goose37 Posted April 1, 2017 Share Posted April 1, 2017 As there are a lot of colds going around, I have a lot of friends going to UC/ER. So many get so frustrated that they "needed" and abx and didn't get one. Tried to have the "not every runny nose gets and" but to no avail. Wondered if any of you have a policy for determining script or not. Anyone do a WASP (wait and see prescription)? One UC policy said that unless patient said "7 or more days" they did no abx. That seems absurd to just forgo the exam results (oddly, was an NP). Link to comment Share on other sites More sharing options...
sas5814 Posted April 1, 2017 Share Posted April 1, 2017 This is a non stop never ending issue in UC. During cold and flu season we would see 60-70 people a day with colds. My organization doesn't have a policy. It is clinicians call. I would say 97% don't get an antibiotic and some have symptoms or history good enough to justify it. We also all have days where we are just tired of having the same argument over and over so we give it to them to avoid the argument and complaint. As for "wait and see" prescriptions we have disagreements. I don't because I assume the patient will just start taking it right away. Others have more faith than I do (but I think it is a lazy way to avoid doing what you should have done in the first place). Opinions vary... Link to comment Share on other sites More sharing options...
Febrifuge Posted April 1, 2017 Share Posted April 1, 2017 It's all about framing. If you can look someone in the eye and convincingly say "good news! You don't need an antibiotic," you're halfway there. Back it up with arguments like "if we give you amoxicillin now, it won't help but it will give you diarrhea" or "let's say this doesn't get better like I think it will, and you have a sinus infection in 10 days - let's make sure that hypothetical Z-Pack is your first antibiotic in the last 6 months, and not the 3rd one." Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted April 1, 2017 Moderator Share Posted April 1, 2017 Everyone at UC needs a lovely parting gift like motrin, tessalon or Sudafed. no abx, but you can't let them leave empty handed... Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted April 1, 2017 Share Posted April 1, 2017 I've got a question for you guys and gals in settings where you're not the PCP. Do you have to deal with any satisfaction ratings such as the private practices? I honestly don't know because for the last 10 plus years in my settings I haven't had to deal with same, other than do we keep the clinic open or not? Link to comment Share on other sites More sharing options...
DiggySRNA Posted April 1, 2017 Share Posted April 1, 2017 Everyone at UC needs a lovely parting gift like motrin, tessalon or Sudafed. no abx, but you can't let them leave empty handed... Interesting because I noticed that the attending provider that I am working with on a typical day receive either a good or bad review based on what's prescribed or lack thereof (we all know how I feel about surveys since I'm the MA who has to deal with it or else I get a talk with the manager if I don't send one to only satisfied patients). If the provider e-prescribes something, doesn't have to be abx, but some sort of cough suppressant or expectorant, everyone leaves happy. The provider who prescribes nothing, lectures the patient, and then send them on their way 80% of the time receive a negative review, and then I'm expected to fix the bad attitude in the room and apologize, and reiterate why they're not getting anything during disposition and discharge lol. Link to comment Share on other sites More sharing options...
dchampigny Posted April 1, 2017 Share Posted April 1, 2017 If Press-Ganey weren't a thing, I'd be more argumentative. Some people are just so rude. What I would really like to say is: "Oh, you're a mechanic? Well how would you feel if I came in and insulted your education and judgement and told you what I thought my car needed even though I had no training/experience in cars?" Link to comment Share on other sites More sharing options...
jlumsden Posted April 1, 2017 Share Posted April 1, 2017 I tend to hand write a short list of OTC meds (and possibly codeine or tessalon perles), tailored to the patient's most irritating symptoms and needs over the next few days. I talk them through how I am reassured by SpO2 rates and pulses, etc... that they are not emergent, as well as how to use the symptomatic meds in 2-4 minutes. I rarely get complaints. I also talk about clinical criteria for antibiotics with URIs, and be as consistent as I can with my antibiotic prescriptions. My patients tend not to complain about not being adequately treated. Link to comment Share on other sites More sharing options...
