Friday, August 24, 2007

I Need My Meds!!


It's August and I'm back in town. Psychiatrists are notorious for taking vacation in August, I hear they all go to Wellfleet. Sounds wonderful.

Back in Baltimore, I'm covering for a vacationing psychiatrist who often covers for me. We've cross-covered for years and I've handled just a few emergency calls, but quite a number of prescription refills.

They never teach you in medical school or residency the exact right way to handle writing prescriptions for patients of other docs while they're away, or if they did, I missed that class. People do what they're comfortable with and I have my own standards. If you'll remember from my post
Covering Your... some time back, another doc (not the one I usually cross-cover with) once insisted on meeting with one of my patients before he would okay a refill on a medication-- it was a med she'd been on for years, and not a controlled substance, so I was surprised that he didn't just authorize the refill over the phone.

So it's August, and my phone rang today with a request: I'm Dr. Wellfleet's patient and he's away and I'll be out of meds tomorrow. Why, I think, does the patient wait until the day before they're out of medicine? This happens all the time. Now the confounding factor here is that Dr. Wellfleet prescribes controlled medications more often then I do, specifically stimulants to treat Attention Deficit Disorder, sometimes in high doses, that I don't generally feel comfortable prescribing. These medications, in Maryland, can not be refilled or phoned in and the prescription can't be faxed. The patient must present a hard copy of the script each month to the pharmacist, so the patient's request the day before creates a number of issues for me: first I'm left to decide if I'll prescribe a controlled substance to a patient I haven't examined, and I have to ask if it's even reasonable to insist on examining a patient I'm cross-covering for particularly on a day's notice when I likely don't have an appointment --or if I do, what if the patient can't meet at the precise time I can? Or what if I meet with the patient and don't agree with the diagnosis and treatment-- is it reasonable to take a patient off a medication their regular doc, a well-respected and experienced psychiatrist, is prescribing anyway, and if not, then what's the point of meeting with them anyway? And what about the time I got a call from a patient out-of-state requesting a medication I would never feel comfortable prescribing-- she insisted Dr. Wellfleet's been prescribing it for years, the pharmacy verified this, the patient was hours away, and if I refused, the patient would go into a withdrawal which would require a hospitalization to manage. Oy.

Mostly, I deal with cross-coverage medication requests by phoning the pharmacy and verifying that the patient has actually been maintained on the medication by the regular shrink, that the medicine really does need to be refilled, that everything is kosher. If I can phone it in, I do. If it's a controlled substance, I authorize enough to hold the patient until their regular doc returns. If it needs a hard copy prescription, I do my best. If the patient calls on a day's notice, and I'm not scheduled to be in the office that day, they're out of luck --you can skip doses of stimulants without getting sick. I suppose I feel a bit like the patient is turning their disorganization into my emergency and when I'm sitting on hold with the pharmacy, negotiating times the patient can pick up the script, or feeling a little uneasy about writing for a specific med, I'm left to wonder if there isn't either a more efficient or more sanctioned way of doing this uncomfortable task without causing people to simply go without their meds, offending the doc I'm covering for, letting the patients risk relapse, or insisting on seeing the patients,with all the muck of what if I don't agree with the treatment and how will I squeeze them into my schedule.

So what do other shrinks do?

And Blue is the favorite color of half of Shrink Rap
readers.

20 comments:

Gerbil said...

I have no prescription privileges; but in the past, my own psychiatrists would ask how I was doing with refills pretty frequently, including before a vacation.

Of course, this did require a little bit of organization on my part. But since I've been taking medications of one kind or another since I was 3 (and in charge of my own pills since I was 7 or 8) it wasn't anything I hadn't been monitoring for years anyway.

But it leads me to wonder whether Dr. Wellfleet et al are remiss in not doing a pre-vacation refill check; or whether I've just been lucky with the combination of well-organized shrinks and well-organized Gerbil.

Gerbil said...

