The Pharmacist as the Doctor’s Nanny? The Time Has Passed

Jp Enlarged

I quit covering doctor’s ass sometime around 1995.  Before that it was part of my pharmacist DNA.  I just did it.  If the doctor made a mistake, I quietly got him on the telephone and we very quietly corrected the problem.  In the beginning, my standard fix-it line to the patient was:

“The doctor has decided this is a better choice.  Can I deliver this new drug to you and pick up the old one?”  I was good at smoothing it over, like the pharmacist’s vanilla frosting on the doctor’s shit pie.  ”No, don’t worry, just don’t take anymore of the first drug.”  

An extreme example, but it actually did happen a few times that the bad drug got out of the store and into the patient’s medicine chest.  Usually, there was an uncomfortable nagging feeling that began a few hours after I filled the Rx.  I’d do my research and BINGO.  The dummy did it again.  Usually, one of a small coterie of doctors who buried their mistakes.

1971.  The doctor was in the habit of prescribing tetracycline 250 mg qid with the added insruction “Take with Milk”.  I never put that on the label, but finally had enough.  My mood that day was dark and I was pissed off so I took it out on the doctor.  I called and told the maternal-acting receptionist that I would not leave a message.  ”Just et the doctor”.

He made it to the phone and I went off.  ”You can’t order tetracycline to be taken with milk.  What are you thinking, man?”  This was still the hippie generation.  Everybody was man.  

“You can’t call me MAN.”

“Okay, Doctor Prince.  I’m Mister Plagakis.”

“What?”

“Plagakis. That’s Pee Ell Aye Gee Aye Kay Eye Ess.  Plauh Ga like in gas kis.”

“Oh, I always order milk with antibiotics.  It prevents stomach distress.”

“It also prevents the drug from working.”  I explained.  I will tell your patients to always avoid milk or calcium-containing products with tetracycline.”

He got all flummoxed to the point of stuttering.  ”You can’t do that.  That is interference with the doctor/patient relationship.”

“So sue me.”  That evening I put a package insert from an Achromycin V box in the mail with the milk warning highlighted.  ’Take with milk’ was missing from his tetracycline prescriptions after that.

I still covered his ass.  Patients were never made to know of their doctor’s stupidity unless the doctor refused to fix the problem.  

What put me over the edge and caused me to never, ever again cover for the doctor was the 1995 incident.  The patient was an elderly woman.  It was Friday.  She was very ill and had been sitting in the waiting area for an hour.  The doctor told her that she would have to promise to take the medicine exactly as prescribed or she would have to be hospitalized.  Her daughter and son-in-law were with her.   They were from out of town and had taken Friday off to be with her.  They planned on staying the weekend to make sure she followed the doctor’s orders.  The problem was there were NO orders. 

She was a 30-something internist.  Her husband was a 40-something psychiatrist.  They had a three bedroom ‘cabin’ on the water over on the Olympic Peninsula.  The two of them and their 2 kids were taking a 4 day weekend.  They took a nanny with them.  The husband and wife were looking forward to some tender hours at Sol Duc Hot Springs at the olympic National Park.  She had forgotten to call in the prescription.

We didn’t get her nurse on the phone until around 3:00 PM.  To make this horrible story short, the nurse could not help because the doctor had not completed her charting.  The doctor left orders not to be bothered and she was so serious about it that she and her husband had turned off their phones and had left them in the glove box in the car.  they were primed ready for a red-blooded American family weekend.   

The patient was admitted to the hospital around 6:00 PM and the new doctor had to start from scratch.  

I got a call from from the first doctor on Monday evening.  She was all over me.  I was having none of it.  I told her that she had screwed up.  I told her that her nurse could have gotten on her horse and drove over to the ‘cabin’, but she had snickered at that idea.  I asked her why she wasn’t talking to the daughter or the new doctor.

The new doctor was unavailable and the daughter refused to talk with her.

She gave up her ‘I-Am-The-Doctor Act’ and sounded so pathetic at this point that I took pity.  ”Better get your attorney involved,” I said.

“Why?’

“Because they have.   I am being deposed on Wednesday about this. “

“What does deposed mean?” 

“They will ask questions and I will answer them truthfully.  I believe your attorney can be there.”  I remember pausing.  ”Not getting the needed antibiotic in a timely manner did cause harm.  Financial harm and physical harm.  The daughter is really pissed off  and she is going after you like the Indians went after Custer.”

