Addressing non-psychiatric requests

[SpongeBob DoctorPants]

I'm wondering how some of you handle requests from outpatients for general medical (non-psychiatric) needs. I am a person who usually tries to be as helpful as I can for my patients, but in situations like this I will typically defer to whomever I think the most appropriate provider is.

For example, I have been treating an adolescent for autism, anxiety, and ADHD. His mother called the office wanting a prescription for ibuprofen 800 mg, or a note she could give the school which would allow him to take the ibuprofen she's been giving him, for his migraines. I suppose the mother requested this of me because I'm the physician this patient probably sees most often, and maybe it's been a while since his last PCP visit. Would it be a huge deal if I ordered the prescription or wrote the letter? Probably not, but given that I had never worked up his headaches nor offered any treatment for them, and because migraines are not a psychiatric problem, I recommended that she contact the PCP instead.

While I do consider this the most appropriate course of action, I find myself wondering if I should have just taken care of the simple request, or if my instruction to call the PCP might be perceived as laziness or an unwillingness to help. However, from a risk management perspective, I think that it would be unwise to officially recommend treatment for a problem I have not evaluated, and which is outside of my specialty. Do any of you get similar requests? If so, how do you address them?

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[Psychotic]

Migraines? Refer to PCP, not our bailiwick...not mine, at least.

 

[wolfvgang22]

You do the right thing. Another thing you could consider is prescribe a one time 7 day or 30 day supply if you think the request is low risk while the patient awaits the PCP appointment. For a juvenile with normal labs and no problems other than migraines and ADHD I'd probably prescribe a one time supply.

For patients I see on long term statins or albuterol inhalers where their is nothing new, no mystery, I do this kind of thing a lot. I don't treat new non psychiatric conditions in general.

 

[hamstergang]

given that I had never worked up his headaches nor offered any treatment for them, and because migraines are not a psychiatric problem, I recommended that she contact the PCP instead.

I'd agree with this. While it's easy and safe to recommend Advil for headaches, once you write that you've now taken some ownership of this issue. Something headache related comes up at school and they're going to you.

 

[Liquid8]

It depends on what is being requested. If a patient has been on long term medications that I've already got formal documentation of (i.e. from referral letters) than I will provide a script if requested, usually in a limited amount. I also have to be comfortable with the dose of what is being prescribed, as there is an onus to review medications for appropriateness too. Eg. I'd be ok continuing someone on brufen 200-400mg TDS PRN as that's what I'd often use for simple analgesia. However, if they wanted 800-1600mg TDS regular I wouldn't as that isn't in keeping with how I was trained to use that medication. For letters, in most cases this should be up to the regular prescriber (which in most cases is usually me!)

In terms of treating non-psychiatric problems that pop up in consultations, I'm quite comfortable doing this within the same kinds of limits. There's a few things I am able to manage without too much difficulty: simple analgesia, nausea, constipation, diarrhoea etc - all things I had to manage on medical and surgical jobs prior to starting psychiatry training. Aside than that, I expect my patients to go back to their regular doctors although there are exceptions: a few months ago I treated one of my regulars with a short course of prednisolone for an eczema flare up as their usual GP was away for a month.

 

[TexasPhysician]

Migraines are appropriate for psychiatrists in my opinion. With that said, I wouldnt recommend treatment for anything that I haven’t evaluated in clinic. The right answer is to initiate a clinic appointment for evaluation and education.

 

[SpongeBob DoctorPants]

I appreciate everyone's responses. It appears there is some variability in how psychiatrists handle this kind of situation, and there isn't necessarily one right answer to this. Perhaps it comes down to how one was trained. Some limit their practice to psychiatric complaints only, while others are more like generalists and treat other kinds of problems. Personally, my experience in treating migraines was limited to a few weeks on a neurology rotation, so it's not anything I'm really comfortable with. I have more experience treating hypertension and diabetes, but I'm not about to take those on in my clinic, either.

 

[NickNaylor]

You do the right thing. Another thing you could consider is prescribe a one time 7 day or 30 day supply if you think the request is low risk while the patient awaits the PCP appointment. For a juvenile with normal labs and no problems other than migraines and ADHD I'd probably prescribe a one time supply.

For patients I see on long term statins or albuterol inhalers where their is nothing new, no mystery, I do this kind of thing a lot. I don't treat new non psychiatric conditions in general.

This is typically what I do with my clinic patients. I will prescribe a small supply of their medications, let them know that they need to follow-up with their PCP, and that I will not provide an additional prescription. I haven't had any trouble with this. For any complaints that are truly concerning, I will refer to the ER (if indicated), tell them to call their PCP ASAP, and/or send a note to their PCP if they're seen in the same hospital system.

 

[MedMan80]

Coming from a CAP perspective, i would definitely ask the family to see advice from the pediatrician regarding this issue. I wouldn't want to step on the pediatricians feet and manage something like headaches, and I would argue that the pediatrician is the one who knows the patient's medical history inside and outside and would be the best to make a decision like this. You're not being lazy at all, just having the best interest of the patient in mind.

 

[VA Hopeful Dr]

This is typically what I do with my clinic patients. I will prescribe a small supply of their medications, let them know that they need to follow-up with their PCP, and that I will not provide an additional prescription. I haven't had any trouble with this. For any complaints that are truly concerning, I will refer to the ER (if indicated), tell them to call their PCP ASAP, and/or send a note to their PCP if they're seen in the same hospital system.

As a PCP, this would be the approach I'd prefer y'all take.

I would also completely understand if you did not do a refill of any kind and would back you up on that as well.

 

[Candidate2017]

Migraines are in the purview of psychiatry. I ain't saying the kid has pilocytic astrocytoma, but juries don't take kindly to doctors who phone in motrin without workup.