meister

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So there's a post in the DPM forum about a pharmacist refusing to fill a #30 Ambien script with 2 refills written by a DPM and I thought the responses there were interesting. What is your guys' take on the scenario?

http://forums.studentdoctor.net/showthread.php?t=585020

I don't want to get into a flame war just seeking opinions. I have a Pt who has a significant foot injury and the DPM who is writing for ambien as needed for insomnia. We filled a couple of 2 week prescriptions for her but the Dr. has now written for 30 with 2 refills. I don't doubt the seriousness of her injury but she is not consistently filling any type of pain medication, narcotic or non-narcotic, no neuroleptics, no nsaids, just ambien from the DPM and phentermine from a different Dr. I declined to fill the Rx and the Dr. is upset. Am I being a butthead pharmacist from your point of view?
I figure the best course would be for the RPh to contact the DPM if the diagnosis is in question to clarify the reason for the extended therapy rather than refuse the script outright. What do you think?
 

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So there's a post in the DPM forum about a pharmacist refusing to fill a #30 Ambien script with 2 refills written by a DPM and I thought the responses there were interesting. What is your guys' take on the scenario?

http://forums.studentdoctor.net/showthread.php?t=585020



I figure the best course would be for the RPh to contact the DPM if the diagnosis is in question to clarify the reason for the extended therapy rather than refuse the script outright. What do you think?
Podiatrists are allowed to use phones, the last time that I checked. He could have called upfront to speak with the pharmacist or called to find out why it was refused after the refusal. The podiatrist just has to know when and where it was refused. No biggie.

It's one thing for the podiatrist to use the 'step down' approach and prescribe Rozerem or hydroxyzine to ween the patient off of Ambien, but that wasn't the case.

Pharmacists do not have to fill every Tom, Dick, and Harry's script. That's the beauty of pharmacy. There is no 'if I refuse to fill a script then I have to call the doc about it'. Pharmacists have their own autonomy to fill, and it has nothing to do with the prescriber.

Ambien can cause flatulence anyway.
 

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If it was me I would call the podiatrist and discuss the rx/dx, but I would likely tell them they should probably refer the pt to their pcp for insomnia due to the anything besides pain of her foot injury. Who knows, there may be a perfectly good reason that the podiatrist is writing for an extended duration of the ambien therapy. The thread over there is getting ugly pretty quick, basically one guy is saying pharmacists shouldn't question the rx and just fill it and that its illegal to not fill a rx if its written by a valid prescriber? Hmmm, not according to the DEA:

[FONT=ARIAL, HELVETICA]To be valid, a prescription for a controlled substance must be issued for a legitimate medical purpose by a practitioner acting in the usual course of professionalpractice. The practitioner is responsible for the proper prescribing and dispensing of controlled substances. In addition, a corresponding responsibility rests with the pharmacist who fills the prescription. An order purporting to be a prescription issued not in the usual course of professional treatment or in legitimate and authorized research is not a valid prescription within the meaning and intent of the Controlled Substances Act and the person knowingly filling such a purported prescription, as well as the person issuing it, shall be subject to the penalties provided for violations of the provisions of law relating to controlled substances.


.So according to the DEA if the prescription was not written for a legitimate medical purpose then it wouldn't even be a legal prescription, regardless of who wrote it. Maybe diabeticfootdr isn't aware of what a pharmacist really does or should do when presented with a prescription. Oh well, no harm done, although I agree that is he coming off a little condescending.
[FONT=ARIAL, HELVETICA]
.
 
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confettiflyer

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i was going to type something long but i figure "lol @ ignorance" would be a better answer/provocation for some carpal tunnel action. :thumbup:

no wonder retail pharmacists get paid so much, gotta deal with asshats like this on a weekly (sometimes daily) basis!
 

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i was going to type something long but i figure "lol @ ignorance" would be a better answer/provocation for some carpal tunnel action. :thumbup:

no wonder retail pharmacists get paid so much, gotta deal with asshats like this on a weekly (sometimes daily) basis!
I tried to educate him but we'll see how well that goes down. :)

I remember one time a DPM came in to my pharmacy and showed us his California license and stated he wanted to receive a $25 gift card by writing a script for Advair for his daughter. Our PIC politely declined his request.
 

