Sunday, August 7, 2022

Prescribing Antibiotics Over the Phone

Recently, a gastroenterologist in our group left our practice.  Of course, the remaining physicians must do our best to provide ongoing care as best we can for her patients.  Ongoing care does not mean seamless care even though some patients expect that a new covering physician will simply assume the reins without so much as a hiccough or a speed bump.  More realistically, there will be a transition period and some inconvenience to the patients and to the covering gastroenterologists.  I was assigned to cover her patients immediately after her departure when the volume of incoming laboratory and procedure results would be heaviest.  Even normal laboratory and radiology results require more work than usual for a covering medical professional.  We can’t simply shoot off a message ‘your biopsy result was benign’ and consider the case to be closed.  There may be many other lingering active medical issues to address.  A modest laboratory abnormality, which would be expeditiously handled in one of my own patients, took much more time as I had to review the chart to make sure I was informed on the patient’s medical history.  For example, perhaps the patient is overdue for a screening colonoscopy or has another gastro condition that needs to be followed?  

Let’s face it.  A doctor who knows a patient well is more likely to give better medical advice with much less effort.  Patients understand this also.  This is why when a patient calls after hours, he hopes that his own doctor answers rather than a partner who does not know him.   

If your doctor is not available, expect speed bumps.

Here's an example of a patient who contacted me expecting seamless care when I was the covering doctor.

My diverticulitis is flaring again.  I need antibiotics right away.

Let me admit from the outset that this patient’s diagnosis and proposed therapy might be spot on.  She knows her body and her medical history.  Perhaps, she and the prior gastroenterologist were in a tight rhythm such that the doctor was comfortable prescribing antibiotics by phone for this patient she knew well.  The chance, however, that I – a covering doctor - would comply with her antibiotic request was zero.  Indeed, I am reluctant to prescribe antibiotics by phone even on my own patients, but I have done so in selected instances.  In the case at hand, this is a patient I have never seen.   Do I acquiesce to her request and risk missing an alternative diagnosis?  What if it’s not truly diverticulitis?   Suppose it’s appendicitis or an inflamed gallbladder, two mimics of diverticulitis which may require urgent surgery?  Perhaps, she is just constipated?  What if it is diverticulitis but is too severe to be managed as an out-patient?   How would she and I feel if I prescribed the requested antibiotics and 3 days later she is admitted to a hospital severely ill?

I directed the patient to be seen that day at one of the area urgent care facilities or by her PCP.  Yes, in a perfect world, I would have had clinic hours that day and availability to accommodate her.

Providing medical coverage for other doctors isn’t easy.  And it may inconvenience patients, as the vignette above illustrates.  But the risks associated with bypassing sound medical judgement are unacceptable and avoidable. 




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