Oh and PS: my favorite color is purple. I notice the only secondary color on the poll is green. Talk about a bad forced-choice paradigm! ;)

yay said...

It depends on the medications. If a patient runs out of anything except a stimulant, they can just get a script for it from their GP.

Stimulants here can have up to 6 months of repeats (usually dispensed at monthly intervals), and as the practice shuts down for two weeks per year (one between Christmas and new year, the other around Easter when we have lots of public holidays), it's not hard to organise scripts around that. If a doctor goes on leave at another time, the others at the practice have access to their files so I'm guessing it wouldn't be a problem like it is for you.

When I'm being a pharmacist, one of my least favourite problems to deal with is patients who come in because they've run out of morphine/dexamphetamine/diazepam/etc and their doctor is away and there's no-one who has access to their records and they're not from around here and they don't have a regular pharmacy and the doctor they went to wouldn't prescribe them 200 morphine 100mg tablets because they thought the patient was a drug-seeker...

I put black as my colour. I was having a bad day.

Aqua said...

I'm a patient, not a psychiatrist, but I can give you my perspective.

I know, for me, if I did phone at the last minute it would be because I put it off because I felt uncomfortable phoning in the first place; uncomfortable about asking for medication, lest I come across as disorganised, or stupid for leaving it so long, or "drug seeking"; uncomfortable about calling my own pdoc, lest I interrupt him; and most of all, if I discovered he was away....really uncomfortable talking to someone I don't know and trust.

I don't really understand how doctors control the medication they prescribe, but maybe it should be up to the person's psychiatrist to ensure his/her medications are up to date BEFORE they go on holiday...that way this wouldn't happen.

It would be fairly easy to create a spreadsheet of the medications prescribed to people and the date those medications run out.

If that was kept up to date after each prescription was handed out it would be easy to see which prescriptions run out the weeks you are off and take measures to update them before you go away.

I understand how prescribing meds to another pdocs patients must be difficult from your perspective and I'm not sure about other patients reasons for calling at the last minute, but I know for me calling at the last minute would be very difficult, and fraught with fears of rejection and judgement and fears about running out of a medicine that may have awful withdrawal effects.

Alison Cummins said...

I know what my shrink does. Starting at least four months before her vacation, she tells me she's going on vacation and checks to see if we'll be meeting before then. If we won't, she makes sure that the prescriptions she writes me cover me until our next appointment. (I see her about two or three times a year now; every two weeks when I first started seeing her.) She has nobody to cover for her when she's away. (Well, perhaps she makes special arrangements for patients who need them, but I wouldn't be aware of them because I have never needed them.)

Personally, I think it's unreasonable for anyone who both writes prescriptions he knows will expire during his vacation and who does not provide you easy access to his records to ask you to cover for him. Especially if he's prescribing controlled substances. That just sounds irresponsible to me.

At the least, he should give you a list of disorganised people whose prescriptions for controlled substances are going to expire on your watch, and discuss any particularly interesting prescriptions with you before he leaves.

I work in the corporate world and I ask people to cover for me all the time. All the work I do is on a corporate ERP and fully documented so that in theory anyone should be able to walk in and pick up where I left off. But still, if there's anything special in the works I make particular arrangements before I leave.

Am I missing something here, or is there a reason you are being expected to cope with someone's regular patients as if you were their regular doctor but without their regular doctor's information?

Alison Cummins said...

Also, this is a partly relevant article about handling last-minute requests for controlled substances from strangers:

http://www.memag.com/memag/article/articleDetail.jsp?id=415845&sk=&date=&&pageID=1

NastyPredator said...

Lifetime of antidepressants: diabetics need insulin their whole lives; ppl with thyroid disorders have to take their thyroid meds for a lifetime. same same same, no shame.

Rach said...

Isn't it up to the patient to take some responsibility and make sure their RX is up to date prior to their shrink going on vacation? I've never had to make the call of shame to ask for more meds (I've needed new meds... that's a different story) but maybe that's because I've organized myself in such a way to know to ask... or at least to find out how long the shrink is going to be away.

