podiatry is medical school

[janV88]

Ok guys, here's the deal with the Physician title. Traditionally "Physicians" are MD/DO. The reason why DPMs, DDS/DMD, etc. want to be called "Physicians" is not because they want the public to think they are MD/DO and spread misinformation. The reason is reimbursement. Medicare considers DPM's and DDS/DMD's as Podiatric Physicians and Dental Physicians, respectively but medicaid is state dependent and some states do not consider them Physicians. Because of this, some insurance companies reimburse Physicians and non-Physicians different rates.

Is it fair for an Orthopod to be reimbursed more than a Podiatrist for the exact same procedure? I hope everyone's answer is "No".

That is why these fields are trying to be called "Physicians".

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[willdaniel76]

no doubt. at the end of the day we're all on the same team.

Agreed, it just sad that these sort of disagreements can serve another purpose in driving away people from a career in health-care. This day and age, title is everything. Someone like that getting ready to spend 200k on an education is going to want to get the biggest bang for his buck. It can be argued that those sort of people probably wouldn't make the best doctors anyway but them again one of them might have the cure for cancer locked away inside them. You get my point.

I know personally at the end of the discussion for myself it came down to factors like my wife, money and location when I decided on what schools to apply to. After letters came back I had to make a decision and settled on an Osteopathic school in state rather then schools that may have interested me more out of state. On the subject of podiatry, had there been a DPM college in state I can safely say I would have applied and gone when accepted. The foot\ankle is what interests me and now I have to hope I can manage to end up recieving the training I want rather then just going straight to a school where I could have assured that.

 

[willdaniel76]

Ok guys, here's the deal with the Physician title. Traditionally "Physicians" are MD/DO. The reason why DPMs, DDS/DMD, etc. want to be called "Physicians" is not because they want the public to think they are MD/DO and spread misinformation. The reason is reimbursement. Medicare considers DPM's and DDS/DMD's as Podiatric Physicians and Dental Physicians, respectively but medicaid is state dependent and some states do not consider them Physicians. Because of this, some insurance companies reimburse Physicians and non-Physicians different rates.

Is it fair for an Orthopod to be reimbursed more than a Podiatrist for the exact same procedure? I hope everyone's answer is "No".

That is why these fields are trying to be called "Physicians".

You make a valid point obviously. However I'm sure there are Podiatrists, optometrists and Dentist that would like to be called physicians strictly because they feel they have not only earned the title but are in fact physicians.

I would also agree that in case of DPMs, dentists or ODs that calling themselves a physician without the dental or optometry part is unsafe and dishonest. If you pick up your phone book and flip to the physician section most of them advertise themselves by their training "John Do, MD Oncologist and not John Do, MD Physician"

Does anyone notice how many different ways you can mistype physician when you use it dozen times a post? lol

 

[phillypd]

you people are idiots for even discussing this! This is so ******ed!

 

[karizma098]

you people are idiots for even discussing this! This is so ******ed!

do you feel cool now? if you don't have anything to contribute, why dont you..well, you know where i'm going with this, don't you?

good night all.

 

[VA Hopeful Dr]

I've never heard of this tbh and I work with a medical school and multiple residency programs.

What system do you work in? And are you still a resident? If you're in private practice managing these things you are under huge liability.

Yes, I am a resident. That being said, about 2 months ago I was at a device rep dinner and sat with a family physician from one town over who (up until last year) did outpt, inpatient, and OB care. He did stop the OB due to malpractice cost though. There are still plenty of FPs that still do all that stuff, especially in more rural areas.

 

[VA Hopeful Dr]

I guess in the "modern" sense of the word the closest thing to a "general physician" is a family physician but you just said exactly what I was saying..."we can't do absolutely everything".

If you read the med student's posts above me they believe that a physician has an unlimited license and can treat everything. Karizma even claimed that he is able to treat anything and everything once he graduates from medical school. Is this true? Can a psychiatrist give botox? or Can an ophthalmologist fix a shoulder dislocation?

As has been mentioned already, practicing physicians have what is called an "unlimited license". That means, as far as state law is concerned, we can do absolutely anything that falls under the scope of practicing medicine.

That said, I couldn't get hospital privileges to take out your appendix or cath your heart. But if some foolish hospital did let me, I would not go to jail over it as it is within the scope of my license.

 

[pinipig523]

As has been mentioned already, practicing physicians have what is called an "unlimited license". That means, as far as state law is concerned, we can do absolutely anything that falls under the scope of practicing medicine.

That said, I couldn't get hospital privileges to take out your appendix or cath your heart. But if some foolish hospital did let me, I would not go to jail over it as it is within the scope of my license.

That may be true, but you have to find a patient who will let you take him to the cath lab and you need to be sure that you have the lawyers to back you up when you lacerate the femoral because you have no idea how to get up to the coronaries.

Just because you're allowed to practice an unlimited scope, the legal system and climate along with patients' choice in doctors will limit you.

We MDs are limited in our scope of practice by those we can practice upon.

It is a moot point.

I believe that DPM is just like opthalmology or any other specialty in the field of medicine. They may have their scope of practice limited from the getgo, but so are we in any other MD (or DO) field.

I'm in ER.... and though I can prescribe nearly any drug, I won't be the one to change your anti-arrhythmic because I'm not going to be responsible for your down-stream consequences. I'm going to reserve that judgement for your cardiologist or IM doc. They can tinker around with your propranol being changed to diltiazem for all I care.

I can do it, but I wont.

So... DPMs are limited, but who cares. I'm limited too.... the only difference are the forces that keep our scopes within a finite arena.

