patient’ may have developed some swallowing difficulties which could signal a serious medical condition.
  • Pt may not need the same dosage of the medicine.
  • Pt may not need the medicine at all.
  • Pt may be on new medications which might impact on the decision to refill the heartburn drug.
  • Pt may be overdue for a screening colonoscopy.
  • Pt may have general medical issues and needs to be encouraged to follow up with the primary care physician.

It might be tempting for one of our staff to ask me for antibiotics because ‘I have another UTI’.  My secretary might hope that with one phone call, I can save her time and money.  While she may be an able secretary, she may be a lackluster diagnostician.  Many of my own patients come to my office ‘because their diverticulitis is back’.  While their symptoms may remind them of their first episode of ‘diverticulitis’ last year, often the actual medical evidence supporting the original diagnosis is rather thin.  I can’t count how many of these patients have never had diverticulitis. 

Prescribing you medication is a serious responsibility.  It’s not an act that should be casually done with a stroke of a pen, or these days, with a stroke of a key.  Wouldn’t you want all the odds to be in your favor? 


4 comments:

Anonymous said...

Colonoscopies should not be embarked upon routinely unless there are problems or polyps.

Unknown said...

As a pharmacist, I completely support your position. Prescribng is indeed an act to be approached with appropriate caution.
May I add one more step? Please inform your patient of your decision. In the event that the request originated from the patient's pharmacy, please communicate the decision to the pharmacist. Every day at my pharmacy counter I see patients who expect (perhaps unreasonably, although they seldom think so) that their prescriptions have been reauthorized by their doctors. Sometimes days pass without receiving a decision from the doctors' offices. This results in requests being needlessly resent, and patients who become angry.
If you will not authorize further refills at this time, please include a note like "needs office visit" or "have pt call office to discuss", or "needs labs". While a simple denial without a note is better than nothing, being able to tell the patient that they need to talk to you prevents patients from becoming irritated with your decision. Yes, I am also being a bit self-serving here. I dislike when patients confront me with the unanswerable question, "Why won't he/she give me a refill?"
Sure, I try to present a rational answer, but after all I can only guess without a note.
If you already do so, thank you!
Respectfully submitted, Tom Keogh, R.Ph.

Michael Kirsch, M.D. said...

Thanks, Tom, for your thoughtful comments. Yes, I am sure that you are blindsided by patients on a regular basis expecting that their refills will be waiting for them. On our end, we try to educate our patients that we will refrain from refilling their medicines if we have not seen them in a year, but the system is not perfect. More challenging, is convincing a patient who is convinced he needs antibiotics that he doesn't. I invite you return to this blog from time to time.

Unknown said...

Thanks, Dr. Kirsch. I can sympathize with the difficulties you and your colleagues face when you withhold antibiotic therapy because a true medical indication isn't present. Somehow, patients seem to feel "cheated" when their physician refuses their request.
They often come to the pharmacy to ask us why the doctor wouldn't prescribe a "Z-Pack", or why did my doctor order a CT scan instead of an MRI, etc.
Naturally, most of us pharmacists would have no way of determining why one diagnostic study is superior to another in a given case. As you know, that's not what we do! However, like most physicians, we do our best to reassure patients that their physician is truly advocating for them.
"When antibiotics are indicated, the doctor will prescribe them, but like all drugs, antibiotics have side effects. These drugs require a prescription because they can be harmful when used inappropriately. Physicians have to make sure that they prescribe medicines judiciously so patients don't get hurt. So follow your doctor's advice, and feel free to let your doctor know if your condition worsens, or doesn't improve in a reasonable amount of time. And I have no idea why he/she ordered a CT scan instead of an MRI."

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