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i was going to type something long but i figure "lol @ ignorance" would be a better answer/provocation for some carpal tunnel action. :thumbup:

no wonder retail pharmacists get paid so much, gotta deal with asshats like this on a weekly (sometimes daily) basis!
I'm so going to steal "lol @ ignorance to prevent carpal tunnel" :laugh:
 

RxWildcat

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I remember one time a DPM came in to my pharmacy and showed us his California license and stated he wanted to receive a $25 gift card by writing a script for Advair for his daughter. Our PIC politely declined his request.
But her foot wouldn't function properly without adequate oxygenation from her lungs! :idea:
 

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Heh, yeah, I guess you can probably relate just about anything to the feet somehow. Has anyone ever filled metformin or other DM meds by a DPM?
That's just weird. They better be prescribing everything else related to diabetes under the son for that to hold up- testing strips, lancets, insulin or regulators like Byetta, low dose aspirin, etc. etc.
So do they arbitrarily pick metformin and call it a day, like 'we fixed your diabetes, so now your foot will be fixed too. all it takes is a little metformin!'. Give me a freakin' break! Next thing you'll know, there will be a podiatrist saying that the patient needs an insulin pump STAT, or else!

So do opthamalogists prescribe foot braces and diabetic shoes because their patients are suffering from diabetes and related conditions like retinopathy?
 

confettiflyer

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haha, what is that shakespeare quote....brevity is the soul of wit? Yeah...brevity saves my hands.

And yeah one can relate anything to feet. Hell, why not do opthalmic agents too? I can see it now...Rx for Ciprodex for eye infection so the patient won't stub their toe on the bedpost due to lack of vision.

With the example of the metformin, I'd let it slide and fill it if this were a regular patient with a previous history of taking it and this new script matches all the previous Rx's from their PCP or endocrinologist. I'd just make it a point to ask the pt when they're due to see their PCP and when their last visit was.
 

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This reminds me of an incident where I refused to fill a script written by a dentist for valium 10mg 1 qd prn sleep w/ 5 refills. Turned out the pt was his assistant who has trouble sleeping (pt told me). I called him up and asked the reason for the Rx. He lied and said that she's his patient and has to undergo some serious dental surgeries. I confronted him and threatened to report him to the board. You could tell he was scared and apologized for lying to me and told me that he'll send his assistant to see her PCP for her valium Rx :)
 

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Jenny: that sounds exactly like the local yahoo dentist near my old job. He used to do stuff like that on and off for a decade, in addition to using anabolic steroids and being an insufferable weekend warrior type. We used to notify the DEA of his prescribing practices all the time and nothing came of it until earlier this year when they finally raided his office and had the California dental board revoke his license. Sweet justice!

I mean the guy used to call in #30 valium 2mg for a patient that was "in the chair." Then when asked why the patient needed #30 he'd say "oh that's for office use." Yeah buddy, office use as you ride your sea-doo on Lake Tahoe. Give me a break. I could link to some court documents for some fun reading but I'm guessing posting his name is against the TOS of SDN so I'll refrain.
 

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Concerning the original post, the answer is a NO. The fact that it is a controlled substance is more than enough reason for a pharmacist to refuse the script if not out right reporting it. This happens a lot and by us not reporting it, they should thank us for it.

If this was somebody who wasnt holding a professional degree, I doubt many of us would be as kind. If it wasnt for the the pharmacists that do take these illegal scripts, a lot of the good ones would not look like *******s.

Dentists and Podiatrists are not allowed to write for anything outside their scope of practice. For example, they can prescribe pain medications relating to foot surgery but not a durietic for ankle edema. In fact, their board encourages us to report people prescribing out of scope. This means PDM should not be prescribing metformin, aspirin, etc. That is something they should refer to a PCP.

Specialized MD/DO for example like pediatricians can write for anything even if it is outside of their scope. They have an unlimited scope of practice. Even if an opth calls in insulin for his family member and have no idea on how to dose it, etc, I would still take it and consult the prescriber.

Most pharmacies that I work in have a strict policy on this. If in doubt, call the doctor to cover your ass. Then note it and report it to the boards. It doesnt hurt either way. Lets admit it, the reason why the pharmacist was in doubt and posted this was because clearly, the pharmacist knows it is wrong and so does her 5 out of 6 collegues.
 
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Concerning the original post, the answer is a NO. The fact that it is a controlled substance is more than enough reason for a pharmacist to refuse the script if not out right reporting it. This happens a lot and by us not reporting it, they should thank us for it.

If this was somebody who wasnt holding a professional degree, I doubt many of us would be as kind. If it wasnt for the ******* pharmacists that do take these illegal scripts, a lot of the good ones would have to look like an *******.

Dentists and Podiatrists are not allowed to write for anything outside their scope of practice. For example, they can prescribe pain medications relating to foot surgery but not a durietic for ankle edema. In fact, their board encourages us to report prescribing out of scope. This means PDM should not be prescribing metformin, aspirin, etc. That is something they should refer to a PCP.