 

[pinipig523]

"Yes, a Physician but which specialties? Do opthalmologists see acutely ill patients?"

What he is saying is that because an opthalmologist attending medical school they technically would have the knowledge to assess them without putting their foot in their mouth HA HA....

I've worked with a number of opthalmologists and they utter the same mantra, "Show me a patient that has a complaint other than one that concerns the eye-ball and I have no idea what they are talking about."

So yes.... opthalmologists know nearly zero about treating anything BUT the eye.

So I don't see how that's any different than a DPM.

I've seen surgeons not know how to treat DM or HTN.

I've worked with an orthopedic attending who knew nothing about the drug claritin and didn't know the first thing to do with regards to a guy who had patellar tendon rupture but also had a brewing butt abscess.

They're response? Send him to the ER... we have no idea what's going on with the butt.

Come on now.... when we specialize from MD school... we do what we are trained to do. Unlimited scope of practice is a term that is reserved for those who are still in medical school or early in their training - once you get out there, there is no such thing.

We're all the same. Big whooping deal.

 

[PodiatryMD]

Thank you so much. I can't agree more. Excellent response above!!!

 

[347932]

Ugh here we go again.

Student/Resident perspective aside, "physician", "*******", "ass man", I don't care what you call me. As long as the Insurances are paying me I couldn't give a rip what anyone calls me.

It is a known, I hate to say "fact" because no one with big enough cajones will own up to this, but Orthopedists get paid more to do a bunion surgery than Podiatrists do. As I've mentioned in a previous thread, I did more bunion surgery in residency than the "renowned" Foot and Ankle Orthopedist whose been in the community for 30+ years has done in his whole CAREER. So who is going to do your Mom's bunion? Also, if you're part of a multi-specialty group, you, as a podiatrist, will get paid for the same procedure, than your colleague down the road who is in solo practice. Especially if this multi-specialty group is owned by an insurance company/hospital system.

Someone mentioned something about an Orthopedist not knowing what Claritin is and that podiatrists shouldn't know/diagnose medical stuff aside from foot and ankle issues. In my private practice, I've saved lives by recognizing severe medical problems that have manifested themselves in a foot disease of some kind. Diabetes is a classic example. Patient comes in with complaint of numbness and tingling recently. They aren't looking so good, tell me they are hungry, thirsty and pee all the time. They are lethargic and can't really tell me when they started feeling so bad and haven't seen a PCP in 2 years. I send them to the ED only to find out that their blood sugar was 600 and they are on the brink of DKA and then while in the hospital they go into a Diabetic Coma, but eventually survive and come back to my office and tell me that if I hadn't intervened, they may not be standing there and "Thanks for saving my life doc". We are THE foot and ankle specialist and work on a large background of medical knowledge associated with disease that AFFECT the foot and ankle as well. I also happen to know what Acute Appendicitis is and sent a patient to the ED only to find out he had ruptured on the way, went septic and had to have his appendix removed within an hour of seeing me. Weird, I know right?

Stop this egotistical banter about who we are and what we can do. Residency is not a good litmus test for this as you can do pretty much whatever you want. Be wise and treat your patients to the best of your ability and be thankful you have a special gift of helping someone to feel better. Jeez folks.

 

[air bud]

Anybody see a common theme here? The ones who are trying to put DPMs in a box are current students who dont know what the real world is like. They like to argue theory. Contrast this with people who practice medicine for a living. They live in reality and the Big Boy World. Huh, kind of like all these students go to the University of Berkeley/Boulder/Madison Medical School....

 

[doctalaughs]

here's my perspective:
podiatrists are more focused on foot/ankle during their schooling, and therefore suffer from a lack of generalized medical knowledge compared to a medical student in exchange for superior knowledge of their specialty area when they graduate.

Unless you argue that podiatry students are SMARTER, BETTER and WORK HARDER than medical students, I think it's hard to argue with that. You can't be better in your specialty area AND know as much general medical stuff in the same time period... and that's what differentiates a physician from a podiatrist.

You can argue all you want about what scope should be, but the fact is physicians are physicians because of their focus on being a generalist before specializing. When I was an intern the podiatry residents during their first year spent maybe 2 or 3 months on being a general medical resident (whereas we spent 12) and the rest on foot/ankle surgery. In addition, they functioned about at the M3-M4 level in terms of knowledge (ie admitted less patients, obvious knowledge deficits during rounds etc). Of course this was in exchange for knowing 10x more than I did about foot/ankle issues... so their is an obvious difference in training.

Who cares about title, but if podiatrists want an unlimited scope they should change to an identical medical school training, exclude all foot/ankle training during those 4 years, and then extend their residency to make up for specialization. Just saying.

 

[Podmeister]

I dont care what all other "haters" think but podiatry is medical school. I am all for changing DPM to PMD. Trust me this is coming and the profession is on the rise.

Do you mean changing DPM to MD?

Believe me, this has been discussed for the past 17 yrs when I first started and I wouldn't hold my breath for any drastic changes in the near future.

In the meanwhile, it is normal for podiatry students to feel somewhat insecure about titles such as "medical school" or "medical students" or "physicians" at such an early stage of one's career because honestly...you haven't acquired the necessary knowledge, skills or competence to become a foot and ankle surgeon. For now, just stay focus on your academic studies and clinical rotations, and by the time you're done with residency training, you will become a competent skilled surgeon in the real world and disregard these minor tidbits about titles or prestige.

 

[VA Hopeful Dr]

That may be true, but you have to find a patient who will let you take him to the cath lab and you need to be sure that you have the lawyers to back you up when you lacerate the femoral because you have no idea how to get up to the coronaries.