jwells78 Posted April 1, 2017 Share Posted April 1, 2017 Tough argument sometimes when it's a mom with 4 sick kids and the IQ of a rock. Ive played the defender, fought tooth and nail to avoid Rx'ing--- only to have an attending write one ???? Also pacified, just like everyone else ("oh wow, her Lt TM is red.....) Done the "wait and see" script too, the "wait" of which lasted all of about the time it took to get to Walgreens I am certain. But these days, you explain it to them and: 1. They dont hear you 2. They complain (poor satisfaction) 3. They go to another ER or UC and get it from someone else 4. We foot the cost of TWO ER or UC visits because: ------> their assigned PMD is 45 miles away, and they couldnt pay for gas to get there because that didnt leave enough for cigarettes and monster. Want to hear a story? Here it goes.... Link to comment Share on other sites More sharing options...
TWR Posted April 1, 2017 Share Posted April 1, 2017 One family practice I worked in in Houston years ago was reprimanding me for patients not getting antibiotics that THEY wanted. I asked I asked if I am expected to give abx out like "candy". The answer was "yes" We parted company a few months after that. I just couldn't justify the "candy". Link to comment Share on other sites More sharing options...
DogLovingPA Posted April 1, 2017 Share Posted April 1, 2017 Winter in UC is the bane of my existence.... seriously every winter I think "I hate my job". As sas5814 said above - some days you win the fight, other days you don't. Some days you just don't have it in you to argue all day long. Although often the problem I run into here is the "But I get this every year and my PCP always gives me a zpack". I try very very hard not to unnecessarily prescribe abx - but when you are surrounded by people that are prescribing them, it is tough. I always send the patients out with SOMETHING. Work note, cough meds, Sudafed, nasal spray, inhaler, etc. There is no rule about prescribing abx where I work - clinicians make their own call. We don't have official satisfaction scores, but patients can complain about anything they want. If we get a complaint, our boss (MD) usually reviews the chart to see if the complaint is warranted. His take on the abx thing is basically to try not to prescribe unnecessarily but if it is clear the pt is going to throw a fit, it's not worth the fight - just document in the chart. I will occasionally do prescriptions to "hold" - I usually reserve those for self pay patients or those getting ready to travel abroad, etc. Link to comment Share on other sites More sharing options...
Katera Posted April 1, 2017 Share Posted April 1, 2017 We are told if they want an antibiotic...give it to them. High google and yelp reviews are the highest priority. Not joking btw.... Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted April 1, 2017 Moderator Share Posted April 1, 2017 This is a non stop never ending issue in UC. During cold and flu season we would see 60-70 people a day with colds. My organization doesn't have a policy. It is clinicians call. I would say 97% don't get an antibiotic and some have symptoms or history good enough to justify it. We also all have days where we are just tired of having the same argument over and over so we give it to them to avoid the argument and complaint. As for "wait and see" prescriptions we have disagreements. I don't because I assume the patient will just start taking it right away. Others have more faith than I do (but I think it is a lazy way to avoid doing what you should have done in the first place). Opinions vary... Studies have shown that 75% of wait and see prescriptions aren't filled. I don't do them either and have the hard conversation, but there's some evidence. Link to comment Share on other sites More sharing options...
Moderator ventana Posted April 1, 2017 Moderator Share Posted April 1, 2017 This is serious issue with UC They feel Iike patients "deserve something" and therefor admin states write them, or worse the providers actually think it.... Then the patient learns that he/she need augmentin for a viral cold and therefor every time in the future they get a cold they feel they have to get augmentin again..... the only one's that win on this is the business of UC - everyone else looses Providers get beat down (I just simply say no and hold firm) if they push and push I go into a long dialogue about OTC's and nasal rinsing and how Ibuprofen would be the worlds biggest blockbuster drug if it came out now.... I NEVER do a WASP (wait and see prescription). I used to do them earlier in my career and then just realized I am giving a total non medical, no training person, that is to involved in the situation to be unbiased, the choice on how to treat.... nope not a good idea.... I still have a few exceptions to the rule - usually around immunocomprimised or truly ill folks. As well in primary care there is a few patients I trust with bad conditions that I will let keep scripts around - but they usually expire prior to using..... In a word - providers need to stand their ground, and have lots of "other" things available for the :Cold: complainers.... Link to comment Share on other sites More sharing options...
