Med Mixups and MD Gripes

[DHG]

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This is really a personal problem, and I wanted input here. If this is not an appropriate topic for this forum, then moderators, feel free to remove it. I wasn't sure if it was ok to post or not, but even though it is a personal experience, maybe others have similar excperience or can offer some advice.


The deal:
My father had a kidney transplant last summer, almost exactly 1 year ago. He has 3 doctors: 1)his family practice doc, 2) his urologist, and 3) the transplant doc. He has had prescriptions from all three docs, and they rarely communicate. There have been too many incidents to count over the past year where dangerous things have happened that NO ONE has seemed to be accountable for.... they all just point and blame each other.

#1- The day he came home from the hospital, he was given a notebook describing his medications. He's on about 20 different meds. THere was a sticker that showed what each pill looked like, a description of the med, what it was for, the proper dosaage (he was on a scaled down program for many of them, and that made it all more confusing), and contraindications. Also a schedule for when to take the meds. The nurse that organized the packet was very nice and explained everything. When we got back from the pharmacy, the drugs that were on the prescriptions (the drugs we recieved) were not the same as the drugs in the notebook. Some were just generics, so that was not too hard to figgure out, some were different dosages, though, and the total dosage on the prescription bottle did not match the notebook. For example, the doc put in the notebook to take 5mg of pill A, three times per day, but the script we got was 2.5 mg pills that said take 2x per day. Many of the drugs that he was scheduled to take at the same time had conflicting info: i.e., pill A and pill B, (both to be taken at 8AM) where pill A would say "DO NOT TAKE ON EMPTY STOMACH" and pill B would say "DO NOT EAT 2 HOURS BEFORE TAKING." !!! Needless to say, this was all very confusing and took about a week of making phone calls to different docs to work out. As the dosing schedules have changes as he has recovered, this situation comes up again and again and again. THe docs DO NOT COMMUNICATE with each other.

#2- The transplant doc just moved out of town. THe meds that were prescribed by this doc included the anti-rejection meds. Pretty important stuff that would be LIFE-THREATENING if doses were missed. THe urologist (hateful woman!) refuses to prescribe these. She says to get the family practice doc to do it. The family practice doc was like, "WHAT?! I don't prescribe transplant meds! You have to get a specialist to do that!!" THese docs did not pick up the phone and call each other, OH NO. THey made my poor dad drive back and forth to each office, make appts., etc. He still has no answer as to who will prescribe his anti-rejections meds, and his doses are running out. All I have to say is WTF!!??? THis is the same uroligist that never called us back after we had an emergency on a weekend. My mother really chewed her a new one on Monday.

#3- One doc at the ER (where we had to go because the hateful urologist never called us back) requested a SPINAL TAP at one point after the transplant. THe transplant doc JUST HAPPENED TO DROP BY RIGHT BEORE IT WAS ADMINISTERED.... He was at the hospital checking on a patient. He cancelled it immediately... saying that a spinal tap for my dad at that point (where he was taking huge doses of immune-supressing drugs) could have been VERY dangerous.


I guess my main question here is this:
I know what to do when I get ****** around by a business. I know my rights as a consumer. I have used the BBB to resolve a complaint or two over the years. BUT HEALTHCARE? I have no idea where to turn for anwers when the people we trust (Doctors) are of NO HELP WHATSOEVER. My feeling is that this type of situation is not only extremelly stressful for someone who has just experienced life-changing surgury, but also DANGEROUS. I think my mother is in the process of contacting the AMA because that is the only thing she knows to do at this point, but is there anywhere else I can get information about resolving this kind of issue?

I don't think expecting doctors to communicate with each other is asking too much. Not ONCE during this transplant situation, when these three docs should have been working together to ensure the best patient care, NOT ONCE did any of them pick up a phone and call one of the others. I mean, we are talking about HUMAN LIFE here. I'm so frustrated I could cry.

I also wonder about how many people who are maybe poorer/less educated/more timid than my family have had issues like this that led them to DIE because of it??? I mean, some people that don't have much education, or maybe elderly people that don't have close family to help them would probably have no idea what to do. We have no idea what to do, and we are pretty well educated!

Is there a patient advocate organization? Should we try to find one practice that has a transplant specialist/uroligist/family practice under one roof? (fat chance) We are in the process of looking fo other doctors, but they are so hard to find and from my experience, docs around here rarely take new patients. I am so pissed at the medical profession right now. 😡

By the way, we have been to two different pharmacies, and the pharmacists at both have not really stepped up to help/offer advice. THey just say we need to talk to the doctors. Neither of them was willing to call on our behalf. One was a family run place (actually we still get one prescription here because it is the only place in town that stocks this one drug), and the other was CVS.

