Anyone noticed a weird trend on this forum where we all compete to see who is toughest on the patients? This seems like one of those threads.
I think there are a couple of related issues that are worth discussing. First, I disagree with that assessment because the general consensus seemed to be that while there are general rules, every patient is different and there are always exceptions. If I wanted to be tough I would say no "feel goods" (as our behavioral med folks like to call them) ever.
All medicine is local. Where I am, it is relatively easy to get patients to see a PCP, assuming that they don't have one already: reasonable health insurance mix, religious non-profit hospitals dominate and they expect their physicians to see Medicare and reimburse for charity care, a couple of FM residency programs that have "undeserved" clinics. etc. If I was in a situation where the ED was essentially primary care, my response would be different. In addition, over the years, we have worked out a truce with our primary care physicians, it is unwritten, and a matter of convention, but it essentially goes,
we will not practice primary care, and they will not practice emergency medicine. Like all platitudes, it sounds better in words than in action. They won't tell their patients, "go to the ED and they can get an MRI and EMG done this afternoon", and we will not deliberately "stab them in the back." There are things that I cannot effectively treat out of the ED; anxiety, depression, insomnia, etc. My goal is to get them alive and in one piece to the physician who can at least give it a shot. If I give the insomnia patient 14 days of Ambien, I have essentially forced their hand with respect to evaluation and treatment. Granted, there is not duty to make their physician's job easier, but their is also no reason to make it more difficult. If a patient tells me that they have an appointment with their FM doc the next day, and I decide to write for ambien, I am writing for one pill. They can deal with it after that. Most of the time our patients can be seen by primary care within 48 business-hours, so that determines the quantity of what I am willing to prescribe. Someone here for business for ten days? That is a different dynamic - in several respects, actually.
As to the "foolish for filling one pill", I picked up a prescription for one Xanax for my wife last month: MRI and claustrophobia, so it isn't
completely unheard of.
But again,
all medicine is local and
every patient is different. I am not going to stop writing for one ambien if indicated (see above) just because it is weird, but I am also not going to keep from writing for 10 in the very rare situation it is indicated.