Katera Posted April 1, 2017 Share Posted April 1, 2017 This is serious issue with UC In a word - providers need to stand their ground, and have lots of "other" things available for the :Cold: complainers.... Except that I have seen providers "let go" for not keeping pt's happy by "standing their ground" on this issue. I've seen it occur several times in Corporate owned UC's in the DFW and Houston area. I agree, it's wrong to do, but we also have a responsibility to put food on the table for our families. Just keeping it real.... Link to comment Share on other sites More sharing options...
Moderator ventana Posted April 1, 2017 Moderator Share Posted April 1, 2017 Except that I have seen providers "let go" for not keeping pt's happy by "standing their ground" on this issue. I've seen it occur several times in Corporate owned UC's in the DFW and Houston area. I agree, it's wrong to do, but we also have a responsibility to put food on the table for our families. Just keeping it real.... If we all practice the same way - then there is no one to hire, and the bean counters will actually have to let the medical professionals dictate the medical treatments.... As well I have to go to sleep every night knowing that i did the right thing.... I have no desire to work at a place that knowingly practices bad medicine..... Let teh UC bean counters have to tell the family of an elderly person who had a cold and got ABX and then C Diff and now has failed so badly that they are goin on hospice that this all started with an ABX..... and see how they feel... A final note - being let go is usually more about personality then just a script - you can't cop an attribute or yell at patients.... you need to have an alternative offering for treatment as listed above and even a hand out to explain when you would treat. Empower the patient with knowledge, but hold your ground.... Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted April 1, 2017 Share Posted April 1, 2017 This is serious issue with UC They feel Iike patients "deserve something" and therefor admin states write them, or worse the providers actually think it.... Then the patient learns that he/she need augmentin for a viral cold and therefor every time in the future they get a cold they feel they have to get augmentin again..... the only one's that win on this is the business of UC - everyone else looses Providers get beat down (I just simply say no and hold firm) if they push and push I go into a long dialogue about OTC's and nasal rinsing and how Ibuprofen would be the worlds biggest blockbuster drug if it came out now.... I NEVER do a WASP (wait and see prescription). I used to do them earlier in my career and then just realized I am giving a total non medical, no training person, that is to involved in the situation to be unbiased, the choice on how to treat.... nope not a good idea.... I still have a few exceptions to the rule - usually around immunocomprimised or truly ill folks. As well in primary care there is a few patients I trust with bad conditions that I will let keep scripts around - but they usually expire prior to using..... In a word - providers need to stand their ground, and have lots of "other" things available for the :Cold: complainers.... I don't think it's so black and white, nor do I think that it's unreasonable IF appropriate information is provided, both verbally and in writing, as to what the correct circumstances are in which to fill the antibiotic. We all know that the vast majority of these illnesses over the past couple of months are viral. What about the low income patient that one did a RFT on (did it really matter since they met ILI criteria?), came back positive, and yet one fails to advise on the number one risk of flu which is an opportunistic bacterial pneumonia? It only takes a moment to explain, make the med available, and tell them that if prescription is filled that they need to be reassessed. Link to comment Share on other sites More sharing options...
Katera Posted April 2, 2017 Share Posted April 2, 2017 I don't quite think you guys have a grasp of corporate urgent care yet. It is much worse then you can imagine. I laugh when self righteous people say...Just quit! I would never work for someone in that setting...blah blah blah. With 250 new NP's and 150 pa's being dumped into the DFW job market every year, the competition for jobs has gotten very heated. And the fact is, if you don't keep patients "happy", they WILL fire you and get someone else who will. I've seen it happen several times. Chew on that... Link to comment Share on other sites More sharing options...
