Posted by: notdeaddinosaur | May 20, 2014

To Refill, or Not to Refill?

I have an ethical dilemma, and would appreciate the opinion of the Collective.

Patient with controlled hypertension who hasn’t been in for a visit for over 2 years keeps requesting refills on her medications, despite multiple requests and decreasing quantities first of refills, then of medication quantities. We are finally down to my Note to Self in the Refill field, “No more refills without visit.”

Pharmacy request comes in for refill. No call from patient; no appointment on the schedule. Ideally, I like to see my hypertensive patients twice a year, but I’ll settle for annually. This patient hasn’t been in for over three years.

What to do?

First round of analysis: What are the harms of going off BP meds? Answer: potentially significant, in that patient is on several meds which are controlling BP well, and has other cardiovascular risk factors. 

Next, anticipating the patient’s objections to a visit: Why exactly to I need to see her? We call it “monitoring”; making sure her BP is still controlled, and that there are no side effects or other related (or unrelated) problems emerging. “But you never do anything,” I hear her responding, and it’s hard to argue. It certainly seems that the greater benefit comes from continuing to authorize the refills.

What’s the down side? This: What if something changes, and either the BP is no longer controlled, or something else happens as a result of the meds (kidney failure comes to mind)? I can just hear the lawyer bellowing, “Why were you continuing to prescribe these dangerous medications without monitoring them?” causing the jury to come back and strip me of all my worldly goods. 

So what to do? Refuse the refill and risk having her stroke out from uncontrolled blood pressure? Or keep on prescribing without seeing her? If so, how long? Four years? Five? Ten? 

Another option, of course, is discharging the patient from my care. But that’s not going to help her in the long run, nor me in the short run. (Discharging a patient is at least a 30-day process, and involves certified mail, which costs money and involves a post office run.) I would prefer not to go that route.

Thoughts?

 


Responses

  1. This is indeed a tough one. I would have my nurse call her personally and find out what is going on. If nothing more to explain why you need to see her. If she lost insurance, then maybe negotiating an affordable fee or payment plan that works for her and you.

  2. I don’t treat hypertension, but I treat ADHD. I like to see my patients at 3-month intervals to make sure they’re doing ok in school, not having any side effects of the medication, and to make sure they’re not selling it. I have a wonderful family with 2 boys that have been diagnosed with ADHD and are on medication. They take med holidays on weekends and school breaks (fine by me – the boys do well in school and are very active, and their parents can handle them off meds and the kids don’t mind it either). Problem is, I haven’t seen them in a long time. Mom keeps calling for med refills, and I put an FYI in the chart to not do any more refills until there’s an appointment. She calls for a refill, schedules the appointment, and then doesn’t keep it. The boys have an appointment this week. If they don’t show, I’m going to discharge them from the practice. They’re already received a warning. I love this family – they’re unlike many of the families I take care of, in that there’s a mom and dad that are married and gainfully employed and the kids are nice and are great athletes and students. But if they can’t hold up their end, I can’t hold up mine. I am not going to continue to waste appointment slots on people that don’t show and that won’t adhere to my recommendation of q3 month follow up.

    While discharging a patient is a pain in the rear, maybe send a warning first? Describe to your patient (in brief) why adherence to the regimen is crucial and that if she cannot adhere to the regimen you have prescribed that she is free to seek care elsewhere. It may be the wake up call she needs.

  3. I usually prescribe a short dose with a warning that this is their last refill pending a kept appointment and a warning of discharge. Then I follow through.

  4. I see a lot of doctors. If I’m spending a lot of time with one I will sometimes forget to make an appointment with another. Personally, I appreciate the reminders. But three years isn’t a thing that slipped off her plate. And I must say, you are being generous with allowing 6 months between appointments. I have four doctors who prescribe blood pressure meds, my PCP, my nephrologist, my EP and my endocrinologist. I see all of them every three months. They aren’t asking too much. The appointments benefit all of us. You wouldn’t be out of line to demand an appointment before allowing a refill. She’s probably trying to see how long you will let it slide. Besides, what has happened in three years? Is she gaining weight? Is she losing kidney function, how is her glucose level? You can’t know if you don’t see her.

  5. Tell that patient to get her ass in there NOW! Refill one week at a time…..copays will drive her crazy. Good luck. M

    >

  6. Not in the medical profession at all, but could you consider a telephone appointment, rather than an in-person visit as a reasonable alternative? Not yes/no questions, but how much you weigh, when was the last time you had your pressure checked, what other doctors are you seeing, what prescriptions are you taking? Is it possible the patient has nursing assistance at home or an aide part-time?

  7. Already done much of this: phone calls (messages left unanswered/unreturned), decreasing numbers of pills, no refills, notes to pharmacists asking them to tell her to call (since they’re the ones seeing her when she picks them up)…and nothing. Almost feels like a game of chicken.

    Little more context: laid back, mellow kind of patient who doesn’t really think she needs meds, but whom I’ve convinced of their advisability. So she’s sort of taking them “as a favor” to me. I don’t think she’d care much if I cut her off…until she has the stroke or heart attack that I think would probably happen, sooner or later.

