Sunday, August 28, 2022

Why Won't My Doctor Refill My Prescription?

Medical care has various tiers of service with differential quality levels.   Each level is designed to meet a specific level of need.  Physicians and patients do not always agree on what level of service is appropriate.  Sometimes a patient feels that a higher level of service is necessary and other times the physician has a similar view.  Consider the listing below of potential medical encounters. 

  • Physician and patient dialogue through the Electronic Medical Record (EMR) portal
  • Physician and patient phone call to discuss a medical issue.
  • Telemedicine visit with audiovisual capability.
  • Traditional office visit with a physician or medical professional.
  • Emergency Room (ER) Visit.

Each one of the above encounters has value, but clearly they are not equal experiences.  The objective is to match the level of the encounter with the medical need.  For example, if you are uncertain if your recently prescribed erythromycin should be taken with food, then an ER visit would seem a step or two too far.  Conversely, if you have developed fever, vomiting and abdominal pain, and haven’t seen your doctor in a year, then leaving your physician a voice mail message seems like a misfire.  

What is the best way to communicate with your doctor?

It's important to know the best way to communicate with your doctor.

I have found that patients tend to inappropriately use lower tier encounters when seeking medical advice. Over the years, thousands of patients have phoned me or 'portaled' me with medical issues that clearly needed face-to-face visits.  These patients often felt that their request for antibiotics or a CAT scan could be easily handled on a phone call.  In general, I ask these patients to see me (or another physician) in the office for a fuller airing of the issues.  After these visits, patients readily appreciate that this higher level of service was essential, particularly when my advice differs from their original request. These patients were utilizing a lower quality platform for convenience which would have been at the expense of quality.  

As always, there are exceptions to everything. Medical judgment is required on how intense the medical encounter level needs to be.  Different physicians have different views and practices on this. Some doctors are more comfortable handling issues over than phone than others.  

Phone medicine can be murky terrain for physicians.  For instance, if you call a doctor after hours who does not know you complaining of chest pain, do you really expect him to simply refill your heartburn medicine?  .  



Sunday, August 21, 2022

Do Patients Know Their Medications?

Do you know what medicines you are taking?  Do you know the doses?  Do you know the purpose of each of the medications? 

These seem like rather basic inquiries and yet you would be surprised how many patients cannot respond accurately to these 3 simple questions.  The medical profession needs to emphasize the importance of patients achieving an adequate level of medical literacy.  Knowing their medications is an important element of this mission.  It is much easier for doctors to care for informed patients.

When a patient is unsure, for example, why he is on Lipitor, we can easily explain this.  It is more challenging, however, for doctors and other medical professionals when patients do not know the specific dose of a drug or if a drug was omitted from the medication list.  This happens all the time.

Now here's a guy who knows how to make a list!

Electronic medical records (EMR) have the current medication list available for the medical staff to review. But, not surprisingly, it is not reliable 100% of the time.  Sometimes, the patient’s written medication list (assuming he has one) conflicts with the EMR’s list.  Or, the EMR may still be including medicines on the list that were stopped months or years ago.  I have also seen EMR lists that include 2 or 3 heartburn medicines and yet the patient tells me his is only taking one of them.  This makes the visit fun when we try to guess together which medicine is real and which are impostors!

I am not faulting patients here.  Many of them are on several medicines with changes in medications and dosages being made regularly.  It is hard to keep track of all this.  Imagine how challenging it is for a patient who is taking 8-10 medicines every day, with dosing ranging from once daily to four times daily, to keep it all straight.

And, if a patient is hospitalized, there’s a good chance that the medication list on discharge will be quite different from the initial one.  It’s understandable that such a patient who is still recovering from illness and may also be facing employment and familial challenges, might not prioritize studying his new drug list. But it is absolutely critical that he or a caretaker do so.

My plea?  Keep an accurate list of all medications – including over-the-counter agents and any other supplements – with the correct doses.  If your regimen is changed, then revise your list.  Bring it with you to every medical encounter.

