Category Archives: Doctors and Stuff

Brain between your ears, not in the palm of your hand

This entry is dedicated to all of the PA’s and NP’s out there who use a hand-held device (palm pilot, iphone, whatever) to dose medications.

STOP FUCKING USING THEM.

Lets be completely honest here. We are both professionals so we can have this conversation.  Do you really think a welfare mother of 4 is going to have the mental horsepower to measure anything other than what is clearly marked on a measuring spoon?  Do you think they can comprehend the idea of anything smaller than 1mL?  Do you really believe in their ability to use a dosing syringe and draw up liquid to a big black line which I draw on there with a sharpie?

No? THEN QUIT WRITING DOSAGES THAT REQUIRE THEM TO DO THAT!

If you cannot use some common sense and round up or down dosages of amoxicillin or Prelone to either 1/2 or 1 full teaspoonful, then please save us both the trouble and write for something else which can.  Seeing dosages of 435mg tid of amoxicillin suspension just makes me wish that you didn’t have prescriptive authority.  I’m just going to round up to 500mg, and when you call me to bitch, I’m just going to tell you to use a little common sense and less calculator.  I’m also going to tell you that the idiot mother in front of me (who has yes to realize that penis + vagina = kid) doesn’t have a snowballs chance in hell in measuring what dose you initially wrote for.

Idiots who write super-precise dosages like that are the retards in college that score 100% on the tests, but can’t apply that knowledge to any real-world situation to save their life.  Unless you are dealing with a hospital staff with very narrow therapeutic drugs, whats the point of writing dosages like that?  Are you proud that you can do math using mg/kg units?  Are you proud that you have a program that figures out the dosages for you?  Have you ever in your life seen the thick pink amoxicillin death that you wish to be dosed out to .004mL digits?

When you write for those dosages, think for a whole 2 seconds knowing that amoxicillin comes in 125mg/5cc (1 cc = 1 mL in case you didn’t know), 250mg/5cc, and the ever not-used 400mg/5cc.  Now, use your math skills and shoehorn the dose that the stupid palmpilot program gives you into one (1) of those dosage bottles so the twatmuffin mother will give 1/2 or 1 teaspoon.  If you can’t, then just round up.  If some kid dies from getting an extra 25mg of amoxicillin, then obviously your diagnosis was so far off you shouldn’t be practicing.

Finally, please, when the pharmacist comments on your dose over the phone, don’t just blow him/her off with a “uh huh” and proceed to write again for stupid dosages.  That just makes us angry (and you get a rant written about you).

Truth about DAW-1

I really get angry when I see a DAW-1 on a prescription.  To me, a DAW-1 without a good reason is like saying “Hey pharmacist bitch, do what I say right now because I’m the doctor and I know whats best in drug-land”.  Bzzt, welcome to AngryPharmacyLand.

For those who don’t work in medicine, a DAW-1 means “Dispense as Written code 1” (There are a bunch of DAW codes to signify different things like “Generic not available”, “Brand dispensed as generic”, etc).  However a DAW-1 is doctor speak for “I want this Rx to be exactly how I want it, I don’t want any changes/substitutions made”.

Now some doctors are confused.  Lets indulge ourselves into what a DAW-1 means from a pharmacist standpoint.  You see, DAW-1 (to us) is meant to be used when a doctor wishes a BRAND NAME medication used instead of a FDA approved generic.  Most (if not all) states allow the pharmacist to auto-substitute a generic when the Dr writes the brand name on the pad.  This is great because I’d rather have doctors write Maxide instead of  triamterene/HCTZ.  Brand names are shorter and (especially with birth control) a whole lot easier to deal with. 

If a Doctor gets a wild hair up his/her ass and wants trade name Maxide (HAHAH!), they would write Maxide (DAW-1) while checking and initialing the little box by where they sign their name (which NO doctor can seem to get right) to prove that they indeed want the brand name dispensed instead of the generic substitution.  This also can be noted by putting “DNS” for “Do Not Substitute”.  Again, the checking & initialing the little “Do Not Substitute” is beyond an MD education.  If you cannot get this right, then obviously there should be some question as if the DAW-1 is education driven, or some big-titted drug-rep driven.