Just because you're allowed to practice an unlimited scope, the legal system and climate along with patients' choice in doctors will limit you.

We MDs are limited in our scope of practice by those we can practice upon.

It is a moot point.

I believe that DPM is just like opthalmology or any other specialty in the field of medicine. They may have their scope of practice limited from the getgo, but so are we in any other MD (or DO) field.

I'm in ER.... and though I can prescribe nearly any drug, I won't be the one to change your anti-arrhythmic because I'm not going to be responsible for your down-stream consequences. I'm going to reserve that judgement for your cardiologist or IM doc. They can tinker around with your propranol being changed to diltiazem for all I care.

I can do it, but I wont.

So... DPMs are limited, but who cares. I'm limited too.... the only difference are the forces that keep our scopes within a finite arena.

You didn't read my post at all, did you? I quite plainly stated that "as far as state law is concerned, we can do absolutely anything that falls under the scope of practicing medicine". I make no mention of insurance or lawsuits or finding patients. Merely that I would not be violating state law as far as practicing medicine goes.

 

[VA Hopeful Dr]

Anybody see a common theme here? The ones who are trying to put DPMs in a box are current students who dont know what the real world is like. They like to argue theory. Contrast this with people who practice medicine for a living. They live in reality and the Big Boy World. Huh, kind of like all these students go to the University of Berkeley/Boulder/Madison Medical School....

I was thinking about this thread earlier today and had the exact same thought.

My experience has been that most physicians don't care what you guys call yourselves. I'll call you "doctor" the same as I do my dentist, my allergist, my optometrist, and the clinic's PhD psychologist.

As my EM colleague above noted, most of us (health care providers) know what our limitations are and stay within them. If you're good at what you do and help my patients, you're OK in my book.

 

[diabeticfootdr]

Wrong

No, he/she is right.

While every state has different regulations on how an MD, DDS, DPM, OD, PharmD, etc can advertise their services, anyone can have a Doctorate and advertise themselves as Dr. X. Their doctorate might be in religion, art, music, etc. Doctor is derived from "doctrine" or teachings and means teacher. It was hijacked by physicians who now seem like they are the exclusive heir to the title.

 

[diabeticfootdr]

I think one of the issues here is that someone holding an MD or DO degree is allowed, by law, to prescribe ANY legally-prescribable substance, regardless of speciality or subspecialty. Some may feel more or less comfortable with certain substances, depending on their respective area of expertise, but, by law, they can write for whatever they want.

DPMs, DDSs, DMDs, etc. are allowed to prescribe substances within their scope only. The degree obtained limits their authority. It has nothing to do with residency training, specialty, or subspecialty.

I'm surprised you made such an error in your post, because you are completely wrong. A podiatrist is also legally allowed to prescribe any medication. They must prescribe that medication for some reason that is in their scope of practice, but they can prescribe any CII-V substance. Like calcium channel blockers (for Raynaud's phenomenon, not hypertension). You as the pharmacist may not know the reason the Rx is written or the condition being treated. It is also not the pharmacists right to determine scope of practice for any practitioner, OD, DPM, DDS. If it is a validly written Rx and there are no safety issues, you fill it.

The state board of podiatry/optometry/dentistry is the only entity that can make judgements if a practice is in or out of scope.

 

[diabeticfootdr]

I'll also add, that if you feel like someone is practicing out of scope, you can file a complaint with the respective state board, but you're not the scope police. Because if you refused to fill one of my scripts and you were wrong, I'd be writing that complaint to your board.

 

[JaggerPlate]

I'm surprised you made such an error in your post, because you are completely wrong. A podiatrist is also legally allowed to prescribe any medication. They must prescribe that medication for some reason that is in their scope of practice, but they can prescribe any CII-V substance. Like calcium channel blockers (for Raynaud's phenomenon, not hypertension). You as the pharmacist may not know the reason the Rx is written or the condition being treated. It is also not the pharmacists right to determine scope of practice for any practitioner, OD, DPM, DDS. If it is a validly written Rx and there are no safety issues, you fill it.

The state board of podiatry/optometry/dentistry is the only entity that can make judgements if a practice is in or out of scope.

Wasn't there an attachment earlier in the thread that specifically showed the prescription rights in a certain state (Oregon I believe) and there was restrictions on what DPMs would prescribe (compared to physicians - MD/DO)??

 

[diabeticfootdr]

Wasn't there an attachment earlier in the thread that specifically showed the prescription rights in a certain state (Oregon I believe) and there was restrictions on what DPMs would prescribe (compared to physicians - MD/DO)??

I just viewed the referenced attachment. 1. I don't know the source. 2. Every state has their own regulations re: clinicians. But I don't think that attachment proves anything different than I stated.

DPMs are limited to prescribe medications in their own scope. The reason why DPMs have unlimited privilege to write for any medication, i.e. DEA registration for CII-V is because many drugs have off-label uses for the lower extremity. So if there might be a reason for using any drug that is in your scope of practice, a DPM can write for it.

Furthermore, it is true that only the respective state board determines if a particular practice is in or out of scope.

Additionally, I chuckled at the table "anti-anxiety" column where it read "DPM - YES (foot only)". For all those nervous feet.

Also, in Iowa the State Board ruled that DPMs were able to prescribe smoking cessation. So, again, every state is different.

 

[Marcus X]

http://doh.sd.gov/boards/pharmacy/PDF/PrescribingAuthority.pdf

That's the link to the full table. It's from the South Dakota Board of Pharmacy. As I said before, specifics will vary by state; that was just the easiest to find quickly. The Oregon Board has one also.