Remember, the holiday song that contained the phrase, ‘he’s making a list and checking it twice’?  You might have been taught that this was Santa preparing for Christmas.  Actually, it was Dr Santa setting an example for his own patients.

Sunday, August 14, 2022

The Right to Refuse Medical Care - Saying 'No' to a Colonoscopy

An 85-year-old woman was referred to me because she was anemic.  She was accompanied by her son.  Anemia, meaning a decreased blood count, is a common reason that patients are sent to gastroenterologists.  The reason for this is that internal bleeding in the gastrointestinal tract – even silent bleeding – can cause anemia.  Gastroenterologists are always locked and loaded with our arsenal of scopes ready to probe into your digestive system in search of a bleeding lesion that would explain anemia.  While we are always hopeful that any discovery will be benign, at times the news is more serious. 

Just after I entered the exam room, the patient offered this declaration.

“I am not having a colonoscopy!”

I had not yet even introduced myself to her and her son, but she was determined to set the ground rules.  Of course, it should be the patient who determines her own future, but generally this occurs after some dialogue with a medical professional.  After all, this is why patients come to see us.  However, this octogenarian had managed to reach the age of 85 years intact, so clearly her personal ‘owner’s manual’ has guided her well.  You have to respect success.

I suggested to her wryly that she might at least have waited for me to recommend a colonoscopy before refusing one, but she clearly wanted to assert her autonomy and authority. I reassured her that if she persisted in refusing any recommended testing that I would support her decision. This response relaxed her as intended.  While she may have been prepared to scrap with me, I communicated my own ground rules that I would not be her adversary. 

My professional task is to educate, inform and to prioritize the options for my patients.  I am not the decision maker.  I do my best to equip patients with sufficient information so that they can make truly informed choices, even if I may personally disagree with the decision from a medical standpoint.

                                                  The Right to Refuse Medical Care - Saying 'No' to a Colonoscopy

                                                      A very clear message from my patient.

After reviewing this patient’s medical history and data, it was clear that a colonoscopy was medically necessary as I had concern that a malignancy – which could be curable – might be the culprit.  As part of the informed consent discussion, I also candidly with her the risks of declining diagnostic tests

With unwavering confidence, this woman expressed that she intended to be left alone.  No scope would be permitted to approach her.   We shook hands and I wished her well.

Over the years, I have come to appreciate more deeply how many elderly folks use different medical playbooks than younger people do.  Many times I have seen an elderly patient decline testing while her child who is present tries to change her mind.   In this example, two different playbooks are being used.

I did counsel the woman and her son that she needs to be a peace with her decision, regardless of unknown future medical developments.  Of course, she already knew this.  It’s in her playbook.  

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. 




Sunday, July 31, 2022

Were You Discharged from the Hospital Too Early?

You sent my father home from the hospital too soon.  Three days later, he was worse than ever and needed surgery!

I’ve heard similar lamentations from patients and their families over decades.  Every doctor and hospital nurse has also.  And I acknowledge that sometimes families are correct; folks were sent home too soon. However, in my long experience, most patients are not sent to the street too soon despite some folks feeling otherwise, usually after the fact.  

First, let’s all agree that the medical profession – like your own occupation – is a human endeavor which means that perfection is aspirational.  An imperfect outcome or a catastrophic development does not mean that medical carelessness or negligence has occurred.  Medical malpractice is a real issue, but that is distinct from adverse medical outcomes, which is what I am focusing on in this post

Medicine is not mathematics.  There is no formula or set of proofs that will reliably bring us the desired result with a calculation.  If you disagree, kindly send me the formulas so I can improve my performance. Medicine is an art where judgments are rendered based on moving targets and incomplete data.  When a sick patient is before us today, we must make decisions and recommendations without knowing the future.  Should we prescribe antibiotics to a patient with a cough even if the chest x-ray doesn’t clearly show that a pneumonia is present?  Perhaps, the patient will recover on her own without any treatment?  Should I wait a day or two and simply monitor the patient?  What if I withhold antibiotics and she ends up in the intensive care unit 3 days later?  Will the patient and the family understand if I prescribe an antibiotic, which I am not completely certain she needs, and she develops a severe side-effect from it? Would I be accused then of reckless over-treatment?

