AREID Posted July 15, 2012 Share Posted July 15, 2012 If a patient comes in for med refill regarding chronic conditions such as hypertension, diabetes, lipids, etc...but does not want to do their yearly bloodwork, do you to stop dispensing medication for the what ifs? Or do you dispense the medication regardless because they are better on than off it? If you dispense anyway, and it is documented that they refuse are you safe from court if something were to happen? Thanks Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 15, 2012 Moderator Share Posted July 15, 2012 probably depends on the medication and how long they have been on it.. if their medicine was an ace inhibitor or diuretic for example, I would want to make sure their renal function was ok. if it was atenolol I would be less concerned about labs. if someone was stable on a certain dose of synthroid for years with contant tsh levels and no change in weight, fatigue levels, cold intolerance, etc I would be less concerned with checking the level at every visit and would allow them to do it less frequently. Link to comment Share on other sites More sharing options...
Contrarian Posted July 15, 2012 Share Posted July 15, 2012 ^^^ Agree with the premise outlined above ^^^ EXCEPT... I have seen the "double standard" that exists in action. Namely, the one that proports that a simple over site by a physician is just that and that poor outcomes happen which are deemed as no fault of that physician, whereas the same oversite or poor outcome happening to a patient under the care of a PA/NP is assumed to be the result of negligence, malpractice, poor training and inadequate SUPERVISION. That said, be careful and DOCUMENT your insistance that patients should be complient with labs and follow up. I deal with this very issue DAILY in my practice specialties of Psychiatry and Addiction medicine where these patients often NEED drugs (which have narrow therapeutic windows that are very close to toxic/deadly levels that require regular labs to titrate and monitor) for daily functioning and to prevent de-compensation to acute/florid psychosis requiring detention/re-hospitalization but are notorious for poor medication/lab compliance and "no-show." Personally... I will only refill a medication after a missed appointment and/or lab once. I usually have the receptionist re-schedule and then only refill up to that re-schedule date. If its a medication that they can't do without, I have on ocassion rescheduled and refilled one day at a time. Until the patient get tired of this and complies... Because at the end of the day... It will be ME who will be scrutinized for re-filing medications without providing proper/appropriate follow up/monitoring and thus failing to meet or exceed the minimum "standards of care." YMMV Contrarian Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 15, 2012 Moderator Share Posted July 15, 2012 agree about the double standard...if a doc messes us "it couldn't be avoided" or "the pt was at fault". if a pa/np does it, it is because of inferior training.... had an interesting occurence a while ago. pt with tibial plateau fx on xray I was looking at. I saw it clearly and was getting ready to call ortho, etc when one of the docs in my group looked over my shoulder at the film, insisted it was a growth plate or normal variation and needed no tx, etc. we went round and round about it and he said it was nothing and would sign a note saying that. I documented the entire event in my note. surprise, rads read the next day is that it is a fx, QA calls me and says my care was inadequate/substandard and " a physician would not have missed that fx". I refered them back to my note(signed by the doc who insisted "it wasn't a fx" and like magic, the issue went away.... Link to comment Share on other sites More sharing options...
Moderator ventana Posted July 16, 2012 Moderator Share Posted July 16, 2012 agree about the double standard...if a doc messes us "it couldn't be avoided" or "the pt was at fault". if a pa/np does it, it is because of inferior training....had an interesting occurence a while ago. pt with tibial plateau fx on xray I was looking at. I saw it clearly and was getting ready to call ortho, etc when one of the docs in my group looked over my shoulder at the film, insisted it was a growth plate or normal variation and needed no tx, etc. we went round and round about it and he said it was nothing and would sign a note saying that. I documented the entire event in my note. surprise, rads read the next day is that it is a fx, QA calls me and says my care was inadequate/substandard and " a physician would not have missed that fx". I refered them back to my note(signed by the doc who insisted "it wasn't a fx" and like magic, the issue went away.... grrrr that would piss me off!!! can't say you did anything wrong (stated for the general reader no as critique of a far senior PA) I only once ried to override (with out success) a SP who decided to stop Methadone 80mg a day with out a taper because he didn't like the patient (and he was a cardiac patient and had never displayed any signs of diversion or abuse, but occasionally some pseudoaddictive behaviors) Course it was Friday afternoon and I called anesthesia department after telling the SP I did not agree with the treatment plan and the I felt it placed the patient in danger,and hence was blowing up the chain of command..... - I never once said anything to the patient that could be heald against me, but I ended up getting to sit through numerous meetings and had to defend the what and why I disagree (stupid double standard) The lesson I learned - when push comes to shove and there is a clinical disagreement the MD/DO ALWAYS gets the last word - it is just the way it is..... I will defer to the doc, and write a small novel on my clinical concerns - and honestly if it went to court I would testify against the doc..... but any other action will likely result in the PA getting in serious trouble and possibly fighting for their license... Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 16, 2012 Moderator Share Posted July 16, 2012 the interesting thing is that they hadn't even read my note before accusing me.... one of the senior pa's at one of my per diem jobs has a formula for QA issues. someone calls him and he does the following: he says: did you read my note? what would you say if a doc made this error? most things then disappear.... Link to comment Share on other sites More sharing options...