Specialized MD/DO for example like pediatricians can write for anything even if it is outside of their scope. They have an unlimited scope of practice. Even if an opth calls in insulin for his family member and have no idea on how to dose it, etc, I would still take it and consult the prescriber.

Most pharmacies that I work in have a strict policy on this. If in doubt, call the doctor to cover your ass. Then note it and report it to the boards. It doesnt hurt either way. Lets admit it, the reason why the pharmacist was in doubt and posted this was because clearly, the pharmacist knows it is wrong and so does her 5 out of 6 collegues.
I probably should have used an optometrist as an example, not an ophthalmologist. Either way, an MD is an MD, and a plain ol' DDS, DPM, or OD (not one of them degrees plus an MD) ain't equal to an MD's edumacation covering the entire human body.
 

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I'll generally write for things like benadryl, restoril, etc for my inpatients. Especially after big rearfoot/ankle reconstruction cases like flat foot recons, ankle fractures, pilon fractures, calc fractures, etc where pain is more controlled than taken away by meds. When I discharge them, I will generally write them for a 7-10 day supply as the most common complaint after any big surgery is "I'm having trouble sleeping". But that's about as much as I generally ever need to do.

Pods will regularly write for pain meds, antibiotics, anti-inflammatories, steroids, and things like Lyrica or Cymbalta for neuropathic pain associated with DM. However, there are plenty of acceptions based on any given situation.

I will say that as I've rotated through other services like internal medicine, general surgery, etc, I've discharged patients and written for pretty much every medication under the sun and have never been questioned.
 

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Problems like this can easily be avoided if the prescriber just writes the use of the medication on the prescription. Not every pharmacist knows SSRI (although not very effective) can be used for neuropathic foot pain so just write, "prozac 10mg qd for neuropathic foot pain". This way the pharmacist knows and has a record of it to cover his butt if something happens.
 
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confettiflyer

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I could link to some court documents for some fun reading but I'm guessing posting his name is against the TOS of SDN so I'll refrain.
Court docs are public record, so post away! I've done that many times on here (with CA disciplinary actions on CA RPh's) and the only warnings I've gotten were for cussing people out. :smuggrin:

Granted, you might have to edit your original "story" post to bring it to non-libelous.
 

confettiflyer

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I will say that as I've rotated through other services like internal medicine, general surgery, etc, I've discharged patients and written for pretty much every medication under the sun and have never been questioned.
Yeah...but you sound responsible and professional, which is why you haven't been questioned.

If you were some yahoo dentist writing for a 6mo supply of Lunesta with no indication and went on SDN to complain that the pharmacy down the street called to ask what's going on, we just might have to flame you.

girllein said:
I probably should have used an optometrist as an example, not an ophthalmologist. Either way, an MD is an MD, and a plain ol' DDS, DPM, or OD (not one of them degrees plus an MD) ain't equal to an MD's edumacation covering the entire human body.
Agreed here. MD = unlimited scope of practice = prescribe to your heart's content. Let the state board figure out whether or not it's a valid doctor-patient relationship when it comes to controlled meds. That, in most cases, is out of the scope of a pharmacist's practice.
 

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There is no way in hell I allow a podiatrist to prescribe a scheduled substance outside of their scope of practice. Insomnia in an way, shape, or form is outside of their scope of practice. Period. I don't care if the source of their discomfort just so happens to come from their feet. If you go down this slippery slope, they can probably justify a reason to prescribe anything....which is something they most certainly don't need to be doing. I draw the line at pain meds...anything more involved than that...I'd tell them to go elsewhere. An actual physician should manage that.

The pederasts can flame me, I don't give a ****. You are supposed to question stuff that may not be used for a legitimate medical purpose and I don't need the DEA annoying me.

Thank God I don't work retail, anyway...
 
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meister

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The pederasts can flame me, I don't give a ****.
:eek:

You wouldn't fill a 7 day supply of Ambien post-op? That seems reasonable. I can see your point though.

edit:
Court docs are public record, so post away!
I think I'd rather keep it nice and anonymous, plus we all have experience with those types.
 
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WVUPharm2007

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:eek:

You wouldn't fill a 7 day supply of Ambien post-op? That seems reasonable. I can see your point though.
And someone else may be justified in doing that. But in this case...to prescribe 30 of them? Hell no.

See...here's my thought on the issue...I think EVERYONE should just go to medical school. Dentists, podiatrists, any sort of profession that acts as a physician of a specific body part. Go through medical school...do a residency in dentistry...or podiatry...then I can feel perfectly fine about them prescribing because they are all trained as generalists beneath their larger facade as a specialist. The idea of anyone who hasn't been a general physician doling out medication that, unfortunately, affects the rest of the body outside of said region....well...sort of frightens me a bit. I know, I know, they get a bit of it in school, but not as much as a typical dude in medical school does. For instance...something that scares me are the podiatrists that prescribe cimetidine. Sure, it can be used for warts...but God knows what that might do with other medications the patient is on concurrently that are metabolized by hepatic enzymes. So the patient is on a high dosage of Zocor....patient is given cimetidine...patient gets rhabdo...yikes.