Whats funny, is when doctors (but mostly PA/NP’s) put DAW-1 on EVERYTHING thinking that it means something.  Diovan (DAW-1), Lipitor (DAW-1), Zyvox (DAW-1).  Now you (and only you) may feel like you are doing the world a favor by putting DAW-1 on a bunch of Rx’s for brand-name-only products, but you’re just looking like an idiot to us pharmacists.  You may think you are actually doing something via the DAW-1 code, but I hate to tell you, most states do not allow us to substitute completely different drugs, only a brand name drug to its FDA-approved generic.  So you are telling us DO NOT SUBSTITUTE a generic for a drug you wrote that has no generic out.  Way to go! You’re a winner!

Wait, you think that the patients insurance company will give 2 fucks about your DAW-1? Hate to tell you, but for all they care you can take that DAW-1, roll up really right and shove it straight up your ass.  99% of the insurance companies laugh at your DAW-1 and make your ass fill out prior-auth paperwork in lieu of putting DAW-1 on the Rx.  Even if they do take the DAW-1 code, they just make the patient pay full price (or just flat out refuse to cover the medication).  Now the patient gets no medication because you are too hooked on the pharma-pot-pie to “settle” for a generic (and the patient cant afford the brand name).  A winner is you! Thats patient care right there!  Remember, patient care does not start with you, it doesn’t start with me, it starts with whoever is footing the bill.  Who pays for the drug makes the rules for the drug (unless your patient wishes to pay for it, but we all know the F in Pharmacy stands for “Free”).

All kidding aside, I’ve seen loads of doctors do DAW-1’s for really stupid shit (like psycho endocrinologists for Glucophage, Glucovance, Amaryl, Glyburide, etc) only to have the patient be SO noncompliant that I could fill the vial up with cow-shit and get more therapeutic response than your DAW-1’d drugs.  Is it my job to make sure they take their medications? Sure, I blow them shit when they are 2 weeks late getting it filled, but I’m not their fucking nanny.  Teachers are also notorious for wanting trade-name stuff because they “deserve it” (and know SO MUCH MORE THAN WE DO).

Really, if you prescribers in the audience really want to get your point across with this DAW-1 bullshit, you are better off telling us WHY the generics cant be used or WHY the formulary cannot be used (brittle blood levels with warfarin/tegretol).  It’ll make it seem less bossy than DAW-1 (bitch!), but maybe (just maybe) we can save you a ton of time by faxing you the proper forms to sign or point you where to get that prior auth.  Give us more “here is why I want this” vs “I just want this because I can”.

So what do we do when a patient brings in a DAW-1 Rx that the patient cannot afford, and the doctor refuses to change it to something else?  The patient is now put into a position where he/she feels they need this super-expensive medicine that their “Obviously” intelligent doctor wants for them.  Never mind the fact that the pharmacist has about 3 alternatives up his sleeves that might not work quite as well as what the reps spout, however its affordable and wont take food off of the patients table.

Here is something else to consider.  Patient brings in a prescription for Drug-X that is DAW-1 for some reason.  Patient cannot afford the $200 cost and the doctor (being an ass) refuses to change it to something else that costs less.  Now the patient either forgoes treatment because the doctor wants THIS and ONLY THIS (even though a $12 generic might not work as well, but its better than nothing) or forgoes buying Xmas presents for their children or some other Quality of Life lowering factor due to the $200 they dropped for this drug.  Or worst case they just go without and get nothing.  Pisses me off when I call the doctor asking to change, and him/her (or one of their front end ‘staff’) says “Nope, we’re not going to change”.  My response is “Good idea, the patient can’t afford this, so now they will take nothing.” Asshats.

There is /always/ some sort of drug alternative in medicine. Sure it may not work as well or be exactly what you are looking for, but having the patient not take/cant afford the medication due to some drug-rep telling you that “this is new and better” when you had been using drug x for the last 20 years before it went generic last week is (to me) bad medicine.

The woes of new prescriptions

Lets face it, pharmacists are between a rock and a hard place when it comes to new prescriptions.  To be more blunt like this, we get bent over and the only choice is between what brands of lube we do (or dont) get.