Contrarian Posted July 16, 2012 Share Posted July 16, 2012 Yeah... Like the former "medical director" MD that only worked 7 days a month (every other weekend) , who after I had done a complete H&P, wrote orders and left the facilty...D/C'd a new admit's opiates & benzos, then wrote in the chart that "this patient has a previous history of poly substance abuse and should not be on these medications, so I don't know why or how the PA was somehow INAPPROPRIATELY convinced to prescribe these medications" ... :rolleyes: When I came in the next day, the patient was in seclusion due to agitation and assaultiveness, and I was LIVID (almost requiring seclusion and restraint myself)....:mad: After re-writing the medication orders and giving her opiates & benzos, then getting her out of seclusion and encouraging her to contact the ombudsman (I even filled out the formal complaint form with the pertinent info for her), I spent quite a bit of time charting and writing a email detailing the "standard of care" required to treat pain and avoid withdrawal seizures in a patient that has a fresh LARGE (9cmx14cm) 2nd degree burn on the medial thigh (very sensitive area), who also happens to have been a epileptic and Benzo dependent for yrs and therefore prone to withdrawal seizures. Basically the MD didn't bother to read my extensive chart note detailing the rather large 2nd degree burn or seizure history... or even the Impression and Plan part of my separate Complete H&P that also detailed my rationale... before deciding that 'the patient somehow convinced the dumba$$ PA to INAPPROPRIATELY prescribe these medications'...:;;D: Yeah... I was a bit "Twisted" about that one. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted July 16, 2012 Administrator Share Posted July 16, 2012 Do any of you who've had MD/DOs overrule proper care with inadequate care have an opportunity to take the cases to M&M? Link to comment Share on other sites More sharing options...
Contrarian Posted July 16, 2012 Share Posted July 16, 2012 Do any of you who've had MD/DOs overrule proper care with inadequate care have an opportunity to take the cases to M&M? Nope... It just "goes away." The "double standard" mentioned above is usually at play... Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 16, 2012 Moderator Share Posted July 16, 2012 on a few occassions I have been able to convince the more reasonable ones to see things my way...generally these are folks right out of residency and so when I say "this guy really should be a trauma activation, on a backboard with c-collar and 2 IV's" instead of having a family member drive them to the local trauma ctr.... they take my word for it. part of that is the "steet cred" I get for PA, EMT-P on my name tags...it's amazing that some docs take me more seriously because I used to be a medic than because I currently work as an em pa... Link to comment Share on other sites More sharing options...
Hemegroup Posted July 16, 2012 Share Posted July 16, 2012 part of that is the "steet cred" I get for PA, EMT-P on my name tags...it's amazing that some docs take me more seriously because I used to be a medic than because I currently work as an em pa... lol yup yup ... well of COURSE, because you weren't a simple ASSISTANT lol ... Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted July 16, 2012 Administrator Share Posted July 16, 2012 Nope...It just "goes away." The "double standard" mentioned above is usually at play... It would be interesting to brainstorm how to make such issues un-disappear. If doctors are second-guessing PAs and making the outcome better for the patient, so much the better: that's what they're supposed to do. However, if docs are making simple errors, avoidable by reading the PA's note, clearly inconsistent with the standard of care, might risk management or the state medical boards want to know about that? Of course, there are no such thing as whistleblower laws in medicine, and we saw three nurses get fired and investigated *by the sheriff* for filing a founded complaint against a provider a few years ago in Texas, if memory serves. Ultimately, the public has the right to the best care, and everyone, physician or PA, needs to own up to their mistakes so that they can be published and others can learn from them. Unfortunately, I suspect the corporate inertia may take a few high-profile example cases (e.g. multimillion dollar awards like for harassment of the surgical PA) to get The Powers That Be to sit up and notice that sometimes, it's the physicians who make the mistakes and PAs who catch 'em. Link to comment Share on other sites More sharing options...
SocialMedicine Posted July 16, 2012 Share Posted July 16, 2012 If you miss an annual physical I will refill the medicine for a short course. If someone does not schedule a physical within a timely manner I will not refill the medication. I make sure this is communicated and documented. I do not manage blood pressure, diabetes, anxiety, cholesterol over the phone. I need to check not only labs, but also check the patients pressure, excercise, mood, appearance, adherence, and other relevant issues at least once a year. If they do not like that plan .. they can find a doctor or PA that practices otherwise. If someones insurance does not cover an annual I will bill as an ofice visit. If they cannot afford an office visit then they should access care at a clinic where they can afford to be evaluated and get the care they deserve rather than a script called in. Link to comment Share on other sites More sharing options...
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