Moderator ventana Posted April 2, 2017 Moderator Share Posted April 2, 2017 I don't quite think you guys have a grasp of corporate urgent care yet. It is much worse then you can imagine. I laugh when self righteous people say...Just quit! I would never work for someone in that setting...blah blah blah. With 250 new NP's and 150 pa's being dumped into the DFW job market every year, the competition for jobs has gotten very heated. And the fact is, if you don't keep patients "happy", they WILL fire you and get someone else who will. I've seen it happen several times. Chew on that... Hence why I said If we all practice the same way - then there is no one to hire, and the bean counters will actually have to let the medical professionals dictate the medical treatments.... Link to comment Share on other sites More sharing options...
Katera Posted April 2, 2017 Share Posted April 2, 2017 Hence why I said If we all practice the same way - then there is no one to hire, and the bean counters will actually have to let the medical professionals dictate the medical treatments.... "if we all practice the same way..." Welcome to fantasy island! Not going to happen. Like I said, there are hundreds of new providers dumped into the job market every year now that are more then happy to do what the corporate overlords require... Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted April 2, 2017 Administrator Share Posted April 2, 2017 When you have people graduating with $150k+ of debt, yes, they will behave like medical prostitutes if that's what it takes to get that debt taken care of. If you think I'm blaming these providers, you probably misunderstood what I just said. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted April 2, 2017 Share Posted April 2, 2017 The ART of medicine is dying. The customer satisfaction and convenience era has settled in. Doing what is RIGHT only counts if the CUSTOMER IS HAPPY. Those pesky facts and evidence don't seem to matter in any facet of society anymore. And somehow suits with MBAs know more about what we should be doing than we know. It is disheartening and dangerous but keeps on. A few more lawsuits for refractory CDiff and toxic megacolon are a few too many to get the point across. My old crabby 2 cents Link to comment Share on other sites More sharing options...
sas5814 Posted April 2, 2017 Share Posted April 2, 2017 I've got a question for you guys and gals in settings where you're not the PCP. Do you have to deal with any satisfaction ratings such as the private practices? I honestly don't know because for the last 10 plus years in my settings I haven't had to deal with same, other than do we keep the clinic open or not? I do now. I recently went from private practice to a large hospital organization. One of the questions I asked when I interviewed was "do you think patient satisfaction surveys reflect quality of car?" I got an answer I liked so here I am. Our satisfaction surveys are all driven towards communication and how you were treated. So far I haven't had one question about anything related to a satisfaction survey. Link to comment Share on other sites More sharing options...
MT2PA Posted April 2, 2017 Share Posted April 2, 2017 Studies have shown that 75% of wait and see prescriptions aren't filled. I don't do them either and have the hard conversation, but there's some evidence. http://jamanetwork.com/journals/jama/fullarticle/203330 That link is specific to AOM but I think you can make an argument for other commonly seen "want an abx but don't need it". I'd also love to know what percent of those that actually fill WASP scrips use them (sometimes you pass the pharmacy on the way home and it's easier to fill it and still wait and see to use it instead of making a trip back out with a sick kid). Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted April 2, 2017 Share Posted April 2, 2017 http://jamanetwork.com/journals/jama/fullarticle/203330 That link is specific to AOM but I think you can make an argument for other commonly seen "want an abx but don't need it". I'd also love to know what percent of those that actually fill WASP scrips use them (sometimes you pass the pharmacy on the way home and it's easier to fill it and still wait and see to use it instead of making a trip back out with a sick kid). We do 48 hour f/u calls on our clientele (all employees/dependents of same employer) and I've had them ask my folks and we found that over a two week random period that ~60% never filled the prescription and actually followed the instructions. As others have beat to death, including myself, some folks just don't get it regardless of what is said. Heck, they even complain about TOO much information. Link to comment Share on other sites More sharing options...
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