Verbal Call Ins:
Usually from someone who has close to zero medical knowledge, these abortions of our profession are littered with “I think that’s….” or “Does … exist?” by some high-school student who is trying to decipher the same handwriting that took us a college degree to learn.  Add onto the fact that most doctors are notoriously cheap (or foreign) thereby hire the bottom of the barrel staff who either know nothing, don’t speak English clearly, mumble, speak softly or all of these.  Although I thought that having Methotrexate 0.2 mg called in by an OB/GYN was a mistake, it however didn’t take the office staff to say “Well I couldn’t really read it” when I called back to make damn sure they meant Methergine.  Now only an idiot can confuse MTX with Methergine, but the point is still there.

Now there isn’t a good way to handle this short of having the prescriber him/her/itself call in.  However, there are a TON of doctors who I cant understand what the hell they are saying, so we’re back to square one.  The prescriber can however hire people who speak CLEAR and LOUD english on the telephone.  However if their girls misspoke on the phone and someone dies, unless pharmacies have call recording software nothing will happen to the MD and his marble-mouthed liability.  They will just show on the chart it was written correctly, taken verbally by Pharmacist-X and that’ll be the end of their accountability.  Pretty sad to know that your career/livelihood is being held by some idiot who cant point to where her rectum is.

So, solutions?  One is pretty damn good that I came up with all by myself (go me).  If a doctors office has someone call in an Rx that you cant understand what the fuck they are talking about, tell them “Excuse me, but I cant understand a word you are saying.  Is there someone there who can call in the Rx for you?”  Sure you’ll offend the person on the phone, but both herself and the Dr should KNOW BETTER.  If the Dr gets pissed, ask if you would like that person calling in Rx’s for his/her family.  See, Dr’s like to get pissed off about things, but most of the time if you hit them with the logic bat (ie: ITS UNSAFE) then they can be pretty receptive.  I’d rather hurt the feelings of some young “nurse” who cant speak the English than hurt the feelings of an entire family because she called in something incorrectly and killed someone.  If we stand up and address the problem then it won’t be as big of a problem.  If we just accept it and let them vowel-guess us to death then it’s just going to get worse.

Now not to belittle techs, but lets imagine a time when a Tech can get a New-Rx over the phone by one of these marble-mouthed idiots.  Yikes!  That right there is pharmacist double-penetration with no lube.

Because today’s society we are so afraid to say to people that they cant speak clear English. Some company (and computer programmers who have NEVER EVER EVER stepped foot in a pharmacy for more than 20 min) created ePrescribing (such as SureScripts)

I’m not going to go into how absolutely EASY it is for anyone who has ever worked in a doctors office to call in phony Rx’s.  Hell, with how substandard the people calling in Rxs have gotten I would take a new one from an autistic dog for Norco without any suspicion (that’s if they actually called it by Norco, instead of Vicodin 5/325 *sigh*).

Seriously doctors, make your life and mine a whole lot easier (and safer for your patients), hire someone who knows what the fuck they are doing.

ePrescribing:
Touted as the next best thing since prepackaged drugs, the ePrescribing system is going to become mandatory in a couple of years.  All doctors will be able to go to their computers, click away and have their Rx magically zipped to the pharmacy of their choice!

Like taxes and welfare, this is a system that looks better on paper than how it really is.  Take this example to my right. 
erx-levaquin.jpg 

Now I’m not sure about you, but if I were some tech who didn’t know any
better and was just hammering out the Rx’s while my pharmacist sat around and drank coffee, I would fill that as Levaquin 750 #5 – 1 tablet 4 times daily.  Thats what it says right?  Now all of the pharmacists reading at home are giggling, the doctors are sighing, and the dentists are wondering what the problem with this Rx is :).   Now I’ve been out of school for a while, so there might be some indication for 750mg of levaquin 4 times a day.  Wait, there is.  Its called WRONGITITS.  Its called the QD and QID drop-down boxes were so close together that someone clicked the wrong fucking one and the Rx was verified and sent out (by the “Dr”).  If a tech filled that and the pharmacist wasn’t on his game, that would of went out vs having the pharmacist on the phone saying “4 times a day? You’re on crack girl-who-cant-speak-english!”  How would their software even allow that to go out with such a blantant mistake?  This isn’t rocket science folks, certain drugs are commonly taken either once or twice daily.  Its very RARE we see a modern (ie: still trade name only) drug that has to be taken 4 times a day.

Is there a cut and dry solution to this problem? Yeah, give pharmacists prescriptive authority like you’ve given everyone else with letters after their names. πŸ™‚

Paging Dr Dave… Your douche is ready..

