SABOTAGING My Patient Care By SYDNEY CRACKOWER
Sydney Crackower, MD, is a family physician practicing in Abbeville, LA. This article is adapted from "Pharmacists Were Sabotaging My Patient Care, " by Sydney Crackower, MD; copyright 1983 and published by Medical Ecol1omics Company, In c. at Oradell, NJ 07649. Reader response to Viezupoint articles is welcomed.
s we all knaw-but tend to' averlook-pharmacists are an essential link in the chain of patient care. Most af them, I'm sure, are responsible and ethical prafessionals. But there are some whose questianable practices can threaten our patients' health and even their lives.
Disturbing Fact That disturbing fact gradually dawned on me last winter, when dozens af peaple I hadn't seen in
years came to me with acute illnesses, mastly upper respiratory infections. One was a middle-aged man I'll call Jones. His chart reminded me that I'd prescribed medicatian far his hypertension four years earlier. Once a patient's hypertensian is under cantrol, I always tell him that I want to' see him every three or four manths, but Jones had ignared that instructian. His blood pressure was now 170/100.
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Myoid prescription was for a month's supply of the medication, and I'd allowed three refills. So I was shocked to learn from Jones that, at his request, his pharmacist had been refilling my order regularly for four years .
Finding Out I began to wonder whether other patients of mine were obtaining unauthorized prescription refills and whether other pharmacists were dispensing them. The answer to both questions turned out to be yes. Over a six-week period I learned , by questioning my office patients, that nearly a third of those I'd placed on maintenance medications in past years were continuing to get refills without my authorization but with my name still on the prescription labels. By merely requesting them from certain druggists, they were getting illegal refills not only of maintenance drugs, but also of antibiotics, cough preparations, decongestants, oral contraceptives, and other medications .
Alarming Consequences The consequences to my patients were alarming. To cite a few examples: • One woman came to my office complaining of chest ,pain and dyspnea. Examination revealed a loud heart murmur and a blood pressure of 1801100. I hadn't seen her in two years, but she assured me that she'd been religiously taking the medication I'd prescribed at her last visit. Her friendly neighborhood pharmacist had continued to supply it, although the prescription was 18 man ths beyond expira tion. I referred her to a cardiologist, whose angiography demonstrated significant myocardial ischemia. • A 35-year-old woman I hadn't seen in four years was still taking her oral contraceptives, although she no longer had a valid prescription. During that time, she'd had no pelvic exams or Pap smears. She'd recently been spotting and had attributed this to breakthrough bleeding un til the flow increased
Surprl . he confessed lliat he had been li'ling my prescJ!i~tions ilieg~_IY. enough to worry her. A Pap smear now revealed Class III cytology, and a biopsy led to a diagnosis of cervical carcinoma. • Another woman recently came to my office with bronchitis. In the course of the visit I noted that I'd started her on medication for hypertension five years earlier. Since then she'd been making regular visits to her pharmacist (but not to me) and continuing to take the same medication. Her blood pressure was far above normal. When she left, I telephoned her pharmacist and asked him how many refills I'd allowed on the prescription. After several minutes of hemming and hawing, he said he'd have to call me back because that information was in his computer. I didn't expect to hear from him again, but he did call back half an hour later. Surprisingly, he confessed that not only had he been refilling my prescription illegally, but he'd received it from another druggist several years before. I asked him whether he planned to go on handling prescriptions that way, and he agreed to toe the line in the future. • Soon after that incident, the same pharmacist sent a patient back to me. / Years earlier, I'd allowed her three refills of a 40-capsule prescription for
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a tranquilizer. The pharmacist, however, had continued to supply her with the drug until my phone call made him stop. Sadly, it became obvious to me that after six years, the patient was' addicted. • Another pharmacist I'd admonished finally sent an elderly man back to me after illegally refilling his Dia.,. binese prescription for three years. The patient was disgruntled when I refused to write him a new script for the same medication. He sang a different tune, though, when a serum glucose test done in my office two hours postprandial read 350. The man hadn't had his blood sugar checked in three years. During that time, he'd continued to take the medication regularly but had paid no attention to his diet or the symptoms he was experiencing.
Stopping the Abuse In my frustration and anger, I pondered what to do about these foul-ups. My first thought was to write the state board of pharmacy listing the names of the pharmacists I knew to be in violation of the law, the names of the medications involved, and the names of the patients to whom they' d been illegally dispensed . But I rejected that plan because my objective was not to punish the abusers, but only to stop the abuses. I'd already accomplished that in two instances simply by informing the offenders that I was aware they were refilling my patients' prescriptions without proper authorization. So I decided to use the same approach with th~ other pharmacists who had been causing trouble. Not all of them took my complaints calmly. One angrily shouted that I had no right to interfere with the pharmacist-patient relation,s hip. "Until now I always thought we were good friends," he told me. "Well, the friendship is over!" After he hung up, I realized that I hadn't made my point about how I expected him to handle my patients' scripts. I did that in a letter to him the next day. In it, I also told him how I felt
about his "playing doctor" and assured him that I'd report him to the state board of pharmacy if he continued to refill scripts with no more authorization than the patient's request. Apparently he got the message; since I wrote that letter he's sent many patients back to my office to have their medications reviewed. But he can't resist telling them I obviously want them to return only because I'm hungry for office~visit fees.
Time to Explain If any of my patients ever thought that about me, I'm sure they know better now. Lately I've been taking more time to explain to them why periodic re-examina tions are necessary and why they need a particular medication for a particular condition . Through my counseling they've come to understand that the few pharmacists in our area who make
One pharmacist angrily shouted that I had no right to interlere in the pharmacist-patient relationship.
a habit of dispensing more prescription refills than the doctor allows are not acting in patients' best interests. A number of my patients have recently switched pharmacies for just that reason. In a further effort to safeguard their health, I now stamp "Refill only as directed" on every prescription I write.
Gain by the Rules If the relatively few pharmacists who ignore physicians' restrictions on refills do so to increase their busi-
ness-and I can't imagine any other motivation-then their reasoning is flawed. True, there's some chance that the patient returning to his family MD for re-evaluation of a medical probJem may be taken off his current medication. But more often than not, he'll present another major or minor problem that will also require medication. As a result, the pharmacist usually gains, rather than loses, when he plays by the doctor's rules. My purpose in writing this article isn't to persecute our pharmacist friends, but rather to urge physicians to check on whether their patients are receiving medications without proper authorization. If they are, physicians needn't fear hurting their reputation with patients by telling them so. Based on my experience, I'd say they'll appreciate this demonstration of your concern for their health. 0
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