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In a small group practice it is usual for doctors to look after the needs of one another's patients in their absence. It provides continuity of care and generally enhances care. Occasionally, it presents interesting dilemmas. One such recent occurrence involved a relative of a patient attending the office to procure a prescription repeat for their father. The medication sought was originally prescribed and monitored by the patient's cardiologist. The relative who was picking up other medication repeats at the pharmacy was informed that it was a simple omission made by the cardiologist and was instructed that matters pertaining to drugs should be addressed to their family doctor who specializes in such trivial matters. The relative called the specialist's office first to obtain a refill, and again was instructed by the receptionist that this was a matter for the family doctor. And so the relative of the patient sought out the substitute family doctor to rectify this "trivial" matter. Two fortunate coincidences then intervened. Firstly, I happened to have access to the patient's file, and secondly, I am one of the few people with a honed aptitude to decipher my partner's Cyrillo-Islamic scrawl. A quick chart-review revealed that my partner had never prescribed the medication, and the chart contained no written direction from the patient's specialist asking my partner to take over the monitoring or prescription of these medications. The relative became testy and upset at my uneasiness to quickly fix this seemingly trivial matter without at least examining the patient. I suddenly became vilified for suggesting that they check with the appropriate prescribing doctor to obtain a refill. They left the office muttering loudly about failing to pay their taxes, made a grab for my autographed Johnny Bower goalie stick and gestured what I thought were traffic signals with their finger. I was saddened to realize that the "system" had sent them on a wild goose chase. Vindication came upon my partner's return. It turned out that the patient had undergone surgery recently and the medications were being withheld intentionally. That simple "favor" could have been fatal for the patient.
People with frail health who require constant care are the same ones who tend to be on multiple medications and are at risk for getting into trouble. More than half of the people who use five mediations or more cannot accurately recall the name, dose and indication for their medication. It presents real problems with their care. Family doctors are often the ones who have to manage the whole picture and turn out being the medication quarterback. They too often forget the simple rules of prescription. It is the duty of the doctor who prescribes the medication to also monitor its effects, promote compliance and make dosage changes as required. I try to use a simple reminder system by prescribing enough medication with repeats until some form of monitoring needs to be done. My patients know that when the bottle is getting low that some form of monitoring is due, and book in to see me. Problems arise when a patient with multiple specialists is receiving medications from everyone. In these cases, family doctors rely on the written communication from their colleagues. Some specialties need to monitor and change dosages regularly. They get rightfully upset when other doctors interfere in this process. If a colleague writes to me and requests that I take over the monitoring and prescription of medication, I will only accede to the request if I feel comfortable doing so. At other times, I may give a short supply to the patient when his or her specialist is away. In these cases, the pharmacist is informed how to handle future renewals. It is inappropriate for a physician, in any setting, whether it be emergency, walk-in clinics or hospital settings to simply start patients on a long-term medication and tell them to see another doctor without communicating with that doctor. One sure sign of persons with a dependency problem is that they always interject that another physician, seen once only, encouraged them to use morphine-like substances regularly and they were reassured that I would deliver an endless supply. This is usually followed by the "check for yourself" comment. I immediately drop everything that I am doing and devote my entire working day to combing the phonebooks attempting to locate this unknown, unreachable doctor. Prescription should be done on a rationale basis with the input of both physician and patient.
The confusion is partially compounded by pharmacists who fax repeat requests. My office receives regular fax requests to refill medications which I am not aware of and which I am not monitoring. Some pharmacists have defended the process by stipulating that the receptionist of the original doctor "told them to do it." This message is driven home by my work as a Coroner. Many death scenes are riddled with prescription bottles which often result in phone calls to the various doctors whose names are found on the bottles. I am confounded at how often a medication is prescribed as a "favor". Now favor is totally unlike compassion in my view, but it somehow absolves one from keeping track and monitoring. On rare occasions, it gets even sadder when records and indications for prescription cannot be found or recalled.
To avoid fatal favors, I would suggest you gather up ALL those pills, herbs and vitamins that you might be taking, put them in a brown bag and book in to see your family doctor. Your family doctor will sift through things and properly enter them in your record. Discuss with your family doctor who is monitoring which medication and how often you should see the specialists involved in your care. If you use more than three medicines, keep a written record with you at all times. Finally, seek out the services of a good pharmacist. Develop an ongoing relationship with one pharmacist. Your pharmacist can answer many of your questions and is able to spot potential problems and errors. Beware of strangers who stuff bags of pills in your one hand and a computer printout in the other without uttering a word!