I was a bit unclear with my words before. The distinction is that MDs/DOs can prescribe anything and are legally-authorized to treat any condition. DPMs don't have that broad scope.

 

[VA Hopeful Dr]

I'll also add, that if you feel like someone is practicing out of scope, you can file a complaint with the respective state board, but you're not the scope police. Because if you refused to fill one of my scripts and you were wrong, I'd be writing that complaint to your board.

I could easily be wrong, but I had thought that pharmacists ccould refuse to fill any Rx for pretty much any reason without catching too much flak about it.

 

[diabeticfootdr]

I was a bit unclear with my words before. The distinction is that MDs/DOs can prescribe anything and are legally-authorized to treat any condition. DPMs don't have that broad scope.

Agreed.

I'm the first to say podiatrists should be podiatrists, if you want a full scope, be an MD. Otherwise, be happy knowing you're the best in your specialty area.

 

[All4MyDaughter]

I could easily be wrong, but I had thought that pharmacists ccould refuse to fill any Rx for pretty much any reason without catching too much flak about it.

Correct in most states (maybe all). Pharmacists are entitled (and expected) to exercise professional judgement in filling prescriptions and medication orders. A pharmacist who is not the owner of the pharmacy might find himself at odds with the owner if the pharmacist turns away large numbers of scripts for whatever reason, but no one can compel a pharmacist to fill and sign off on a prescription that goes against his or her professional judgement.

Part of professional judgement is determining whether an RX is validly written, as was stated upthread. Part of that equation is whether the prescriber is legally entitled to write the prescription. So yes, we do have to be aware of scope of practice, and about laws restricting prescribing of certain substances (mostly controls). It is an important question, and it's included in our law courses and tested on our law exam.

I've seen (remember these examples are consistent with the law in MY state):

Lortab written by a PA --> rejected
Viagra written by an optometrist --> rejected
Birth control written by a dentist (for his wife) --> rejected
One month supply of amphetamine written by FNP --> rejected

The pharmacist could face sanction on his or her license for filling any of the above written orders, in my state.

If we're unclear about why a prescriber is writing for a particular agent (simvastatin from a dentist, for example) and/or feel it is inappropriate we can either decline to fill the script (which is completely within our rights) or we can pick up the phone and call the prescriber for clarification. I think most pharmacists would call in borderline cases rather than turning the patient away.

But we are not obligated to fill.

 

[All4MyDaughter]

And before anyone gets their panties in a bunch, let me say this. We don't sit around thinking up reasons to reject prescriptions. There is no pharmacist-led plot to restrain DPM's (or anyone's) prescribing rights. Our main interest is taking care of the patient. But we are obligated to comply with the law in doing so. We have licenses to protect just like other professionals do.

 

[diabeticfootdr]

And before anyone gets their panties in a bunch, let me say this. We don't sit around thinking up reasons to reject prescriptions. There is no pharmacist-led plot to restrain DPM's (or anyone's) prescribing rights. Our main interest is taking care of the patient. But we are obligated to comply with the law in doing so. We have licenses to protect just like other professionals do.

Thanks for clarifying, because your first post certainly gave me a wedgie.

But there are also cases where action is taken against pharmacists' licenses for malice or obstruction when not filling a legal Rx.

 

[All4MyDaughter]

Thanks for clarifying, because your first post certainly gave me a wedgie.

But there are also cases where action is taken against pharmacists' licenses for malice or obstruction when not filling a legal Rx.

Do you have links to these cases, if they are online? I'm interested in reading more about this. The example I can think of concerned a pharmacist who refused to fill a prescription and then refused to return the written RX to the patient, thus preventing the patient from getting it filled at another pharmacy. The drug in question was Plan B. Clearly, the pharmacist was wrong to confiscate the RX and that is not appropriate.

I'm also not sure what was in my first post that was so concerning to you. What was inaccurate?

 

[diabeticfootdr]

I'm also not sure what was in my first post that was so concerning to you. What was inaccurate?

Nothing, really. Just pulling your leg.

 

[The Poet Sings]

Nothing, really. Just pulling your foot.

fixed it. ba dum chhh.








i know i'm cheesy. just let me be.

 

[347932]

I've had pharmacists deny my patients Rxs for Neurontin. Gabapentine is used off label for Diabetic Neuropathic Pain. Its primary use is in Children with seizure disorders, and these patients were all adults with no h/o seizure disorders. I had to get on the phone and "argue" my case with the Pharmacist after I got an angry call from one of patients while they were at the pharmacy.

Frustrating but true.

 

[All4MyDaughter]

I've had pharmacists deny my patients Rxs for Neurontin. Gabapentine is used off label for Diabetic Neuropathic Pain. Its primary use is in Children with seizure disorders, and these patients were all adults with no h/o seizure disorders. I had to get on the phone and "argue" my case with the Pharmacist after I got an angry call from one of patients while they were at the pharmacy.

Frustrating but true.

I find that hard to imagine since any pharmacist would know that gabapentin is used far more often for off label indications than as an anti-convulsant. It's not a first line anti-convulsant for pediatrics or adults but is rather considered to be adjunctive therapy. The vast majority of gabapentin scripts at my practice site are for neuropathy. Other indications I've seen include fibromyalgia and mood stabilization. My facility spends close to $35000/month on gabapentin, so I've seen it a lot.

I have seen third party payors restrict the use of gabapentin for neuropathy, or require other agents first such as a TCA or an SSNRI. The evidence for gabapentin for pain related indications is not that great especially at high doses. So I don't think it's unreasonable to expect patients to try another agent first. My facility considers a TCA first line therapy. Then you can go to gabapentin or an SSNRI. The patient has to fail two of those agents before moving on to Lyrica.