Also, when you Rx meds, do you give the patient repeats? wouldn't that help decrease the number of calls you get in this type of situation?

BTW, am I the only one who said my fav. colour is yellow?

Dinah said...

Gerbil: I tried to add purple, I'm not sure why it got eaten.

Aqua, and everyone else who thinks the doc should check on everyone's meds before vacation:
-- I have a small practice, this because I don't do med checks or split therapy, and still, I get calls about med refills pretty much every single day.
Logistically-- yes, I give refills on meds, they still run out. Because I've been in practice for years, some peeps only come in a couple of times a year, the numbers add up-- To go through EVERY chart and call every patient before I go on vacation would be ridiculous. Plus many people are on multiple meds and they each run out at different times (so yes, I'll get calls about the same patient several times a month, the meds can never be synced because of the insurance 30 day supply thing). And more logistics-- I often get called for refills in the evenings and the weekends or on days when I'm at the clinic and not in my office, a flow chart isn't feasible.
A full time private practice psychiatrist who does medication management (10-15 minute visits) carries a caseload of rougly 300-400 patients (in understaffed clinics, this can be as many at 1000).
The medications are the patient's responsibility-- a doc can't keep track, and there's always the unknown issues that patients don't run out when they should (forgot to take some doses, got refills from primary care doc without telling shrink, took relative's meds, and the list marches on, or ran out too soon: the meds that got left in a hotel room, eaten by the dog, etc..).

It would be nice if Dr. Wellfleet either checked on the folks with stimulant scripts (here they can't be refilled or phoned in) or trained them to call well in advance.
And Alison, if your doc knows she's going on vacation 4 months in advance, please please ask her to come organize my life.
Yay, no stimulant refills, and no office shut down without any coverage.
Rach, thanks for your input and you are the only one who likes yellow.

Aqua said...
This comment has been removed by the author.
NeoNurseChic said...

Can't comment from the provider's standpoint either, but I certainly can from the patient's!! There was a time when I used to wait to the last second to get refills on my meds - this was mainly a problem because I'd actually have a refill left on the med, but just wait to go to the pharmacy until the last second, and then they'd be out of that particular med and it would take a couple of days to get. And I'd be sick as a dog in the meantime off GI meds or headache prevents, abortives, and so on. I've learned my lesson!!

I've stated before that I am not the most organized person... So, I now have a system to manage the 7 meds I take daily and 3-4 other meds I take as needed. Just before I went on vacation to the shore in July, I filled them all......which was an expensive venture, but got them all finally on the same schedule. In PA, they can now give 3 month prescriptions (no refills) for stimulants, and since I'm on concerta AND ritalin, this is helpful. I try to fill them both on the same day. I have 3 different GI meds that are each 3 month prescriptions...that's helpful. My headache meds - well, I go to the neuro or the neuro NP every single month. For my triptan abortives, I get a script every other month (has one refill), and the NP never minds telling me if she gave me a script the month prior or if I'm due for a new one. I always fill my abortives and preventives at the same time - the same day of the appt each month. That way, I'm never stuck wondering what happened. My neuro told me a long time ago to keep backups of all my meds in a different drawer or in my parents' house or something so that I would never be caught on a holiday or weekend without my meds...especially given that I'm not always the most organized person when it comes to managing all this stuff!! All in all, I think I do pretty well with it.

My psychiatrist keeps a paper chart for me (at least, he has throughout his residency and fellowship, and I think he still does now), and there must've been some special sheet that he kept track of my prescriptions on. One month, I asked for a prescription for my concerta, and he checked the sheet and said it had been a long time since he gave me the last script and asked if I'd been taking it properly. I thought that was a good way to keep track. He didn't remind me to get a script when the time came due, but when I asked him for one, he checked to see how long it had been since the last one he gave me.

