How NOT to prescribe

[rev ronin]

This is a public document that I've further redacted. It relates to an NP in my local area, but could just as easily have been a PA without a lot of oversight.  I see a lot of discrete issues, often repeated throughout multiple patients here. I see some things in here that I've seen, or done, or could have seen myself doing, though not to the extent or severity here. For example, even when I download and review a copy of the PMP query for a patient, does my chart note document that I did, in fact, review what I reviewed? Use this as a mirror--where is my practice ever at risk of looking like this?

My challenge to you: Pick one bad habit here and describe why it's bad, but also how to make sure we never teach our students to fall into such habits.

Again, the point is not to dunk on this NP, who was probably set loose too early without good mentorship, and that's why I've further redacted it. It's a public record you can go look up yourself if you want to do the homework.

HowNotToPrescribe_Redacted.pdf

[iconic]

It is amazing to me but schools do NOT teach about PMP, safe opioid/controlled substance prescribing, addiction medicine, or even the laws that relate to controlled substance prescribing for PAs (which vary from state to state). I do teach these things to students on rotations and the ones who were previous MAs at PCP or other offices do often know about PMP at least. I believe a big issue is that many schools do not have faculty with those types of backgrounds to teach about these issues. We certainly did not have anyone with addiction experience. Yet, it’s so easy to create a huge problem with just a few clicks on the computer. 

Edited September 15, 2023 by iconic

[rev ronin]

1 hour ago, iconic said:

It is amazing to me but schools do NOT teach about PMP, safe opioid/controlled substance prescribing, addiction medicine, or even the laws that relate to controlled substance prescribing for PAs (which vary from state to state). I do teach these things to students on rotations and the ones who were previous MAs at PCP or other offices do often know about PMP at least. I believe a big issue is that many schools do not have faculty with those types of backgrounds to teach about these issues. We certainly did not have anyone with addiction experience. Yet, it’s so easy to create a huge problem with just a few clicks on the computer. 

I don't think I was taught well how to do controlled substance prescribing in PA school or rotations, either. I really appreciate 3 years of my Group Health mentors and SPs being all "no, we don't do dumb stuff like that here." when patients asked.

I really learned when I inherited a panel of very sick, previously badly managed patients in 2015. I didn't ever really start people like this, but I didn't hesitate to escalate as much as I should have, nor did I try to taper folks like I should have.

Did you notice the comparison between dates of NP licensure and dates of these issues?

[iconic]

I've only glanced over the document, but that's more counts than I have ever seen against any medical provider. Would be interesting to know where the person went to school (and I suspect an online diploma mill). Who was the SP (or is one even required for NPs in WA?). It is astounding that a diploma mill new grad NP can open a shop independently in many states and start writing all of the controls they want (and I do see this in my community as well). PAs are at least taught to know what they don't know. Every singe PA will encounter patients on controlled substances who may try to take advantage seeing that they have a new grad in front of them and it is absolutely essential to get good supervision in this area of medicine from seasoned clinicians for any new grad provider.

Edited September 15, 2023 by iconic

[rev ronin]

5 minutes ago, iconic said:

I've only glanced over the document, but that's more counts than I have ever seen against any medical provider. Would be interesting to know where the person went to school (and I suspect an online diploma mill). Who was the SP (or is one even required for NPs in WA?). It is astounding that a diploma mill new grad NP can open a shop independently in many states and start writing all of the controls they want (and I do see this in my community as well). PAs are at least taught to know what they don't know. Every singe PA will encounter patients on controlled substances who may try to take advantage seeing that they have a new grad in front of them and it is absolutely essential to get good supervision in this area of medicine from seasoned clinicians for any new grad provider.

To answer the fact questions as best I know them:

- Based on the website verbiage, the NP was a 1099 of an established family medicine practice.
- No, no SP is needed for an NP in Washington State.
- The NP school is online. I've precepted an NP student from there before. Based on a quick perusal of the website, it does not appear to be competitive: BSN with 3.0 (or an explanation) and unrestricted RN license, and you're in. I don't particularly think that it's an outlier among NP schools.

