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