Out of your options for refusing to help with the current (non)
cutbacks (see, that is what a court order does genius, STOPS something
from being implemented, hence NO 10% cut….oh, skip trying to explain
THIS to a pharmacist) I must take option 3 below.

Genius? Me? Did you even read the first paragraph of that last entry? You know, the one that I said “However, last Saturday the courts overturned the ruling until 8/11/08. Their computer systems still have the 10% cut, but they will let us know how they wish to deal with that ball of wax once the shit stops falling from the sky in the legal department.”
Update: Got the fax yesterday saying that the 10% cuts are here to stay. The injunction was injuncted upon by yet another injunction reversing the injunction-junction (whats your function). Yeah, I cant believe it either. This is really going to suck.

1. Lazy
2. A dick
3. Think so little of us that you don’t give two shakes of a mouses
dick what happens to us.
4. Have some ill-gotten god-complex that fell out of fad about 20 years
ago when managed care/insurance companies snipped off your scroatum and
dangled it in front of your face while saying ‘HAW HAW’
4. All of the above
Since most pharmacists I have to deal with here are 1, 2, 4 and (the
other) 4 (with THAT counting ability can you wonder why I doubt the
competence of most people in your business? 5 comes after 4 genius!). I
really think 3 is my own position. Sorry you won’t get a 150% markup on
your generics for a while, but in case you didn’t notice, the Feds
tried to do the exact same thing to us, and it fell through too. The
10% cut will also die on the vine thanks to the court order.

Yeah, I did put 4 twice. Sorry, my mistake. Thanks for pointing that out to me in the most asshole way possible. I originally had 4 be “all of the above”, but then I decided to add something in about the god-complexes that you oh-so-quaintly have shown everyone still exists.

Unless the PHARMACISTS start lobbying. When they are through WE will
have to pay the State….

Uh, we’re lobbing the hell out of the state. However lobbying does only so much when the state is 1000 trillion dollars is debt.

Here is my own quiz, based on the previous model:
Most, but not all pharmacists are:
1. Lazy
2. A dick
3. Think so little of everyone BUT themselves that they don’t give two
shakes of a mouses dick what happens to us.
4. Have some ill-gotten god-complex that fell out of fad about 20 years
ago when managed care/insurance companies snipped off your scrotum and
dangled it in front of your face while saying ‘HAW HAW’
4 (which SHOULD be 5 – leave it to a pharmacist). All of the above

Thats cute, just copy and paste what I wrote. I can see now how you got through medical school.
— Round 2 —

I am NOT a chronic pain patient, I am a practicing physician and I am
absolutely sick and tired of idiot pharmacists having a bad day calling
me to tell me what I fucked up on my scripts.

Then don’t fuck up on your scripts πŸ™‚ Seriously, do you think we want to sit there and waste our time calling your obviously unhappy soul to tell you what you messed up on? Do you think it gets us off to be yelled at by some doctor who obviously takes his frustrations out on his office staff and the pharmacist who calls to save his ass? No.

If I wrote a particular
treatment prescription I did it for a reason. Please don’t argue with
me as you attempt to be so many amateur physicians. I realize that you
went to 5 years of school to learn pharmacology, and I respect that.
What I can NOT stand is that fact that none of you seem to respect that
I and my colleagues went to school for 10-12 years and, whether you
want to hear it or admit it, know a fuck of a lot more about medicine
and pharmacology, and more importantly how they interact and will
effect OUR patients than most of the arrogant, self absorbed, insecure
pharmacists that call to tell me I can’t prescribe A with B.

See, the fact of the matter is that if we just “fill the prescription” and the patient dies due to your arrogance and stupidity, then we are at fault just as you are. However if we call and you make our requests known (and obviously document it), then when your arrogance and “10-12 years of school” kills someone (or lands them into the hospital), we don’t get hauled into court. Well, I take that back, we do get hauled into court, and there is no doubt that you would lie and say that you didn’t talk with us about our concerns.
Now due to the condescending asshole tone of this email, I have no doubt in my mind that if we are sitting both in court, the very first thing you would do is point at me and said “THE PHARMACIST SHOULD OF CAUGHT THE MISTAKE” (even though you bitch here that we bug you too much).