How was it when you had to get on the phone to "argue" with the pharmacist? Were you able to educate them?

 

[347932]

I find that hard to imagine since any pharmacist would know that gabapentin is used far more often for off label indications than as an anti-convulsant. It's not a first line anti-convulsant for pediatrics or adults but is rather considered to be adjunctive therapy. The vast majority of gabapentin scripts at my practice site are for neuropathy. Other indications I've seen include fibromyalgia and mood stabilization. My facility spends close to $35000/month on gabapentin, so I've seen it a lot.

I have seen third party payors restrict the use of gabapentin for neuropathy, or require other agents first such as a TCA or an SSNRI. The evidence for gabapentin for pain related indications is not that great especially at high doses. So I don't think it's unreasonable to expect patients to try another agent first. My facility considers a TCA first line therapy. Then you can go to gabapentin or an SSNRI. The patient has to fail two of those agents before moving on to Lyrica.

How was it when you had to get on the phone to "argue" with the pharmacist? Were you able to educate them?

Yes after educating this pharmacist, he relented and agreed to fill the Rx.

 

[diabeticfootdr]

Yes after educating this pharmacist, he relented and agreed to fill the Rx.

That's never happened to me, but if it did I would have gone ballistic on the phone.

It's not a pharmacists job to determine what medication can be used for what condition. You, as the doctor, can prescribe any medication as an off-label use. If you can find a use for Viagra in the lower extremity, you can use it (it's actually being studied for PAD). It doesn't matter if there is 1 published paper or not, it is your privilege to write off-label.

If your prescribing practices are not in the community standard, the pharmacist can report it to the state board. That's it. They are not the scope of practice police or the label indications police.

Even if there are risks of interactions or side effects, as long as you've explained the risks to the patient, and you an the patient accept those risks, it still has to be filled.

Yes, pharmacists have a license and they are obligated to practice in a certain manner to avoid discipline (like everyone else with a license), but they can not obstruct the delivery of care ordered by a doctor. That is also actionable.

 

[347932]

That's never happened to me, but if it did I would have gone ballistic on the phone.

It's not a pharmacists job to determine what medication can be used for what condition. You, as the doctor, can prescribe any medication as an off-label use. If you can find a use for Viagra in the lower extremity, you can use it (it's actually being studied for PAD). It doesn't matter if there is 1 published paper or not, it is your privilege to write off-label.

If your prescribing practices are not in the community standard, the pharmacist can report it to the state board. That's it. They are not the scope of practice police or the label indications police.

Even if there are risks of interactions or side effects, as long as you've explained the risks to the patient, and you an the patient accept those risks, it still has to be filled.

Yes, pharmacists have a license and they are obligated to practice in a certain manner to avoid discipline (like everyone else with a license), but they can not obstruct the delivery of care ordered by a doctor. That is also actionable.

Although I agree with your assessment, in any situation like that (it has happened a few times) I take the high road as I practice in a smaller community and even though it irks me, I take the time to do what's best for my patient and practice by getting on the phone and making the situation disappear politely, but with authority.

We are all on the same team, and if sometimes the team mate is misguided and over steps their bounds, we still need to work together.

 

[JaggerPlate]

I just viewed the referenced attachment. 1. I don't know the source. 2. Every state has their own regulations re: clinicians. But I don't think that attachment proves anything different than I stated.

DPMs are limited to prescribe medications in their own scope. The reason why DPMs have unlimited privilege to write for any medication, i.e. DEA registration for CII-V is because many drugs have off-label uses for the lower extremity. So if there might be a reason for using any drug that is in your scope of practice, a DPM can write for it.

Furthermore, it is true that only the respective state board determines if a particular practice is in or out of scope.

Additionally, I chuckled at the table "anti-anxiety" column where it read "DPM - YES (foot only)". For all those nervous feet.

Also, in Iowa the State Board ruled that DPMs were able to prescribe smoking cessation. So, again, every state is different.

Shrug??? Seems restricted (in the sense that it has limits in that particular state that physicians don't). Guess it could be a state by state thing.

 

[All4MyDaughter]

Although I agree with your assessment, in any situation like that (it has happened a few times) I take the high road as I practice in a smaller community and even though it irks me, I take the time to do what's best for my patient and practice by getting on the phone and making the situation disappear politely, but with authority.

We are all on the same team, and if sometimes the team mate is misguided and over steps their bounds, we still need to work together.

Good to hear that the pharmacist was receptive. I still doubt that there are significant numbers of pharmacists not familiar with gabapentin for neuropathy, but that doesn't diminish the impact of the anecdote. It could be any medication, and I'd hope that any prescriber would be receptive to addressing another professional's legitimate questions or genuine concerns without having a hissy fit.

Anyone who "goes ballistic" on the phone gets hung up on. End of story. It's childish and unprofessional.

If your prescribing practices are not in the community standard, the pharmacist can report it to the state board. That's it. They are not the scope of practice police or the label indications police.

Incorrect. They can decline to fill the prescription, document why and hand the prescription back to the patient with a full explanation. We cannot be compelled to fill.

Even if there are risks of interactions or side effects, as long as you've explained the risks to the patient, and you an the patient accept those risks, it still has to be filled.

Also incorrect. There is no "has to" in this equation. Pharmacists can decline to fill prescriptions if they feel they are not in the best interest of the patient or are unsafe or illegal. I have seen this happen. A doctor wrote for Viagra for a patient who was on concurrent nitrate therapy. The doctor was called and said "I want to do it anyway." The patient knew it was risky and wanted it anyway. The pharmacist returned the script to the patient because the pharmacist did not feel comfortable filling the script. The patient was free to go to another pharmacy and perhaps he found a willing pharmacist. Perhaps he didn't.