Because so often, I'll get to my appts and forget to ask for the scripts because I get talking about things, I have previously called his voice mail to let him know I need prescriptions the next time I come in. That way, I've already told him - and then both of us are working to remember!

Ultimately, I know it's my health care, my prescriptions, my responsibility. The times when I've forgotten to ask for refills and he's been away, I've simply gone without my meds. I realize I couldn't even do that with all the meds I take - I'd be in serious trouble without my GI/neuro meds, and I'd have to call whomever was on call, but for the ADD meds, if I miss a few days, it won't kill me. However, it definitely seriously impacts my job/functioning by not having them - which in turn can create a huge heap of problems. I nearly didn't make it when I was on orientation for my job because I tried to come off the concerta and was a mess without it. So I do believe it is an important/necessary med for me, even though not something I will die without.

Take care!
Carrie :)

NeoNurseChic said...

P.S. My favorite colors are actually blue and yellow, but you could only pick one, so I put blue!! My bedroom here at my parents' house is yellow though, as that is my other fav color. So Rach, you're not alone!! :)

Take care,
Carrie :)

Sarebear said...

I discovered a Firefox extension today, Bork. It Swedish Chef's stuff, among other things (you know, the muppet?)

It's Oogoost und I'm beck in toon. Psycheeetrists ere-a nutureeuoos fur tekeeng feceshun in Oogoost, I heer zeey ell gu tu Vellffleet. Suoonds vunderffool.

Hee hee. Sounds like you've been eating some brandy-soaked Black Forest Chocolate Cherry Cake (Germany was the closest desert that came to mind, to Sweden . . .)

Now I'm hungry. Darn it.

Well, I've called my shrink before, about out of meds or past out. The "past" out, was because I didn't want to be one of those calling at the last minute people, but then the effects get bad, so . . . but I still didn't want to bother them, so finally my ologist called my GP and arranged some samples for me to pick up.

I was too afraid to call the GP, either.

Course, this was back with my first iatrist, and I'd only seen him two or three times by that point, and DANG if he wasn't as intimidating as hell. It was after that that I started standing up for myself/standing up to him.

Anyway, sometimes it's fear, although maybe not in your covering cases, fear of an intimidating doc (the one you are covering for). Lots of reasons to be afraid.

Course, that's coming from someone who's afraid of just about everything, and not afraid enough of some things I might ought to be, of.

When I recently started Adderall, he told me to experiment with the dose (within a certain range).

Anyway, after that, s'more figuring out, experience, another apt, reporting back, discussing, etc., we started me on the XR form.

So, I nonchalantly tell my ologist at the next appt. the doses, since I had no clue any might be out of the ordinary, and whoa if he wasn't rather taken aback at the Adderall XR dose. I was taken aback at his taken aback-ed-ness.

My new iatrist says I'm a complicated case; as applied to your post, here, someone like that would not be easily asessable in a covering appointment anyway. Yet one more challenge in this matter;

I know I, personally, try to do everything I can (setting aside my frequent poor memory and forgetfulness/adbsentmindedness) to make calling in to the iatrist for a problem on a prescription, or a refill, etcl, as easy/convenient for them as I can.

It would be good if there were classes, in med school, for this type of situation. It'd also be good if there were "When your doctor is away or when it's a weekend or such and someone else is on call for his practice, etiquette/protocol/what to do" type of public education class or something. Because I know I've felt very unsure, very wary, and frightened even, during such situations.

Or when I had to call my GP's answering service, on a weekend, and they referred the doc on call for him as they traded weekends, to call me, as I was having that Lamictal rash reaction . . . I was very unsure and nervous about calling my own GP, even if someone else hadn't been on call for him, about an iatrist issue . . . so I was positively FRIGHTENED to speak with a strange GP about it; I could not get ahold of my iatrist (my first one) tho, that Saturday, no matter how hard I tried, and this issue couldn't wait 'til Monday.