Shut up
and fill the fucking scripts unless you are damn sure there is a
mistake. As I get at least two dozen calls a day between “corrective”
calls about my prescribing and suspicions about my patients that I
prescribe anything stronger than Ibuprofen, it gets ridiculous.
Pharm D? THAT is a fucking joke!

Two dozen calls a day? Okay, either this figure is way out of line, or you are prescribing some really shady shit to some shady people. “Just fill the fucking script” doesn’t quite work if the patient received 100 norco from another pharmacy yesterday.
You see Dr Dave, this whole situation really smells fishy. Most pain management clinics really have no problems with pharmacists and pharmacists don’t have a problem with them UNLESS a huge red flag comes up. If “two dozen” pharmacists are calling you about your “prescribing and suspicions” about your patients then obviously you aren’t just giving out Amioderone to a patient on Warfarin (which your ****10 YEARS OF SCHOOLING!@!@#!@$**** should tell you why that one is a biggie). So tell us Dr Dave, how many gallons of Norco do you write out on a daily basis to have all the pharmacists on alert? Have your Rx’s (and patients) been booted out of every pharmacist in town? Is that why you are so hateful?
You see, part of being a pharmacist is that you get good at sifting through the bullshit.

You’re either with us or … a huge douche!

As you have read before, California instated a 10% cut for its Medicaid Rx reimbursement.  However, last Saturday the courts overturned the ruling until 8/11/08.  Their computer systems still have the 10% cut, but they will let us know how they wish to deal with that ball of wax once the shit stops falling from the sky in the legal department.

Now, I don’t do this very often so you might want to bookmark/take a picture of this page.  The doctors have done a tremendous job in helping the local pharmacies keep their doors open and their paychecks from bouncing.  They have been more than receptive and more than helpful in switching their patients to generic drugs with little to no prior notice.  For how much shit I talk on doctors on here, they really helped us out.

However (you knew this was coming):

There seems to be a few doctors in town who did not get the memo.  You see, when we fax you a nice little note explaining the cuts and if we can switch our patients to something that cost less (so we wont lose money when we fill what the drug reps sucked you off to prescribe), and you write a big NO on it, that really upsets us.  Its not like you’re a cardiologist or writing for weird stuff like Tekturna.  Denying our request  from Nexium to OTC Prilosec isn’t rocket science, and obviously you must of slept through that class to realize how much power pharmacists have.  In fact, blanket denying everything that we send you to switch with a NO means that you are either:

1. Lazy
2. A dick
3. Think so little of us that you don’t give two shakes of a mouses dick what happens to us.
4. Have some ill-gotten god-complex that fell out of fad about 20 years ago when managed care/insurance companies snipped off your scroatum and dangled it in front of your face while saying ‘HAW HAW’
4. All of the above

Like I said before, this isn’t rocket science.  If I would of said that the insurance didn’t cover this medication you would of switched it in a hot second, but because we asked for a professional favor you decide to shit in your hand and rub it in our faces.

However, Pharmacists (believe it or not) like to take the high road.  So when your patient has a stupid medical question like what to take when they are constipated, we will not refer them to you and waste your precious doctor-time.  When potential new patients come and ask what we think of you, we won’t say that you are a flamboyant small-penis douche who hates pharmacists.  We wont make you wait an hour on hold or happen to forget to fax over that med list that one of your dropout front-end girls called and sorta-asked for in something-that-resembled-english.  I’ll look the other way when your minimum wage hired help totally fucks up.  Oh, and when you call me personally for a favor, I will (with a smile on my face), not bring up the time you totally FUCKED us when the cuts happened.  You see, we have professional courtesy, and even though you may bad-mouth us to your patients, we spend 10000x more time with them than you, so they’ll STILL come to us regardless what you say.

To all the doctors who stood up to help small pharmacies stay in business during the cuts, we love you.  We’ll refer patients to you, we’ll sing your praises from when the gates open until the gates close.  We’ll buy you drinks at the CE dinners (heh, they reps buy the drinks, but they dont know that) and run medication by your house late at night when your kids are sick.  We’ll cover for you when you write that Amoxicillin Rx to someone that you knew had a Pencillin allergy but just brain-farted.  We will drop everything to happily look up something that you just as easily could of looked up on your palm-pilot.  We’ll give you our cell phone numbers and open the store at night for those once-a-year emergencies involving a screaming grandchild, zithromax suspension and some auralgan (the original cheap one) drops.