'I should have known it was going to rain.'

If you present the above patient vignette to 10 experienced clinicians, there will be no consensus.  The conservative practitioners may hold their fire while more aggressive physicians will pull the treatment trigger. Physicians with divergent recommendations may all be correct, a fact that is mystifying to the public who tend to believe that there is one best answer to a medical issue. 

We cannot foretell the future.  If you leave your home on a sunny day to walk in the park, and it starts raining later, is it really your fault that you didn’t bring an umbrella with you?

When I am wallowing in the medical gray area, a daily occurrence, I do my best to convey the vagaries of medical science and judgment to patients and their families.  I review the options with their respective advantages and drawbacks. But I emphasize that we all have to be at peace once the informed decision has been made.  If a patient makes a considered and informed decision to proceed with surgery, and a post-operative complication ensues, we should not challenge the original decision ex post facto.  The time to debate, question and challenge is best timed prior to the decision, not afterwards. 

Physicians are also mindful of the risks of keeping folks in the hospital -a building full of germs and other demons - a minute longer than is necessary.   Families, however, rarely gripe that we are keeping granny in too long, as they are less aware of these risks which may include. falling, an infection or a medication reaction.  

If we could foretell the future we would make better decisions.  (Think stock market or Las Vegas!) Might this futuristic objective be in the realm of artificial intelligence?  

Sunday, July 24, 2022

Why This Doctor Gave Up Telemedicine

During the pandemic, I engaged in telemedicine with my patients out of necessity.  This platform was already destined to become part of the medical landscape even prior to the pandemic.  COVID-19 accelerated the process.  The appeal is obvious.  Patients can have medical visits from their own homes without driving to the office, parking, checking in, finding their way to the office, biding time in the waiting room and then driving out afterwards.  And patients could consult physicians from far distances, even across state lines.  Most of the time invested in traditional office visits occurs before and after the actual visits.  So much time wasted! Indeed, telemedicine has answered the prayers of time management enthusiasts.

At first, I was also intoxicated treating patients via cyberspace, or telemedically, if I may invent a term.  I could comfortably sink into my own couch in sweatpants as I guided patients through the heartbreak of hemorrhoids and the distress of diarrhea.  Clearly, there was not much of a physical exam that could be performed virtually, but as I have opined elsewhere on this blog, in most cases the physical exam is not essential.  I felt that the quality of my virtual care approached the level that I performed in my traditional office visits.  There were instances, however, when a virtual visit was inappropriate and I advised a face-to-face meeting with me.

But the novelty of the experience wore off after a few months.  Many of my patients are chronologically advanced but technically limited.  A recurrent frustration for many participants was when they couldn’t connect to the platform or activate the audio.  Those lucky enough to have a 12-year-old grandchild nearby could be easily rescued.  For the rest, my staff would be calling the patients to try to guide them toward cyber success, an exercise that burned up staff time and burned out my patients.  This demographic rapidly became disenchanted with this experience. And so did I.

Remember this?

From my standpoint, telemedicine was simply less fun.  I realize that the work of doctoring is serious business, but the personal rapport and interactions I have with patients contributes greatly to the reward of what I do.  I found that this could not be replicated with two of us staring into our computer screens.  Virtual visits are transactional experiences.  Similarly, much of America soon tired of zoom meetings recognizing that efficiency has costs.  Ever heard of the term ‘zoom fatigue’?

But telemedicine won’t be deterred as the forces favoring it are overpowering.

Wonder what the patient experience will be when conventional medical care is replaced by artificial intelligence?  How important will the human physician be then?

There is already too much technology separating patients from medical professionals.  How much time do patients watch us pecking on our keyboards during their visits?  Do you think that telemedicine and the next technological frontiers will bring patients and physicians closer together?  As technology advances, our health may be much better and we will reminisce about doctors of yore as we do today about typewriters, pay phones and the Kodak Instamatic camera.