Yes, pharmacists have a license and they are obligated to practice in a certain manner to avoid discipline (like everyone else with a license), but they can not obstruct the delivery of care ordered by a doctor. That is also actionable.

They can't obstruct, but they can't be compelled to participate if they feel that it is illegal, inappropriate or unsafe. No pharmacist is going to be disciplined for exercising their professional judgement as long as they have genuine, reasonable concerns about the issue at hand.

 

[densmore22]

To get back to the original question at hand. I'm going to propose this scenario (as it happens to be how things are now). People have stated on here how Podiatry isn't med school, there isn't parity (in the sense of education), etc. My question to you all is this, since Allopathic, Osteopathic, and Podiatric Medicine REQUIRE post-graduate training (read: residency) to obtain state licensure and practice (there are 2 states (?) I believe that technically allow a pod to practice w/o a residency, but I'm unsure on the specifics, they can only do calluses and cut nails I believe), would it be safe to say that in the future, that it may be feasible to include Podiatrists in the same tier or level or whatever it is as an allopathic and osteopathic physician? Being that we are required to obtain this secondary, higher, post-graduate level training. I'm not saying that it needs to be a degree change or anything like that, but since OMFS needs a residency to do what they do and we need a residency to do what we do, allopaths and osteopaths...I'm beating a dead horse here. What do you all think? I personally think it would be great for us to be up there just for insurance coverage and reimbursement, I don't see it changing much else in our profession. IMO...

 

[diabeticfootdr]

They can't obstruct, but they can't be compelled to participate if they feel that it is illegal, inappropriate or unsafe. No pharmacist is going to be disciplined for exercising their professional judgement as long as they have genuine, reasonable concerns about the issue at hand.

It's not up to you to determine the scope of practice. I've said this over and over again. The state board determines the scope practice not a lone pharmacist in a CVS. If you have a question about it, you can call the state board, you can not deny the patient a legally written Rx for medications they need - hence you will be liable despite any possible philosphical argument you pose.

Yes, you can refuse an Rx that in your judgement appears fraudulent. Yes, you can question a treatment that you have a question about the safety, but ultimately the decision is the physician's, not yours. You call the physician, make them aware of the interaction. A pharmacist's job is not to practice medicine or podiatry or dentistry. I do a lot of expert legal review for malpractice. Never once have I seen a case where the pharmacist was added to the list of defendants because they followed a doctor's legitimate orders and we all know how lawyers cast a wide net when they consider the list of defendants.

Look, everyone has their place on the team. My place is a podiatrist. I shouldn't overstep my role. The pharmacist should be content in their role and not overstep it. I'm hospital-based. I use pharmacists everyday and they play an invaluable role on the team. The best delivery of care happens in teams. When someone get's a chip on their shoulder is when the system get's mucked up.

What's great is that everyone on SDN has an opinion and often there are disagreements. But there is the "SDN philosophical world" and the "real world." In the real world these types of issues are handled at the appropriate levels - if one is astute enought to direct it/escalate it to that level.

 

[All4MyDaughter]

Honestly, this is stupid. How often do you think this happens in community pharmacy? How often do pharmacists decline to fill RXs for the reasons we've been discussing? Exceedingly rarely, I'd say. But if you think you can somehow FORCE a pharmacist to fill an order that they think is illegal, unethical, dangerous or inappropriate, then show me a citation that backs up your claim.

Yes, you can question a treatment that you have a question about the safety, but ultimately the decision is the physician's, not yours.

Absolutely. The decision to prescribe the treatment remains the physician's. The decision to take the treatment remains with the patient. But I am not required to participate and I am not required to provide my professional services. I am permitted to thank the patient, return the RX and advise them to seek another pharmacy/pharmacist.

 

[347932]

Honestly, this is stupid. How often do you think this happens in community pharmacy? How often do pharmacists decline to fill RXs for the reasons we've been discussing? Exceedingly rarely, I'd say. But if you think you can somehow FORCE a pharmacist to fill an order that they think is illegal, unethical, dangerous or inappropriate, then show me a citation that backs up your claim.



Absolutely. The decision to prescribe the treatment remains the physician's. The decision to take the treatment remains with the patient. But I am not required to participate and I am not required to provide my professional services. I am permitted to thank the patient, return the RX and advise them to seek another pharmacy/pharmacist.

Last week, my partner had a patient's pharmacist deny giving her a post op Rx for Darvocet N100, because "she's too old for that medicine". She ended up having to go to the ED for a shot of Morphine since she was unable to get to another pharmacy and have it filled before they closed. It happens more than you know in the real world sir. It really does.

You're right. It IS stupid.

 

[diabeticfootdr]

Honestly, this is stupid. How often do you think this happens in community pharmacy? How often do pharmacists decline to fill RXs for the reasons we've been discussing? Exceedingly rarely, I'd say.

I would agree. I've never heard of it happening from any source other than people's rants on SDN or their hypotheticals. So you are right. It is a stupid argument.

 

[diabeticfootdr]

It happens more than you know in the real world sir.

Ma'am

 

[All4MyDaughter]

Last week, my partner had a patient's pharmacist deny giving her a post op Rx for Darvocet N100, because "she's too old for that medicine". She ended up having to go to the ED for a shot of Morphine since she was unable to get to another pharmacy and have it filled before they closed. It happens more than you know in the real world sir. It really does.

You're right. It IS stupid.

Did you call me SIR? If you're going to condescend, at least be gender accurate.