Advice? Comments? Anyone else have a similar situation?

 

[bananaface]

I'm sorry to hear about your dad. I hope he can find a new physician soon to help him with his transplant meds.

You dad needs transplant meds prescribed by someone who is comfortable managing the regimen. Any physican who isn't comfotable managing such a regimen (and few are) has no business trying to. Both physicians have every right to refuse to prescribe.

Perhaps your father's previous transplant physician would be willing to refer him to someone else in town who he feels would be able to manage his post-transplant care. Generally when physicians leave town they give a notice of a month or two so that the patient has time to find a new physician. And, often times, they will provide enough refills on the meds to last until a new physician is found. All of this is done as a courtesy, though. There is no way to force a provider to extend these services.

Even if you can get the physicians to talk, what inevitably happens is that every physician thinks that certain meds are the most important and wants the other physician to adjust their proposed scheduling around those meds. You need a neutral third party who knows what they are doing to intervene. Pharmacists will do this as a courtesy for single issues. But, hammering out a huge regimen is a time consuming service, which is generally only done by select providers, as a part of a fee for service type setup.

 

[trishias]

Im sorry about your dad as well. My mom had heart surgery a last year but she didnt have your dad's problem because her docs communicated. I hope for your dad's sake that they can start communicating because your dad's life hangs in the balance. Like bananaface said, see if the transplant doc can refer u guys to someone to manage his care from now on and get a new urologist because if you cant communicate with her, then she is in no position to help/treat. Good luck and best wishes to your dad.

 

[MoosePilot]

I've had some experience with a family member with a transplant.

Get a new transplant specialist. I think many transplant recipients use a transplant specialist as their primary care provider - in other words ditch the GP. Every health issue is now tied up to the transplant and those complications.

 

[TucsonDDS]

The transplant program that your dad was in probably has a transplant coordinator to help with things like this. Unless the entire program disapeered when the surgeon left I am sure that someone picked up his patients. It also sounds to me like your dad needs both a new Urologist and a new GP. Neither one seem to care enough to pick up a phone. I wouldn't blame either the Urologist or the GP for not wanting to order more meds related to the transplant. Most of these medications are fairly well monitored and adjusted to specific blood levels in the body. These lab tests should be followed by the transplant surgeon.

I know what you are going through, my Mother-in-law just got a new kidney about 6 weeks ago and my wife and I have been going through the same thing. Luckily the coordinator for our program has been pretty helpfull.

 

[DHG]

Thanks for the advice everyone. Hey banannaface:

Perhaps your father's previous transplant physician would be willing to refer him to someone else in town who he feels would be able to manage his post-transplant care. Generally when physicians leave town they give a notice of a month or two so that the patient has time to find a new physician. And, often times, they will provide enough refills on the meds to last until a new physician is found. All of this is done as a courtesy, though. There is no way to force a provider to extend these services.

That's another funny part. The transplant doc referred him to a different urologist in the same practice where the doc he sees now is (the evil hateful doc that dad can't stand). The office manager for the practice refuses to switch dad from the one doc (who doesn't want to do anything to help) to the other (who, according to other people is the best doc in town fro managing kidney transplant regimens). I think we'll end up having to go out of town, as this is the only specialized practice we know of here.

I'm not sure how they can't be forced to extend the extra month of scripts for a transplant case. That would be like denying dialysis, or oxygen to someone until they find a new doc. The average wait for getting into a new doc, if you can actually find one, is about 3 months. I just think a lot of things happen to people all the time as a result of inadequate access to docs. Stuff that should never happen considering what the docs are getting paid. Most of the time people see PA's, the doc breezes in for 30 seconds and then they are gone. I'm a little jaded, if you can't tell. The transplant doc was the only one I've ever liked, and now he's gone. I'm not just blaming them, the whole system is screwed up.


Good luck Tuscon, moosepilot and tricias! I hope your experiences are better than ours!

 

[MoosePilot]

Good luck Tuscon, moosepilot and tricias! I hope your experiences are better than ours!

Thanks for the thought.

 

[bananaface]

Unless the physician and your father have a contract, the physician is able to quit as your father's physician at any time. One he quits, he doesn't have an obligation to prescribe, because your father is no longer his patient and he is no longer monitoring your father's therepy. Since monitoring is key to your father's heatlh, prescribing without monitoring is not responsible behavior. The situation sucks all around. The best place to concentrate your efforts is into finding a new physician.

How far did the guy move? Could your dad possibly travel to see him until he can find someone new?