SO. I've rambled, again; big surprise. I certainly don't think of any of you three as surrogate shrinks; I just like to relate my experiences, thoughts, and feelings as they relate to things you post . . . .

Alison Cummins said...

"And Alison, if your doc knows she's going on vacation 4 months in advance, please please ask her to come organize my life."

Um, doesn't everybody? Not being sarcastic, just demonstrating my limited experience and perspective! I think it's normal to be aware of a week-long to month-long trip well in advance and I am an extremely unorganised and undisciplined person, but I guess that's context.

I know in advance because I have to cooperate with my co-workers to ensure that we are always able to cover for one another. So at the beginning of the year we block out our vacation times, including 'tentatives,' to see if there will be any conflict. I take some time in the spring and summer, but I try to take my big vacation in September and arrange for extra time around the holidays. Sometimes I only know approximately, but I and everyone who works with me knows not to plan for me to be around in September. It's true, if it were left strictly up to me I would probably not bother to tell anyone until the last minute, except that in a group of four or five there's always someone who has it together and asks in advance.

Also, because we work for a corporation, we are assigned a set number of vacation weeks per year (four, in my case) and if we don't use them in a given year we lose them. So we know in advance exactly how much vacation time we need to plan. I guess this doesn't apply to you!

For my doctor, she knows because she visits her family in Uruguay. That's not a last-minute trip.

I think she also goes on drug-company-sponsored junkets ("conferences") in the Carribean, and those seem to have a shorter lead-time. Once she called me to say that she needed to move my appointment and would I need a refill?

jcat said...

I keep a spreadsheet of what meds I take and at what times because they change so often at the moment. So I automatically have a record of when I'll run out, and if I have any refills available. When it gets complicated, like now, I'll generally take a copy in for p-doc at each appointment. Makes it easier for him as well.

When he goes away, he'll generally advise the people who are on weekly appts 2 or 3 weeks in advance and give enough repeats to cover his absence plus an extra week. At least he does that for idiots like me who squirrel stuff - most people I guess are on longer scripts than a week at a time.

Otherwise, the 5 p-docs who admit at the same hospital cover for each other, and they can generally get access to each other's patient files within 24 hours.

And if there was really a major problem with what meds could be given, he also has the "secret cell" :-), the only phone that he actually answers of the 5 he carries around. Only the other p-docs and his family have that number. So the covering doc could get hold of him if it was really critical.

I'm disorganised about most things, except meds and appts with p-doc and t-doc. Those are all too important to me....

Rian said...

A couple of thoughts for you.

1) The 11th law of the dinosaur is relevant, here.

2) Good job on calling the pharmacies to make sure everything is kosher. Many covering doctors don't, and we see all kinds of crap behavior/deception as a result.

3) When in doubt, do what makes your life easier, if it's not harming anyone. If someone has been on a med for a while -- even a drug at a dose you may not feel comfortable with -- it won't hurt to fill it once, so long as you've verified that they are, in fact, taking that medication in that dosage.

4) It doesn't hurt to write "Covering for Dr. So-and-so" on the prescription. We see this all the time at the pharmacy, and it wouldn't hurt to have a little CYA insurance. You could also make a note of the conversation with the pharmacy in your notes should it ever become a legal issue.

5) Ultimately in this case, the pharmacist is your friend and ally. I think doctors forget that sometimes.

Gerbil said...

Dinah: obviously it was the purple people eater.

Midwife with a Knife said...

Dinah: It seems like a tough position for the patient to put you in, but maybe the patient doesn't realize the difficulties of being in that spot. I'd see her if I were you, after all, she has to physically come get the prescription anyway (or have it mailed to her). If she ends up waiting a bit or having to change her schedule to see you, it's sort of part of the consequences of her acting on running out of drugs so late.

