Prescribing Antibiotics Over the Phone

With some regularity, patients contact me requesting antibiotics.   Many patients regard this as a casual and routine request, but I don’t.  When I hit the ‘Send’ button authorizing an antibiotic – or any medication refill – I am declaring that I personally agree that the medicine is medically necessary.  In general, I sign off on most routine medication refill requests without issue, unless the patient hasn’t seen me in the past year or so.  I would hesitate to refill if patient communicates that his heartburn is worse and requests that I double the dose of his reflux medicine.  This patient will be asked to see me in the office.

There are times that I will prescribe antibiotics without an office visit.  This assumes that there is an existing professional relationship between me and the patient and that the medical facts support sending in a prescription.  There also needs to be a reservoir of trust such that the patient would contact me if his symptoms are not responding.   

I won't state that I've never phoned in antibiotics to a patient I haven't seen before.  But, these are exceptional events.

Consider this example.  One of my longstanding patients phones me requesting antibiotics for diverticulitis, an infection in the large bowel.  The patient has had 2 prior episodes which were evaluated and demonstrated to be diverticulitis each followed by successful antibiotic treatment. The current episode is identical to the 2 prior ones.   Prescribing antibiotics without an office visit might be reasonable here.

So, you want me to call in antibiotics over the phone?

A few weeks before penning this post, I was covering for a colleague who was on vacation.  One of his patients requested antibiotics through the electronic records portal for his diverticulitis.  I had never met this patient. Moreover, a review of the record was not sufficient for me to acquiesce to his request. I advised the patient that he needed to be evaluated by a medical professional and offered him options on how this could be expeditiously accomplished.

Here are reasons underlying my prescribing hesitancy in this case.

• The patient’s diagnosis of diverticulitis may be wrong.  Suppose he suffering from a bowel obstruction or an acute ulcer.  Antibiotics would offer no medical benefit and would likely delay making an accurate diagnosis during which time his condition would worsen.
• Suppose the patient’s diagnosis of diverticulitis is correct, but he should be seen first in an emergency room to determine if he has a complication of the disease and should be hospitalized for close observation.  Phoning in antibiotics would clearly be insufficient and potentially dangerous.
• Suppose antibiotics are called in and were later determined to be the wrong medical option.  Consider this therapeutic wrinkle.  The patient develops a serious complication to the unnecessary antibiotics such as a C. diff infection.  This infection can be a life changing event and is particularly unfortunate when caused by a medicine that was not needed.   In this example, if the patient is seen initially by a medical professional, then it is more likely that a correct diagnosis and rational treatment is proposed.

Yes, a quick phone prescription is convenient.  But we are not in the convenience business.  The stakes are high.  Don’t expect your doctor to deviate from sound medical practices and principles just to save you a trip to the doctor.  Indeed, if your doctor did so and your health suffered, what would your reaction be?