At my facility (haven't worked in community pharmacy in a while) we deny almost all RXs for Darvon and Darvocet. They are crap drugs, no more effective than APAP alone and have increased toxicity. Both are listed in the Beers Criteria. Propoxyphene is nonformulary at my facility and we are moving toward eliminating it.

That said, if I were working in the community I'd probably fill it because prescribers want to use it and patients want it. It's still available and on the market, so whatever. You pick your battles. I'm just lucky to work in a facility that uses a fair degree of evidence based prescribing.

EDIT: If you want a reference for the propoxyphene information, The Pharmacist's Letter has a great summary and detail document. I'd assume the same content is available via The Prescriber's Letter if you have a subscription. Here is some information that is available without a subscription: http://www.pharmacist.com/AM/Templa...mplate=/CM/ContentDisplay.cfm&ContentID=18538

 

[All4MyDaughter]

I would agree. I've never heard of it happening from any source other than people's rants on SDN or their hypotheticals. So you are right. It is a stupid argument.

I think it's rare. I also think some of the examples people have thrown around in this thread are BS... but it's easy to make up stuff on the internet. The only concrete example of an otherwise valid RX not being filled b/c the pharmacist wasn't comfortable that I can fully recall from my time in community pharmacy is the Viagra/nitrate situation. There was another, involving a pregnant patient and a Category X medication, but can't remember the details. It was 4 or 5 years ago.

Of course things that are truly and obviously wrong (PA/NPs writing improperly for controls/optometrists trying to treat ED/dentists trying to refill their own cholesterol meds [check out that dentist vs. pharmacist thread in the dental forum]) get rejected more often. As they should.

Now at my current practice site, clinical pharmacists deny/decline to fill tons of orders daily, because they don't meet VA Guidelines. The big ones lately have been propoxyphene and propoxyphene/APAP, Lyrica and Lidoderm patches. The new guidelines for the use of Lidoderm have caused quite an uproar. But the VA is very different from the rest of the world...

 

[347932]

Whoa easy people.

I'm not being condescending. I'm replying to a post ma'am. Rather than get hung up on gender specific terminology on the internet where I have no earthly clue what gender the posters are how about we get back to the issues at hand.

I don't particularly care what you think about Darvocet ma'am. When a patient shows up at your pharmacy for a post operative pain medicine, you should fill it unless you have some philosophical reason not to. Call me and ask me questions if you want. I don't mind. If you refuse and cause my patient undue stress and potential harm by not filling it, "she's too old for that medicine" is not adequate, sorry. No drug interactions for this patient. Codeine allergic. Tried to get her Nucynta, but her insurance didn't cover it. Asked for Darvocet. Fill it please. Thanks. The patient's best interest was not served by having her have to go to the ED and wait four hours for a shot of morphine.

 

[347932]

I think it's rare. I also think some of the examples people have thrown around in this thread are BS... but it's easy to make up stuff on the internet. The only concrete example of an otherwise valid RX not being filled b/c the pharmacist wasn't comfortable that I can fully recall from my time in community pharmacy is the Viagra/nitrate situation. There was another, involving a pregnant patient and a Category X medication, but can't remember the details. It was 4 or 5 years ago.

Of course things that are truly and obviously wrong (PA/NPs writing improperly for controls/optometrists trying to treat ED/dentists trying to refill their own cholesterol meds [check out that dentist vs. pharmacist thread in the dental forum]) get rejected more often. As they should.

Now at my current practice site, clinical pharmacists deny/decline to fill tons of orders daily, because they don't meet VA Guidelines. The big ones lately have been propoxyphene and propoxyphene/APAP, Lyrica and Lidoderm patches. The new guidelines for the use of Lidoderm have caused quite an uproar. But the VA is very different from the rest of the world...

Not BS, I promise you.

 

[All4MyDaughter]

Where did I say that I would NOT fill your patient's Darvocet (if I worked in a hypothethical community pharmacy)? Oh wait... that's right... I didn't say that... I said:

That said, if I were working in the community I'd probably fill it because prescribers want to use it and patients want it. It's still available and on the market, so whatever. You pick your battles. I'm just lucky to work in a facility that uses a fair degree of evidence based prescribing.

I don't particularly care what you think about Darvocet ma'am. When a patient shows up at your pharmacy for a post operative pain medicine, you should fill it unless you have some philosophical reason not to. Call me and ask me questions if you want. I don't mind. If you refuse and cause my patient undue stress and potential harm by not filling it, "she's too old for that medicine" is not adequate, sorry. No drug interactions for this patient. Codeine allergic. Tried to get her Nucynta, but her insurance didn't cover it. Asked for Darvocet. Fill it please. Thanks. The patient's best interest was not served by having her have to go to the ED and wait four hours for a shot of morphine.

Overreact much? I said I'd fill it (in this hypothetical scenario), probably because I wouldn't want to deal with you. And because that seems to have been the only (somewhat) reasonable alternative you and your partner were offering the patient.

Although I think I could make a valid case for a philosophical disagreement based on the fact that it's 1) ineffective and 2) dangerous for all patients and 3) especially dangerous for THIS patient (if she is elderly), but that's OK. That's why in my REAL job, orders for Darvocet don't get filled at our facility. We prefer safe, effective, appropriate treatments for pain. I'm not being flippant either.

So the only options for this patient were Darvocet, Nucynta and a shot of morphine? What happened to the patient after the morphine shot wore off (about four hours)? Why not call in some tramadol? Why not have the patient return to your office and pick up a script for a C2 pain med? Those options might be preferable to telling the patient to go to the ED.