Alison: I don't know I'm going on vacation 4 months in advance. Right now, I just know that there's no good time for me to go on vacation for at least four months. But I have four weeks of vacation a year, and I usually don't plan ahead more than 2-3 months (usually when call schedule requests are due), and then only to request a week or two without call so that I can take vacation if I decide to.

FooFoo5 said...

I worked in a county clinic, downtown, persistently mentally ill, homeless; 1 full-time doc, 2 part-time docs, a few rotating (i.e. one day per week) residents, and 1 nurse covering nearly 700 patients, the vast majority of which were "meds only." Friday was, without a doubt, an horrendous day for med refill problems (all week-end & "after-hours" issues were ER issues as we were not an acute care facility). Appointments were done on a "first available basis," so a patient didn't even necessarily see their original prescribing physician.

If you are "covering" or the "first available," at least you had the chart. But some docs are not as scrupulous as I would be about what they're doing, and as you say, prescribed medications & in dosages I would not. A homeless 60 year-old Bipolar man on a Schedule II stimulant for ADHD and a bezo to sleep? An older woman on 4 mg. of clonazepam who is falling out of bed. I don't think so. That prescribing colleague left us to undo his mess when he moved on.

Now toss in the issue of "lost" medications. Oh, the stories I have heard. And no one I recall called or came in looking to replace an antidepressant or an antipsychotic; always a Schedule II or a benzo. "You just filled it last week." "I know, but I was at the beach asleep and the tide came in..." Go to the ER.

I believe the police had to be called to our clinic over irate patients and medication re-fill issues than for any other reason. Friday, 4:15 pm: Showtime!

Then at 4:50 pm, in walks the guy who says, "The ER doc told me come here to get meds..."

I do not miss this madness.

Anonymous said...

Such universal issue. I had a similar issue with a colleague. I had to turn down the request to cover at one point because I was really over-extended at the time. After that, my colleague just developed the habit of trading with someone else. Cross-coverage is "built in" to my current position.

I've always thought this was ironic: Sched II meds require paper scripts in person for the class of meds for the very group of people who are least likely to plan ahead. Since this discussion started, the DEA permits writing multiple stimulant prescriptions, if you specify the first date they can be filled. Maybe this summer, all will go smoothly. http://www.fdalawblog.net/fda_law_blog_hyman_phelps/2007/12/dea-final-rule.html

I reviewed some of the replies to the post: a spreadsheet would never work. I always ask my patients what meds they are taking--actually taking--when they come in. People often do not follow the directions properly, go off the meds for a week or two, take half of the amount of medication they are prescribed, skip some days, misplace a bottle, take a few extra because they are stressed--so no matter what you do as the physician, you can only keep track of what you PRESCRIBE. Ultimately, you can only hope the person has the sense to follow the treatment plan to which they agreed.

A private-practice colleague should be warning people a few months in advance. If the patients are always calling at the last minute on Friday, maybe he should give you a verbal run-down of the borderlines &/or ADHD-ers who might call last minute. When you discuss the cross coverages, you might mention what a relief it is that the DEA changed the position re: stimulants and mention that you get stuck with a lot of stimulant requests when he is away. Maybe you can leave on your outgoing VM that medications for scheduled substances require the person's pharmacy phone number (so that you can verify the prescription with the pharmacist)and can take up to 72 business hours to process, they must leave ph# where they can be reached or no script. Stimulants are important meds, but most of the folks will just be a little more disorganized during those days (thank goodness antipsychotics are not schedule II...).

If you are tucking your patients in before you go out of town, and you are still getting all these calls, maybe you should consider swapping with someone else. If you happened to have vacation during the same time as the colleague you usually trade with, and the colleague had to get someone else to cover, it might be an opportune segue for you--Dr. Freud, I would really like to cross cover for you like we have done for years but since last time I have been trading with Dr. Kraepelin, so I am not able to take on another cross coverage at this time. Thanks for thinking of me!

Anyway, I have been there. Those cross cover calls for stimulants--or worse, Prior Authorization-- always come Friday at 445pm. Good luck!