[TWR]

In my 37 years of practicing, the biggest problem with dealing with a patient seeking controlled meds is the common answer being "I never had a problem before getting refills from Dr., PA, NP, why are you giving me a hard time?  I know my body and I need this!"  They can be quite intimidating with their demand.  Sadly, previously they had gotten what they wanted rather than confronting the patient in a professional manner.  It easily can turn into a scary situation.

[thinkertdm]

It seems like the basics were ignored or never learned.  
1. what am I treating (aka the problem)

2. Do they have the problem, what stage is it in

3. what is the best way to treat it, based on my training and experience.

i constantly tell my patients that each clinician needs to assess and treat appropriately.  This may or may not be the same as the previous clinician, but that’s up to me.  I take the patients report of what worked well into consideration but again, I’m treating them.

[Joelseff]

I'm so glad that now I'm back in GI/Hep and when I get my monthly DEA prescribing report it's always only one med on there.... Lomotil... Which I still use with caution especially with elderly and check for DDIs and polypharmacy before prescribing.  

[PolakPA]

It’s interesting when people jump the gun on ADHD dx and tx. Executive function and concentration are central to mood disorders and should be screened and treated first esp with hx of substance misuse, as well as managing the substance disorder. 
 

The psych practice I work at won’t even let us consider ADHD as dx w/o a neuropsych eval from a pysd

Edited September 19, 2023 by PolakPA

[rev ronin]

2 hours ago, PolakPA said:

The psych practice I work at won’t even let us consider ADHD as dx w/o a neuropsych eval from a pysd

Really? How long do you have to wait for a neuropsych consult?

[iconic]

2 hours ago, rev ronin said:

Really? How long do you have to wait for a neuropsych consult?

It's really not necessary to refer to "neuropsych" (there is only a handful of them in every state) for ADHD eval as it is well within a normal psychological assessment. Very few psychologists accept insurance and psychological testing costs 2-3k or more with looooong (many months) wait since they only usually do 1 a day and not every day. I would say that it is unnecessary for diagnosis of ADHD but also sometimes reports come back vague and inconclusive. ADHD has become the bane of many practices as everyone seems to think that they have ADHD now. But certainly the way the NP was approaching it, is NOT the way to do it (e.g. concentration issues =/= Adderall rx). I get these referrals all the time from PCPs who start patients on Adderall, max out the dose and then send to psych.. The patients are then informed that they probably don't have ADHD in the first place and to go back to their PCP. I am not sure what the PCPs do at that point.. probably continue Adderall (same issue with BZOs..). It puzzles me why PCPs do not refer to psych sooner when there is lack of diagnostic clarity. No one should be giving out controlled substances like its candy

Edited September 19, 2023 by iconic

[sas5814]

That was a brutal read and it just went on and on.

There are a lot of things in play that create these scenarios. Training and experience are at the top of the list. Patient satisfaction.... I think we could all rant on that. Pain as the 5th vital sign which is long obsolete but we still have the remains of that horrible policy. Having the fortitude and maturity to say no. Knowing when you are out of your depth.

I have a lot of sympathy for people who get hoovered up by the system and flogged for the kind of simple mistakes any of us are capable of making. This was quite beyond the pale.

I have been at this a long time and I wouldn't even try to manage a lot of the thing discusses in the complaint and certainly would have punted many of them.

Just too much here to unpack.

[ventana]

4 hours ago, Hemmingway said:

 

There are a lot of things in play that create these scenarios. Training and experience are at the top of the list.

even at 20+years out I would not touch most those patients (and I am comfortable with heavy IM/Addiction and some psych.  

 

A NP that was first licensed in 2017 (and worked through pandemic) should have known better

 

Medicine is about knowing what you know and don't know

[Reality Check 2]

2 hours ago, ventana said:

A NP that was first licensed in 2017 (and worked through pandemic) should have known better

But But But - Doctorate - call me DOCTOR, Dammit..................

 

'nuff said