Epic Labs and Medication Refills, discharge summaries and the intern fears

[deleted1053216]

One of the things that I have observed in residency is that as I am the PCP for a number of new patients, I am forwarded their labs from different specialists and medication refill requests.

Labs-
1. I compare any received patient's labs on epic to the past labs and am forgiving of one to three point discrepancies, for instances, if glucose goes from 121 to 124, I forgego it. I spoke to my senior mentee, who reports I don't really need to do anything, but my question is as follows:
- When do I press the panic button, what would concern you that you would request your nursing staff to call the patient for a visit?
- do these labs get passed on to the patients without me taking any action? What I mean by that is if I click done and the results are taken away from my inbox, is that all I need to do, or do I need to find a way to share these results with the patient?

Medication Refill-
I am sent over prescriptin refills on epic, an usually, I am quite glad to refill medication. However, I find that my senior residents and attending have a discretionary view with refills. They will refill medications for their patients, however, for some medications, they will ask that the patient is seen in the clinic again. This can be for anything, from LIsiniopril to Zofran.
Hence, I always worry that am I doing something wrong by blindly refilling their medications.

Intern fears-
1. I remember how much I loved clinic during Sub-I's, But now, I read up about each clinic patient the night before and then try to consider what is the best way to pan each visit out and brace myself for the said time. I mean slowly, but surely, I feel myself becoming intolerant towards clinic days. Where my rotation serves as a distraction and is more enjoyable than clinic. What is to be said about a doctor who is scared of seeing patients? I fear that I will not be the provider that my patients need, will not be able to meet their expectations, make a misstep that my attending will call me out on and what if that is enough to kick me out of residency program. Sometimes I feel I am more guarded in every interaction, having that thought in the back of my mind.

Residency is a tough cookie, but, seniors seem to be enjoying it. What can I do to move past that fear of failing out?

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[deleted87716]

1) Why would you be getting labs on a patient if you, a) aren't going to see them shortly, or b) didn't just finish seeing them...? If the labs were ordered by a specialist, they aren't your responsibility.
2) You aren't getting requests for "refills." You're getting requests for NEW prescriptions. Understand the difference. If you always write prescriptions during routine office visits, and provide sufficient refills to last until the patient's next appointment, you will minimize the need to deal with "refill" (new Rx) requests in between visits.
3) Yes, if you're "blindly" refilling meds, you're doing it wrong. All prescriptions require some sort of medical decision making re: safety and efficacy. That might just mean a chart review, but more typically, it means an appointment.

 

[hallowmann]

1. Specialist results are the specialist's responsibility to notify the patients about. If they have a visit with you and ask, feel free to answer, but make it clear that they should discuss those results and meaningfulness of them, unless its something obvious you can answer (you don't need an endocrinologist to explain what an A1c value means).

If you are talking about test results for tests you or someone else in FM has ordered, that's your responsibility to notify the patient. You can do this in a number of ways. First, if you have a visit coming up, you can just tell them then. Second, you can call them or send them a letter or send them something like a MyChart message (if that's something they have). Third, you can have nursing staff notify them. Ultimately it will depend on what the culture of your clinic is like whether you'd notify them and how you'd do it or whether its done through nurses. I make it pretty clear to patients that I'm not going to call them unless something needs to be discussed. Even then, sometimes I opt to have that discussion over MyChart. For normal results I either send a MyChart message or a letter with a copy of their test results for their records.

As a patient, I hated not getting some sort of notification, and unfortunately in one instance it resulted in something being missed for more than a couple years that resulted in organ injury. Don't do that. The patient should be notified, even if its the nurse calling and saying all results are normal.

There's no "point" rule for labs. No one cares if their glucose is 120 vs. 124, what's their A1c? Was it even a fasting sample? etc. Numbers out of context mean nothing. If a lab is abnormal enough that it needs to be followed up you either need to have them come back for another lab/recheck, or you need them to schedule a visit for further workup. When you order a lab test, you should already have a plan for what you will do depending on the result of the lab.

As for what happens when you "Done" results, that varies by system. If your system incorporates MyChart and the patient has it, most likely there is a timeframe until those labs automatically become visible to the patient. In my system its 48 hrs. If I don't release it before then, then the labs will automatically be released. If I just hit done, nothing happens until that time. You should be hitting "Reviewed" or "Reviewed/Release to MyChart" to indicate you've actually looked at the results, but verify this with your own system. As I said above, you should find a way to share the results with the patient, even if its just a letter that says "all normal".


2. As @Blue Dog said, you're getting a request for a new script. They should always be filled intentionally. Often the refill is prepped by RNs, and they sometimes make mistakes as well. You should always have a plan here. When you see a patient for their annual physicals and they've been on lisinopril forever with a normal BMP, then give them a 12 month supply. When the refill request comes in, and you haven't seen them in a year, you know you should be seeing them soon. If they don't have an appointment, then you need to request that they make one and give them a 1-time 30-90 day refill until they see you again.

Obviously how much leeway you give them is up to you, but just know that ultimately you are liable if something goes wrong there. Are you refilling lisinopril when they have an AKI? Are you refilling their Zofran when they were recently maxed out on Celexa, started on a quinolone for a recent bout of pneumonia, and haven't had an ECG in 2 yrs? These are reasons why people need to be seen somewhat regularly, even if it is only every 1-2 yrs. If others are less lenient, you should probably be asking why, what do they know or have they experienced that I haven't?


3. You shouldn't really have a fear of failing out. Its a rare occurrence, and as long as you are completing your work responsibly, its very unlikely you'll be removed.

As for clinic, clinic is hard. There's a broad range of things you could possibly deal with, you're never going to be prepared for everything. You should briefly pre-chart, but don't spend a ton of time on it. Think about things that would be good to address, but know the actual visit may be different. Work on agenda setting. Become more comfortable with the idea of not knowing things. There is going to be a lot you do not know, especially in intern year. You get better over time, but there's nothing wrong with admitting that you're unsure of something to a patient. Say you'll discuss it with the attending, and see what they recommend. When you don't know something, its better to be upfront about it, then try to BS your way through it or tell a patient the wrong information. Like I said, you'll get better at it over time, you're only 1 month in afterall.

 

[deleted87716]

If I have anyone on a refillable prescription medication for a chronic condition (no matter what it is), they're seen at least annually. There's a reason prescriptions expire after a year.