 

[PharmD4Me]

Unless the physician and your father have a contract, the physician is able to quit as your father's physician at any time. One he quits, he doesn't have an obligation to prescribe, because your father is no longer his patient and he is no longer monitoring your father's therepy. Since monitoring is key to your father's heatlh, prescribing without monitoring is not responsible behavior. The situation sucks all around. The best place to concentrate your efforts is into finding a new physician. QUOTE]

You maybe right, but I think a court would see that as NEGLIGENCE on the doctors part. Its almost the same as hospitals getting sued because gun shot victims came in with no insurance and they let the person die by refusing care.

My thought is that the doctor is responsible because if he knew he were moving, he should have not scheduled a surgery that he knows will need specific care and monitoring afterwards. He virtually is refuseing care to someone that cannot easily find it else where and putting his patients health at risk, not to mention adding much stress to an already weak person. By performing the sugery, contract or not, he is should be responsible for the well being of his patient, which is the morally right thing to do and a part of the oath that he took before becoming a doctor.

 

[bananaface]

The surgery was a year ago. While you might like to live in a world where physicans are obligated to care for everyone for an infinite period of time, you don't.

 

[PharmD4Me]

The surgery was a year ago. While you might like to live in a world where physicans are obligated to care for everyone for an infinite period of time, you don't.

1. I was not trying to attack you bannanaface.

2. I do not live in a world where I think physicians should give care for an infinite amount of time.

3. I do think the doctor is responsible for ensuring that his patient gets the meds he needs--he at least should have consulted with the health care team to make sure he was referred to a doctor that was comfortable dispensing the meds.

 

[bananaface]

I know you didn't attack me. My point is that moving to a new city a year post-surgery is not an unreasonable abandonment of the patient. Many patinets will require long term or even lifetime follow-up care post-surgery. To expect providers never to move or retire is ridiculous.

On referrals: In my area there is a shortage of physicians who take clients with DSHS medical coupons. Many providers have turned patients out, because the state reimbursements are so low that seeing these patients recuces the practice income to the point where the business is jeaopardized (seriously). When these patients are released, it is their own responsibility to find a new provider. Expecting your old physician to find you a new one is a bit like expecting your high school guidance counselor to find you a job after graduation - it's nice if they do, but it's really your own responsibility.

 

[baggywrinkle]

I'm not sure how they can't be forced to extend the extra month of scripts for a transplant case. !

You might ask to speak to the office manager to find out why there is a failure to transfer and point out that you are on the verge of taking your business out of town. If the manager is unsympathetic you mention that you might contact the medical board to report that office for access to health care. Urologist A will not help you and you are denied access to Urologist B and are now forced to travel seeking health care. Go to this meeting with your lawyer or at the very least a witness who will go to court with you.

Your pharmacy has an obligation to keep you in medicine until you can hook up with another physician. In Washington a pharmacist may dispense a 72 hour supply of a maintenance medication to buy time and it is not unusual to see several three day supplies come and go before resolution of the problem.
The more likely scenario is your pharmacist will hunt your original pracititioner down for emergency authorization. If they refuse to help you that is also a board issue.

 

[bananaface]

Your pharmacy has an obligation to keep you in medicine until you can hook up with another physician.

I disagree on that one. 3 day supplies are a courtesy, not something we are required to give. I say that because we give them at no charge, and I can't picture any business being required to give something they pay for out free at no charge. We can't guarantee that the patient will fill an Rx for the drug at our pharmacy and allow up to recoup our losses. (Interestingly, Bartell Drugs charges for their 3 day supplies.) Also, hardly anyone will give out 3 day supplies of narcotics. If we had an obligation to dispense 3 day supplies on maintenance meds, we would expect this to include maintenance narcotics. Some places have policies of giving 3 day supplies on all maintenance meds, which might obligate them to treat everyone the same. But, I don't see a blanket requirement for all of us to keep patients in their meds until they find a new physician. When there is a problem finding a new provider, it's likely to last more than the 3 days we are allowed to provide anyway. The bottom line is it's the patient's responsibility to find someone to prescribe, whether that be a new physician or an ER doc.

I do emergency supplies regularly. I'm just saying it's as a courtesy, not to satisfy a legal obligation. The law reads "may" not "must".

 

[baggywrinkle]

I disagree on that one. 3 day supplies are a courtesy, not something we are required to give. ".

Let me put it this way. If you refuse to provide a maintenance medication and that patient comes to harm, you had best be reading the fine print in your malpractice insurance because you are wide open for civil litigation at the very least.

