When Does a Patient Need to Be Seen?
| July 28, 2014
You need a refill for a prescription that's about to run out. You've taken the medication for years without any problems and can't think of any reason why the prescription can't just be automatically continued. But the doctor won't order a refill unless you make an appointment and come in to be seen. Is this an unfair burden on the patient or due diligence by the doctor?
Dr. Lucy Hornstein, a family practice physician who blogs at Musings of a Dinosaur, was up against the wall recently with a patient who needed refills for blood pressure medications but wouldn't make an appointment, despite repeated reminders. "What to do?" Dr. Hornstein asked her blog readers:
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 do 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?
It's a good summary of a dilemma that puts the doctor between a rock and a hard place no matter which course of action she chooses.
Patients don't necessarily see it this way, though, judging from many of the online conversations about everything from seasonal allergy medications to antidepressants. Sometimes it ends up being a source of conflict, as in "Why are you making me jump through all these ridiculous hoops for a routine refill?" Sometimes patients are running out of medication but can't get in for an appointment right away – what then? In some cases they're genuinely worried about the cost of an office visit, especially if they have a large copayment or lack health insurance.
Dr. Hornstein's readers, most of whom seem to be health care professionals, didn't mince words on the need to crack down on this patient. "No more refills until she sees you in person. Period. You are not a refill machine," was one person's blunt assessment.
There seems to be room for debate on how often patients should be required to see a doctor for a prescription refill. Is twice a year excessive for someone whose blood pressure is well controlled with medication and experiences minimal side effects? Is once a year enough for someone who has complex health issues and is taking multiple medications? What about prescription narcotics? Should it make a difference if the patient is someone the doctor knows well?
Truth be told, I don't enjoy the hassle of getting a refill. But after reading Dr. Hornstein's side of the story, it's easy to see why doctors don't like reauthorizing prescriptions willy-nilly. After all, it's their name on record as the prescriber if something happens to go wrong. Sometimes the patient really does need to be seen.
This post originally appeared on Anne's HealthBeat blog on May 29, 2014.