A very long pause.  Her breath was coming in gasps.  ”Are you okay?”

“No, I am not okay.  I am a doctor, not an attorney.”  Another long pause and then the statement that caused me to go telephone postal.  She added, “I believe that I DID call in the prescription.  You lost it or something.”

“And you are fucking crazy, Doctor, if you think you can make that fly.  Do you know how easy it would be for me to have PacTel give me a list of the source of every single incoming call from Friday?  Take responsibility like an adult.  Call your lawyer.”

She hung up on me and I decided right then that I would never again cover any doctor’s ass.  After that, whenever there was a problem that caused harm, I went into full disclosure mode directly to the patient.  I took names of nurses and receptionists and gave them to patients with the advice, “Give these names to your attorney.”

I felt much better after that.  I even took that course with PBM Prior-Authorization Agents.  I know that it is really not a pharmacist’s job to go after Prior Auths, but there have been times when I believed that it was important.

I remember asking the name of  A PBM CPhT who was refusing the Prior Auth.  She was uppity and in charge, she thought.

I said, “This patient, your client, is standing right in front of me with a puddle of blood around her feet.  There is blood running down her leg.  I am going to tell her, Brenda, that you have refused to authorize payment for the drug that can stop the bleeding because it is expensive.  I am going to advise her to give your name to her lawyer.   I will suggest that your name be on the lawsuit.

She asked me to wait for her supervisor.  I said, “No, I am not waiting for anyone.  Do NOT put me on hold.”

The Supervisor came on the line in about 2 minutes.  I asked her name and she ignored that request.  However, she gave me the Prior Auth number with PRN refills for 6 months.

There are times, you guys, when you just gotta go out there and be Wonder Woman or Bat Man.  It is actually fun and the reward is enormous self respect.   Yes, I did that.  I made a difference.  I fought the system and I won for the patient.”

I got a little off the track at the end, but contextually it is all the same.

Jay Pee

 

2 Comments

2 Comments

  1. pharmaciststeve  •  Dec 6, 2013 @5:47 pm

    I have worked in LTC , in-house pharmacy in out patient clinic as well as community.. one thing that seems to be a common denominator is that prescriber/nursing/staff will throw a RPH under the bus at the drop of the hat..

    If they screw up.. typically you get a lie to cover their ass or a “OPPS”.. end of discussion.

    RPH’s – collectively – are pleasers and always try to take care of the pt.. from whatever they have been told or prescribed and do it… while protecting the prescriber/staff at the same time..

    IMO.. one of the reason that we catch so much flack is that we do our job so well 99% of the time.. that when we run into a bump in the road or a “brick wall”.. the pt cannot understand why things are different.

    We tend to ignore that the pt’s health insurance is a contract between them and the insurer… if we go thru the normal billing process and it does not clear.. it is not our responsibility to deal with it.

    I have always questioned why we “loan” doses to the same people every month..because they can’t get their act together..

    Nothing irritates me more than faxing the prescriber for a refill authorization and the office CALLS BACK to authorize the refills.. haven’t they ever heard of a PAPER TRAIL ? Besides the waste of time of the pharmacy staff.. stopping to answer the phone…

  2. RalPh  •  Dec 7, 2013 @2:35 am

    Doctors in my area are usually pretty cool when I actually talk to them. Specialists become trouble.

    I find it so hard to deal with support staff. I say I am calling to clarify a prescription and some receptionist starts to read it back to me and indignantly ask what the problem is. Then I have to explain it to them and they see the problem, but instead of getting the doctor immediately, they try to guess. “He must have meant BID.” I’ll then ask their full name to document it and they will THEN start to head toward getting an MA or RN or the MD.

    We also keep getting damned electronically signed controlled Rxs, i.e. the image is from a jpeg with their signature or something like that. I then have to remind them that controls must be manually signed by the doctor. We have one clinic that is the worst offender. We started out nice, calling and gently reminding them. They never wanted to change. Their office manager says that it’s a paperless office now so don’t send a fax. Screw that. I stopped covering for them and now I just send a big fax to the doctor with the rule from the Controlled Substances Act and I tell the patient the delay is the doctor did not complete the prescription.

    I agree with Jim. The doctor is his or her own problem. It is not my responsibility to shield him or her. I shield the patient and myself the best I can, that is all.

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