Assuming harm came to the patient as a result of your inaction it would make a very interesting test case, don't you agree? Personally I would not want to be having that conversation with an inspector. It would be much easier to defend error on the side of protecting the well being of the patient, rather than standing on the letter of the law (no valid prescription) and allowing the patient to come to harm because you refused to give them some Sandimmune. This entire argument is invalid if we are talking about a controlled substance.

It isn't black and white, rather, shades of gray.

It comes down to taking care of the patient. You take care of them and LET THEM KNOW you are sticking your neck out to help them and they will take care of you. As LBJ once said; I would much rather have them on the inside of the tent pissing out than on the outside of the tent pissing in

 

[Caverject]

I disagree on that one. 3 day supplies are a courtesy, not something we are required to give. I say that because we give them at no charge, and I can't picture any business being required to give something they pay for out free at no charge. We can't guarantee that the patient will fill an Rx for the drug at our pharmacy and allow up to recoup our losses. (Interestingly, Bartell Drugs charges for their 3 day supplies.) Also, hardly anyone will give out 3 day supplies of narcotics. If we had an obligation to dispense 3 day supplies on maintenance meds, we would expect this to include maintenance narcotics. Some places have policies of giving 3 day supplies on all maintenance meds, which might obligate them to treat everyone the same. But, I don't see a blanket requirement for all of us to keep patients in their meds until they find a new physician. When there is a problem finding a new provider, it's likely to last more than the 3 days we are allowed to provide anyway. The bottom line is it's the patient's responsibility to find someone to prescribe, whether that be a new physician or an ER doc.

I do emergency supplies regularly. I'm just saying it's as a courtesy, not to satisfy a legal obligation. The law reads "may" not "must".

It's more like a moral obligation. Of course there is nothing in the law that says WE MUST FILL THIS (unless you live in Illinois, but that's a different matter 😉) In all cases, we must use best judgement. If this person has been on cyclosporin for 5 years and now is looking for a new PCP, it would be my best judgement to go ahead and fill it. Of course, there is limits to everything. I would only do this one to two months tops because morally I couldn't just cut a patient off

 

[DHG]

You might ask to speak to the office manager to find out why there is a failure to transfer and point out that you are on the verge of taking your business out of town. If the manager is unsympathetic you mention that you might contact the medical board to report that office for access to health care. Urologist A will not help you and you are denied access to Urologist B and are now forced to travel seeking health care. Go to this meeting with your lawyer or at the very least a witness who will go to court with you.

Your pharmacy has an obligation to keep you in medicine until you can hook up with another physician. In Washington a pharmacist may dispense a 72 hour supply of a maintenance medication to buy time and it is not unusual to see several three day supplies come and go before resolution of the problem.
The more likely scenario is your pharmacist will hunt your original pracititioner down for emergency authorization. If they refuse to help you that is also a board issue.

Thanks.

Here's the deal with the manager at the transplant office (who, once he heard what was happening at the urology practice, has been helpful, BTW) He referred all of Dr. MovedOutOfTown's patients to a urology practice here that specializes in transplant care. This is the same practice where my dad's uroligist is anyways. The problem is that she (the urologist) is refusing to do dads meds. There is another doc inside that practice that does do this (and who is really good), but the office manager at the urology place will not let dad switch doctors. The manager at the transplant office has tried to call on our behalf as well, but they still refuse. Dad actually tried to switch to the other doctor several times before the transplant, because he really hates this urologist (he's not alone... she has quite a reputation, and my nurse friend--nurses know all the dirt-- told me that there have been many, many problems with this particular doc).

So now we have a referral out of town. Which is a pain in the ass, but probably the best thing at this point. The new office is about 20 miles away, as opposed to 2, but I think we'll live---though it will be about 4 weeks until he can get his first appointment there.... which still leaves a window of a couple weeks where he doesn't have his meds covered... I don't know if this issue has been resolved or not...

I think there are some bad/unprofessional things going on in that particlular urology practice where dad has been though, and my mother has everything documented. She's soooooo pissed about all this. I won't be surprised if she sues someone. At the very least she is going to talk to people about the situation, make a formal complaint.

Thanks for your input.

 

[bananaface]

20 miles isn't bad. I live 45 miles from school and 35 miles from work. 🙂

With reference to the conversation above, if we dispense much beyond the 3 days we are allowed to dispense by law, it is really sticking out neck out legally, because we could be seen as providing them with an incentive to delay care. All actions or inactions have risks. You have to do what you think is best. Personally, I don't see me perpetually feeding the patient meds under the table as an appropriate or responsible course of action.

 

[DHG]

20 miles isn't bad. I live 45 miles from school and 35 miles from work. 🙂

yes, all in perspective 20 is not that bad.