 

[347932]

Where did I say that I would NOT fill your patient's Darvocet (if I worked in a hypothethical community pharmacy)? Oh wait... that's right... I didn't say that... I said:





Overreact much? I said I'd fill it (in this hypothetical scenario), probably because I wouldn't want to deal with you. And because that seems to have been the only (somewhat) reasonable alternative you and your partner were offering the patient.

Although I think I could make a valid case for a philosophical disagreement based on the fact that it's 1) ineffective and 2) dangerous for all patients and 3) especially dangerous for THIS patient (if she is elderly), but that's OK. That's why in my REAL job, orders for Darvocet don't get filled at our facility. We prefer safe, effective, appropriate treatments for pain. I'm not being flippant either.

So the only options for this patient were Darvocet, Nucynta and a shot of morphine? What happened to the patient after the morphine shot wore off (about four hours)? Why not call in some tramadol? Why not have the patient return to your office and pick up a script for a C2 pain med? Those options might be preferable to telling the patient to go to the ED.

Ma'am,
You are still glossing over the fact that in MY community what happened is unheard of. I'm sorry, but I use Darvocet quite a good bit as a replacement for Codeine derived pain managers. If you don't like it, I'm sure that you can make a case for not giving to the patients that come to your facility. Unfortunately, these are not your patients, and you don't have the final say on what meds they do actually get in the long run.

You don't know me at all. I don't know you, but your snap judgment is cause enough for me not to ever hope to deal with you. What you are proposing that what you do in your company is down right dangerous in my opinion. Whether you agree with a decision or not is not part of your job description. If its dangerous to the patient, then you can intervene by deciding not to fill the Rx or calling the Dr. that gave out the Rx. You even go so far as saying that you would probably fill the Rx to not have to deal with me as a physician. That is a dangerous way to do business. So do you have the principal of not filling an Rx or do you just make a decision on the spot, based on whether you want to "deal" with it or not?

It says you are a Pharmacy student? It sounds like you are already in practice. Which is it?

Finally, I'm not overacting. I don't take kindly to be called condescending, nor do I take kindly to flippant judgments on how I treat my patients. Particularly when alluding to the fact that the meds I prescribe are "dangerous" whether you think they work or not. I can show you just as many studies that show that some of the drugs you mentions are claimed to be as ineffective. Evidence based medicine is fickle still. The sword has two edges.

 

[All4MyDaughter]

Ma'am,
You are still glossing over the fact that in MY community what happened is unheard of. I'm sorry, but I use Darvocet quite a good bit as a replacement for Codeine derived pain managers. If you don't like it, I'm sure that you can make a case for not giving to the patients that come to your facility. Unfortunately, these are not your patients, and you don't have the final say on what meds they do actually get in the long run.

I never claimed to have any influence on what you prescribe for your patients. I think what happened to your partner's patient is unfortunate because it doesn't sound like she was taken care of, by the pharmacist or by the solution she was provided by your office (going to the ED). Did you or your partner speak with the pharmacist about this while the patient was at the pharmacy? I feel like there is a lot of information missing in this scenario.

I don't HAVE to make a case against Darvocet at my facility. It's already policy, per our P&T committee. Making propoxyphene non-formulary is part of a larger strategy to phase it out of use in our medical center. No new patients can be initiated on the drug and eventually, it will not even be an option in our e-prescribing system.

You don't know me at all. I don't know you, but your snap judgment is cause enough for me not to ever hope to deal with you. What you are proposing that what you do in your company is down right dangerous in my opinion.

How is it dangerous? Patients end up getting a more effective, less toxic drug to manage their pain. How is this bad? And I don't work for a company. I work for the federal government.

Whether you agree with a decision or not is not part of your job description. If its dangerous to the patient, then you can intervene by deciding not to fill the Rx or calling the Dr. that gave out the Rx. You even go so far as saying that you would probably fill the Rx to not have to deal with me as a physician. That is a dangerous way to do business. So do you have the principal of not filling an Rx or do you just make a decision on the spot, based on whether you want to "deal" with it or not?

Not sure I understand the question about my principles. Or was it something to do with the principal of a school? Kidding.

It says you are a Pharmacy student? It sounds like you are already in practice. Which is it?

I'm in my last year of pharmacy school, completing my internship (rotating sites). On evenings and weekends I work as an intern (a paid job, not for school) at the VA, where I have worked since 2007.

Finally, I'm not overacting. I don't take kindly to be called condescending, nor do I take kindly to flippant judgments on how I treat my patients. Particularly when alluding to the fact that the meds I prescribe are "dangerous" whether you think they work or not. I can show you just as many studies that show that some of the drugs you mentions are claimed to be as ineffective. Evidence based medicine is fickle still. The sword has two edges.

I assure you I am not being flippant about Darvocet. Darvocet is a bad drug. It will probably be withdrawn from the market. Even if you could show me a study that said that ANY of the drugs I mentioned was "equally ineffective" as Darvocet for acute pain (and I only mentioned ONE by name, but there are a number of options), Darvocet would still lose on analysis because it's MORE toxic. So... if we have to chose between two "equally ineffective" drugs, shouldn't we pick the one with fewer toxicities? I think it's a fair question.

You of course, are free to continue to prescribe whatever you choose for your patients (but do you really use Darvocet "quite a bit" for pediatric patients?). I'm speaking in the larger, more abstract sense of "what is the best option for patient care" (in general).

I think you were being condescending, and still are. If I'm incorrect about that, I'll offer an apology. But I predict your next post will involve some form of trying to dismiss me as "just a student" and telling me that I'll understand "when I'm older" or something. Again, I could be wrong.