To all the doctors who decided to not answer our pleas for help.  Eat shit.  The cards are down, and we know where you stand.  We will still treat you with respect, but excuse us always looking over our shoulder for the knife when the shit hits the fan.  We are more than just pill counters, and you are damn lucky that (unlike you) we have the moral and ethics to show you exactly how much influence over the patients we have.

Paging Doctor Sandy Pants…

The original post is here. TAestP didn’t want to field this one, so hell, its my duty to stand up for my loyal readers.
http://dinosaurmusings.blogspot.com/2008/05/rant-alert-attention-pharmacists.html

To the friendly, trusted neighborhood pharmacist who told my 74-year-old diabetic patient with coronary artery disease and arthritis to stop his Zocor because maybe that’s what was making his knees and hips hurt:
You fucking moron! Do you have any idea how hard I worked to get this guy to take this stuff in the first place? Do you know how long it took, how many visits over how many months of teaching, explaining, describing, convincing, persuading, cajoling and begging to get him to agree to even try this medication in the first place? Are you even aware of evidence-based guidelines that recommend statins for patients with diabetes and CAD? I assume you’re aware he has these conditions BECAUSE YOU FILL HIS FUCKING Avandaryl, Diovan and Procardia!
And guess what, asshole: his knees and hips still hurt. Think it might be osteoarthritis? You think you’d never seen that in a septuagenarian before.
So thanks for nothing, fucktard. No matter how hard I work my ass off trying to educate my patients about the need for their various medications, you go and undo it all — why? Because you can? Just to prove to yourself that patients hold you in higher regard than they do me? Think I can get you named as a co-defendant when he has a stroke and the wife sues because I wasn’t following the guidelines? No, of course not. You’ll just keep smirking there behind your counter, saving poor patients like him from us arrogant docs whom you claim don’t know one tenth as much about drugs as you do. Well guess what, you cum-burbling trout-fucker [thanks, CrankyProf!]: you may think you know all about drugs, but you don’t know the first motherfucking thing about using them in people.
So why don’t you go down a bottle or two of tylenol and chase it with a quart of vodka for good measure. Your basal metabolism is contributing to global warming, and there are slime molds who’d make better use of the oxygen you consume.
End Rant.

Are you mad because we undid your work with one statement what took you a while to accomplish? A bit bitter because your patients listen to US over you? Its okay, heres your ID card; Join the club. Not my fault that we spend more time with your patients than you do. Maybe if you didn’t take appointments and allowed them to just walk in to pester you they would think the sun rose and set on the crack of your ass like they do their pharmacist.
Now, after you have washed the sand out of your neither-regions, should you also maybe take what your patient says with a grain of salt? Say, like when YOUR patient comes to us and said “Doctor said I can have my Soma early”? Because we /all/ know that the PATIENT never gets what you say wrong. NEVER EVER.
Since the patient said that their knees and hips hurt, they probably pointed to their legs and said “It hurts me here”. I’m sure the pharmacist said “Talk to your doctor, the pain could be because of your Zocor” and the patient took that as “Stop Zocor”. Hell, the pharmacist could of said “Your Zocor is no longer covered, I’m faxing your doctor” as “Doctor told me to stop”. Old people don’t hear things correctly, you know this and I know this. I don’t care if another person “heard them say it”. If a doctor called me over something as stupid as this I would just say “yeah, whatever *click* ” just so you would stop wasting my fucking time. You don’t see us calling you to bitch you out for having a bunch of morons phone in your prescriptions and all of the retarded errors they make.
If the patient initially didn’t want to take Zocor (which you said that he didn’t) then don’t you think that MAYBE he was looking for the tiniest reason to stop taking it even if it meant taking things completely out of context? If your patient refuses to take it and dies, its not your problem. You said he should be on it, he doesn’t want to, end of story. Your patent could just be getting it filled and NOT taking it. Ever think that? Happens all the time. Just decided to rant on poor pharmacists over something stupid that your patient did.
Oh, and to shit in your punchbowl some more – if a 74 year old dies, I doubt they will sue you for not following guidelines considering HE’S FUCKING 74! Why doesn’t his wife sue God while she is at it. You should of made your story involve a 45 year old to make this point a bit.. uhh.. less retarded.
Heres an idea, Maybe you should have the Avandryl and Diovan reps talk with your patient, we all know that you’ll do whatever they say – maybe your patient will do the same.