 

[baggywrinkle]

With reference to the conversation above, if we dispense much beyond the 3 days we are allowed to dispense by law, it is really sticking out neck out legally, because we could be seen as providing them with an incentive to delay care. All actions or inactions have risks. You have to do what you think is best. Personally, I don't see me perpetually feeding the patient meds under the table as an appropriate or responsible course of action.

That is why it is gray.

Here in Yelm, for the first time in my career, I encountered people who abused the courtesy fill to get free meds. They came in when different pharmacists were on duty deliberately. The fellow I have in mind was on digoxin which is cheap anyway. When we caught on to his game we flat cut him off with a terse "DIE PIG DIE!"

When he follows our good advice and his family sues we can demonstrate attempt to contact the physician, and several courtesy fills in good faith.

With our father in distress of this thread I would most likely fill for a month looking both ways to make sure the inspector wasn't watching then tell the family I am out on a limb for you here so they are in my corner and wait. If nothing was resolved at the end of thirty days they would be placed on three day increments to make it as inconvenient as possible. After the third courtesy fill - no particular reason for that number - it is time to turn cold shoulder and refer them to the emergency room for authorization.

What you don't want is for the inspector to come in and find a patient on a maintenance drug who has not seen a physician in several years due to the pharmacists negligence, the physician long since retired/dead. Don't laugh, it happens. I have also seen a pharmacist called before the board in Texas to explain dispensing a controlled substance without a valid prescription over Restoril. All he did was spot the patient enough to get through the weekend and the physician dobbed him in for it.

 

[Caverject]

20 miles isn't bad. I live 45 miles from school and 35 miles from work. 🙂

With reference to the conversation above, if we dispense much beyond the 3 days we are allowed to dispense by law, it is really sticking out neck out legally, because we could be seen as providing them with an incentive to delay care. All actions or inactions have risks. You have to do what you think is best. Personally, I don't see me perpetually feeding the patient meds under the table as an appropriate or responsible course of action.

When in doubt, patients always comes first. If I lose my license, I lose my license knowing I did the right thing.

 

[bananaface]

That is why it is gray.

Here in Yelm, for the first time in my career, I encountered people who abused the courtesy fill to get free meds. They came in when different pharmacists were on duty deliberately. The fellow I have in mind was on digoxin which is cheap anyway. When we caught on to his game we flat cut him off with a terse "DIE PIG DIE!"

When he follows our good advice and his family sues we can demonstrate attempt to contact the physician, and several courtesy fills in good faith.

With our father in distress of this thread I would most likely fill for a month looking both ways to make sure the inspector wasn't watching then tell the family I am out on a limb for you here so they are in my corner and wait. If nothing was resolved at the end of thirty days they would be placed on three day increments to make it as inconvenient as possible. After the third courtesy fill - no particular reason for that number - it is time to turn cold shoulder and refer them to the emergency room for authorization.

What you don't want is for the inspector to come in and find a patient on a maintenance drug who has not seen a physician in several years due to the pharmacists negligence, the physician long since retired/dead. Don't laugh, it happens. I have also seen a pharmacist called before the board in Texas to explain dispensing a controlled substance without a valid prescription over Restoril. All he did was spot the patient enough to get through the weekend and the physician dobbed him in for it.

If you know the original prescriber is not willing to authorize a refill, you are simply prescribing on your own, knowing full well that you are not going to get a physician to later sign off on your actions. For me, when the original prescriber has already refused to fill, this (technically illegal) option goes out the window. If there weren't an ER right down the road, I might feel differently.

My interpretation of the law is that we may give out a single 3 day supply per instance, not serial 3 day supplies. Not that the law is always practical or followed. 😉

 

[baggywrinkle]

My interpretation of the law is that we may give out a single 3 day supply per instance, not serial 3 day supplies. Not that the law is always practical or followed. 😉

That is the law. My priority list reflects my pilot training; Safety, legality, convenience. I would take it to court in that order and never loose a bit of sleep knowing I broke the law to preserve safety. If that means relinquishing my license, so be it.

In the aviation world there are what they call legal minimums required to keep an airport "open" and it has happened that inexperienced pilots have allowed their fear of the legal authority to scare them away from safe haven in a storm only to die in a field somewhere. More experienced pilots, in contrast, exercise emergency authority of pilot in command to land anyway. Dinner is still waiting when the air traffic controller looks out the window of his tower over his below minimum airport to see a fireball in the distance and says **** It is up close and personal for the pilot of that fireball. So it is also when the inspector looks at records of something which happened months ago. You had to be there and you have to look at yourself in the mirror.