Saturday, March 12, 2016

Dr. Butthead at Urgent Care(less)

So I get a text from Auntie on Sunday morning:

I've been down this road enough (AS A PHARMACIST) to know how it is going to play out. In this state, what different insurance covers in terms of inhalers is a complete mystery and you have to be prepared for all possibilities because we can't swap out one inhaler for another unless they write "albuterol inhaler" on the script or as I texted to Auntie.

Hours later, Auntie calls me and tells me Dr. Butthead wrote her a prescription for ProAir and didn't write what I suggested. I asked her if she told him I was a pharmacist. She said yes and that she even read the text message I sent her to him. 

He didn't listen, and now because the Urgent Care(less) is now closed, Auntie has to wait until tomorrow to get her inhaler. Her pharmacist has to wait until they're open so he can get it changed. They don't have a doctor on call... because they could care less.

Dr. Butthead, you're a pompous ass.


Anonymous said...

1) While your suggestion re: albuterol inhaler prescribing is good, your anger is focused at the wrong target. It's not the doctors fault that insurance formularies are so inane and we can't write every prescription trying to guess for every eventuality that will make them happy. Although in this case, your suggestion was reasonable.

2) You really shouldn't be offering medical advice to family. Stay supportive, but remain detached, let other objective professionals do their job.

3) Some of your treatment suggestions remind me of why I'm reticent to have pharmacists as prescribers. You recommend she take nasal steroids for probable bronchitis? Probably harmless, but also pretty questionable indication and efficacy. And why are you recommending codeine for a lower respiratory tract infection? Codeine for symptomatic relief carries plenty of risk and really shouldn't be used at all anymore.

4) Doctors don't like when patients treat them like a fast food joint, much like your own blog. A patient showing up saying "I have bronchitis, prescribe me this list!" gets our back up, when people treat us like a dispensary vs seeking a professional medical opinion.

I love your blog, but this post shows that we are all human and irrational at times.

Anonymous said...

Why not tell her to just ask for the albuterol inhaler then rather than a brand?

Crazy RxMan said...

In response to these good comments, let me add:

I fill at least one to two prescriptions per day written by a doctor for their own family member, which is not at all "detached." In my case, however, I'm not prescribing anything... I made a suggestion based on my experience with Auntie's history of pneumonia. Auntie actually ended up in a hospital about 10 years ago because an Urgent Care refused to listen to her when she told them she had previously had pneumonia. That fact is that I wasn't with Auntie, but based on what she told me, apparently the doctor agreed with some of it because he did in fact send her for a chest x-ray and prescribed an antibiotic, Flonase, and Phenergan with Codeine.

My issue is that the doctor showed attitude to Auntie because she simply wanted him to write on the prescription "ok to switch to inhaler covered by insurance" on the prescription. Based on what happened, Auntie was left to suffer simply because the doctor didn't want to take another 30 seconds to write that. The issue that I'm trying to point out here with this blog post is that some doctors, especially those in "Urgent Care" tend to get careless. And like I said, I know how it is going to play out with insurance and I was simply trying to avoid that. Since my specialty involves dealing with insurance, taking my advice with the inhaler would have been the wise course of action, because, as mentioned, doctors are unaware of everyone's formularies. In retrospect I should have just told her to ask him to write for an albuterol inhaler.

My suggestion of Flonase was based on the symptoms she described to me. A nasal steroid is very commonly prescribed in this area for the same symptoms. The Phenergan with Codeine was based on the same. As such, it was only a suggestion. I didn't instruct her to go to the doctor and demand that he write prescriptions for these items. I deferred to the doctor judgment, of course. And knowing Auntie, she would have handled it professionally and never would have demanded anything.

I can say with a certainty that Urgent Care centers have done overwhelming damage to the image of medicine as a profession. They have turned care into a "fast food joint," where you can get in and out with lower quality care. That's my opinion, of course, but it's based on seeing people every day come in with the same prescriptions prescribed by the same doctor over, and over, and over. It's almost as bad as "Pain Management" centers.

And yes, I am human and irrational most of the time. Retail pharmacy has done that to me.

James Pookay said...

Thanks for the reply, Crazy Rxman

As a fellow Urgent Care doc myself (in Canada), I see a lot of the same low-quality medicine you describe. Maybe the MD was a pompous ass, maybe they weren't. But there's a good chance they were. But being a fellow MD, I'm sensitive to such criticism because someday that guy will be me.

My biggest thing that drives me nuts is a lot MDs don't seem to consider some basic tenets such as "What are we treating here? What's the diagnosis? What's the evidence for the treatment we're considering". But asking questions takes time. And time costs money. And the pay is terrible and by the head. The pompous doctors definitely make double or triple what I make.

The evidence for nasal steroids and codeine for your average viral illness, which is what most of these things turn out to be short of a positive chest x-ray, is pretty weak.

But of course, we weren't there and we can only brainstorm from afar and may not be privy to all the details, which is why second-guessing physicians is always so frustrating. They might know something we don't. Or they might just suck.

Anonymous said...

I dont know how its done in your state but here in Californiacwe can switch between the three major albuterol HFAs without permission from the doctor. All the same stuff, so gove them whatever the insurance will cover. Always try to give them exactly whats prescribed, but if it isnt covered or isnt on hand (we have had supply issues with ventolin for the last few weeks) we go with what works...

Unknown said...

Because I have spent the past 35 years spending my work days looking at the details and playing "what is wrong with this?", it should be "...because they COULDN'T care less". And because I am a pompous ass.