ATAP: Medication changes and how I deal with them

I received this question from a doctor who frequents the site:

I have a question regarding changes in medication. I am a physician.
The way I usually handle it is that I tell the patient the new dose and
then write a prescription to reflect that dose. I then tell them that
they’ll have to go in earlier than usual to get a refill and to use the
new prescription to let the pharmacist know that the dose has been
changed. Is that the best way to handle it?

This is an excellent question. I far far too often have patients tell me (when they are out of medication) that doctor has changed the dose. Usually this is on a Friday night about 10 min before closing.
In the case above, you, Dr, are doing the correct thing. Seriously, I cannot express this enough that writing a new Rx for the patient to bring in (or fax over from your office) is the absolutely best thing to do. Telling the patient about the new dose is like talking to the sky (or filtering piss out of the ocean). I have seen more mistakes with patients getting their pills mixed up and taking double on something they shouldn’t have. Usually things turn alright, but when they get instructions to double up on their HCTZ and instead double up on warfarin, things turn sour really quick. If doctors always assume that their patients cannot wipe their own asses without written instructions, the world would be a better place.
This is what I do with a sig/dose change for which the MD has done “The right thing(tm)”:
When the patient comes in, I get the new Rx in hand, and right then I have verification that the dose has indeed been changed which I input into the computer and fill the Rx (if they are out). If the patient comes in and still has some medication at home I put the changed Rx on file, and if the drug & strength are the same I print out a new label and tell the patient to apply it to their old bottle (I write the Rx number down which to apply the label to). Usually the patient is smart enough to match 2 numbers together and apply a stupid sticker. However this is a huge judgment call, and on more than one occation I have told them to come back with all of their medications so I can do it myself. I instruct the patient to come in when they are out upon which I fill the Rx that was put on file and everything is happy in pharmacyland.
So if you are an MD/NP/PA/DO/CNM/Janitor who is reading this, here is a few tips on how to make your pharmacist love you.

  • Any changes in dosage or sig, write the patient a new Rx. Using a sharpie on my pharmacy label is just going to waste both of our times with a fax over confirming what you wrote.
  • If any medications are DC’d, let us know. Nothing annoys us more than to have to wait for a fax-back asking if the patients Lotensin needs to be DC’d because you wrote an Rx for Diovan. Its not that its a waste of our time, but the patient obviously has no clue what’s going on, and the terms “possible therapy duplication” is like speaking chinese to them. They have to come back to the pharmacy, or wait an unknown period of time until we get an answer.
  • Write down any and all information on the Rx that might save a phone call or fax when switching to formulary alternatives. Unless you really want Protonix for some god-forsaken reason (like the reps are giving you lapdances), writing “or equiv” will save us both a ton of time. A PPI is a PPI for gods sake.
  • If you have any questions about whats covered, a rule of thumb is that if its cheap and generic; its covered. Prilosec vs Aciphex, Lotensin vs Aceon, etc etc etc. Have you tried generic Mobic vs Celebrex? You should! If you don’t really care what NSAID the patient gets, then state “Feldene, but whatever is covered, therapeutic sig”. Any pharmacist worth his salt will take care of your patient and not bother you. We may fax you what we gave so you can keep your records updated, but we’re not going to ask you a bazillion questions if its okay. Remember, we went to school to learn about drugs; have a bit of trust in us.
  • Hate to tell you, but most NEW drugs now days are just knock-off me-too’s that are out because their replacement is going off of patent soon and will be dirt cheap. Look at Paxil CR, Coreg CR, Adderall XR, Lexapro. All came out shortly after Paxil/Coreg/Adderall/Celexa went off patent. You have been using these agents for 10-15 years, and all of a sudden they suck because something new came out? Think of it this way, if they were so “new” and “breakthrough” and “revolutionary”, then why weren’t they out when there was 5 years left on the patent on the drug they are meant to replace?
  • If you have any questions about pricing, call us. Seriously. Nothing makes me happier than churning my workflow to a grinding halt to answer a phone call from a local doctor wanting information vs some crackhead asking for their vicodin a week early. Believe it or not, we’re in the same boat, and we cant exist without each other, so lets actually talk once in a while.