    Definitely a tough decision.

  8. Don’t make this more complicated than it should be. No more refills until she sees you in person. Period. You are not a refill machine. Hypertension is a medical condition and needs monitoring. How do you know it’s controlled? How do you know there are no renal effects of HTN or medication? Annual visits are not too much to ask. I will extend to 18 months. After that, no refills. You have to have limits and feel secure in your professional knowledge.

  9. Except that abrupt stopping of meds (triple therapy, moderately high doses, including a beta blocker) could easily precipitate stroke or MI. How about phrasing it like this: Which is worse: sub-optimal care, or no care?

  10. Easy peasy. When the pharmacy calls tell them she can’t get a refill until she has an appointment with her doctor and for them to relay that to the person. They have to call the patient back anyhow. Don’t refill a script unless you have seen the patient. If the person doesn’t respond then you did your job. Sometimes you have to force a person into something they don’t want to do. A lot of pharmacies are now doing a customer service by calling customers doctors before their scripts are up and getting them refilled. Some patients may not realize how long its been since their last visit. In the case you speak of there has been plenty of chances.

  11. One year seems reasonable for seeing a compliant patient with controlled hypertension, but not more. And certainly not increasing dosage without being seen. I think a reasonable answer is to get her in as soon as possible (within two weeks), prescribe enough medication for that period + three days, and when she is in the office give her a good work-up. If after the appointment she can say “you didn’t do anything! ” that should be music to all of your ears.

    By the way, if you are going to ask the nurse to call for you, don’t send her into the call without telling her what the whole situation is.

  12. I am really sick: I see a PCP plus 14 specialists (My PCP is pretty much a quack). I’ve been diagnosed with 17 different diseases. I take a gazillion pills, which are expensive. I am absolutely terrified of doctors, but I go to the doctor all the time, at a cost of $30 per visit. I can’t afford any of this, but I go. I know how important it is, and am fortunate that with the exception of the quack PCP, I have excellent doctors.

    There’s a reason this patient is not seeing you. Maybe she lost her job or insurance or both? You should have the pharmacist call you when she shows up for her refills. Maybe then you can talk to her.

  13. I submit that you had me get a colonoscopy and joked about it as a “cover my ass move”. Granted, I was not extremely early for the procedure given my age and I have insurance,but the point is you cannot afford to do something in your profession you don’t feel warm and fuzzy about. If for no other reason CYA. Signed the cynical needlepoint.

  14. Okay, this is the point. You don’t know what is going on with this patient. Three medications to control hypertension, well that is a lot. She really needs to be serious. As a preteen and a teenager I watched hypertension steal the quality of my father’s life. He lost kidney function to it and eventually it disabled him. I know this for sure, she may not want to know. But if she has something serious it will shake her hand and introduce itself to her. Whether it is heart disease, kidney disease or cancer it will be in her best interest if it is caught early. And your best bet and her’s is for you to see her regularly so you can notice subtle changes. Take it from a stage 3 cancer survivor, she wants to be diagnosed early. She needs tough love. Pushing a 3 month appointment out to 6 months, well that’s normal. Pushing 6 months out to a year is a little more on the edge, but three years is extreme. Since you went concierge and she followed you, she has already shown that she doesn’t want to change practices. She’s already paying for the appointment. So I’m thinking that there is something that she doesn’t want to answer for. To me, that is a scary thing. I have had too many women tell me they don’t go to the doctor because they don’t want to know what that lump is about. They don’t want to know what that shortness of breath is about. You can add in what ever you can imagine. Being obese, I don’t want to be scolded for gaining weight again. But I keep thinking that there is something she doesn’t want you to know about. She wants you for her physician. If you won’t treat her without her seeing you, she will be motivated to see you.

  15. Agree with above. No visit no refill. Liability for treating over the phone/in absentia is just too high. A visit after 2 years(really?) is NOT asking too much.

  16. 30 days notice — I am refilling your prescription for the next 30 days, if I don’t see you within 30 days, then I am discharging you from my practice with 30 days more meds. This is giving 60 days notice, in reality.

    I usually discharge these pts in PERSON with their note, so that the “clock runs” from the time they hit the door.

    You are not their parent, you are their doctor.

    Greetings from Western PA

    Dr M

  17. pick up the phone and call the person…. unless you speak with the person, you know, your mouth to the patient’s ear and vice-versa, everything you think or think you know is just speculation.

  18. All of us who manage chronic medical conditions will eventually run into this situation. When I have had enough, I usually give them 1/2 of one month worth of medicine. This almost always provokes a conversation with the pharmacist as to why they have to pay a whole co-pay for a 1/2 month of a prescription. That then leads to the patient calling my office where my staff informs them they MUST come in for an appointment if they want to continue as a patient. You either discharge a non-compliant patient, or you get the patient to be compliant again. Usually works.

  19. So how did this turn out? Inquiring minds would like to know.

    The house looks beautiful, BTW.


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