I’ve noticed an increasing amount of request for refills over the phone or coming directly from the pharmacy via fax or Electronic Health Record notice (about 20 request per day). I realize that I needed to explain why we often can’t refill them. It looks like we don’t care or are being unreasonable, but that is not the case.
Almost any time a refill request comes in, it is a red flag. The reason is, we always give the patient enough medication to carry them through until the next visit. Most of the time, when a refill request comes in, it is either because the patient didn’t follow up as scheduled or they are over-using the medication.
The Standard of Care
I must also explain about the standards of health care in America and how it applies to this situation. There are two levels of standards. The first level are the many state and federal rules that govern the practice of medicine. But there is a far higher bar that we must clear and that is the bar of perfection, which patients and malpractice lawyers have put on us over time. So this has created a world where we must act in what appears to be unreasonable ways, to keep that extremely rigid standard.
Why Follow Up is Required
If I prescribe a medication, this standard of perfection says that I must follow up to make sure that there are no side effects or other issues that would make taking that medication dangerous. Therefore, when we see new patients, we don’t just write them prescriptions recklessly for a year with no scheduled follow up. But we must monitor the drug use. Once we know that the patient is doing well, we can eventually stretch out appointments up to one year apart. Beyond that violates this high standard of perfection.
In the case of a lawsuit and it appeared that one of our patients was harmed by a medication and we claimed that we had been refilling the medications over the phone and not seeing the patient, the court would quickly support the suit, seeing our behavior as not meeting the standard, which society holds for us.
Most of the medications, which we prescribe, are benign (meaning few insignificant side effects). However, for some of them laboratory measurements must be done and face to face monitoring. Patients on these medications must follow on a more regular basis.
So, while I understand a patient’s perspective, we prescribe something that really seems to be working, so why come back? Why not just send in refills? Hopefully we can get to that point but we must see you face to face to document that you are doing well. Phone conversations to deliver medical care are frowned on by the court of law.
In the other common situation is where the patient is overusing medications. We always give enough pain medications and triptans (Imitrex type medications) to carry you over to the next visit. If you ran out early, you are using them beyond our recommendations. So simply refill them is reckless on our behalf.
Patients from a Previous Practice
Another common situation is where we are getting refill request by patients whom we have never seen here. These were patients whom we followed are our previous practices. So, a request comes in on a patient, we have no chart records. We don’t know the essentials of what other medications they are on and what has changed in their medical care since they were seen last (for many it has been over a years). To prescribe medications for a patient that has never established in your practice, who has no chart notes, no history or basic information . . .that is a clear violation of this standard of care.
If you are an old patient, and you are doing well and just want your medications, you just have to come in for the one “New Patient” visit. This is a longer visit than you will have in the future, but we must go through your story, get your basic information, so we can continue prescribing your medications.
I hope you understand the situation we are in and we are acting in a reasonable way considering the standards of care we must ascribe to.