I never have been able to understand why some professions aren't put under the same curtain as medicine...but, hey, that's just me.
 
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All4MyDaughter

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And someone else may be justified in doing that. But in this case...to prescribe 30 of them? Hell no.

I have to agree with WVU. A little post-op insomnia may be reasonable, but if someone is having continued problems A MONTH after the surgery, what's really going on? If pain is keeping her awake, why aren't they treating the pain (OP indicated no pain meds were being prescribed)? Insomnia, other than short term post-op, is not in a podiatrist's scope of practice in my state.
 

WVUPharm2007

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It's getting chippy over there...interestingly, they are insult ME and I'm not insulting THEM. It's like bizarro world...
 
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Looks like my attempt to have the pharmacy forum battle the DPM forum was successful. LOL at you schooling a DPM on a supposed state board of podiatry in proper prescribing practices.
 

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Here's the part that I don't get:

You are wrong. If I think treating a condition is in my scope, then I have the legal ability to write a medication for it...SNIP
Eh, what?? In my state, the podiatrist is limited to the foot and ankle. So...a pod can just decide that say, hypothyroidism is within their scope and it's all OK? No, not according to what I've been taught in my two years of pharmacy law courses.

Let's take diabetes for an example. Patient presents with infected foot ulcer. DPM asks the patient if they are diabetic. Patient doesn't know. Should the DPM order tests (FBG, A1C) to find out? If the patient is diabetic, can the DPM put them on metformin and recommend diet/exercise? Afterall, the diabetes *IS* affecting the patient's feet... I would say NO. The patient needs to be referred to a primary care physician or endocrinologist for diagnosis/management of DM. The DPM can treat the conditions of the foot caused by the patient's DM but management of the systemic disease is out of his/her scope.

This "it's in my scope because I **SAY** it is" business is a new one for me. :confused:
 

WVUPharm2007

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LOL at you schooling a DPM on a supposed state board of podiatry in proper prescribing practices.
...and now you know why people on this forum don't argue with me anymore. There are two things I do well. Play NCAA 09 on Xbox...and argue....to the death.
 

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Yeah that guy was being a turd well before he started attacking you as well, as I politely pointed out earlier. Oh well, I'm sure he'll ignore everything we said anyway.
 

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Here's the part that I don't get:



Eh, what?? In my state, the podiatrist is limited to the foot and ankle. So...a pod can just decide that say, hypothyroidism is within their scope and it's all OK? No, not according to what I've been taught in my two years of pharmacy law courses.

Let's take diabetes for an example. Patient presents with infected foot ulcer. DPM asks the patient if they are diabetic. Patient doesn't know. Should the DPM order tests (FBG, A1C) to find out? If the patient is diabetic, can the DPM put them on metformin and recommend diet/exercise? Afterall, the diabetes *IS* affecting the patient's feet... I would say NO. The patient needs to be referred to a primary care physician or endocrinologist for diagnosis/management of DM. The DPM can treat the conditions of the foot caused by the patient's DM but management of the systemic disease is out of his/her scope.

This "it's in my scope because I **SAY** it is" business is a new one for me. :confused:
Scope should be base, roughly, upon the etiology of the problem. They at least have an ARGUMENT with a short course of Ambien (but not the aforementioned 30 days)...maybe...I disagree, personally...however, a discussion could be had about it. Now diabetes....I 'd say categorically NO. DM does not pathophysiologically stem from the feet/ankles...thus it's not within their scope of practice.
 
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meister

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Do your damn job and FILL MY PRESCRIPTIONS!!! What's that? Of course I can prescribe for Viagra for myself, I have PH that causes me to not exercise which leads to weight gain which leads to ankle problems. Hah!
 

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There is at least an argument to be made for the Ambien. Although if the patient is in so much pain they can't sleep, why not just treat the pain more effectively? Give a higher dose of painkiller QHS (don't forget the docusate) and kill two birds with one stone.

I can see the need for short term Ambien, but a months supply? Highly suspect, IMO.
 

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Here's the part that I don't get:



Eh, what?? In my state, the podiatrist is limited to the foot and ankle. So...a pod can just decide that say, hypothyroidism is within their scope and it's all OK? No, not according to what I've been taught in my two years of pharmacy law courses.


This "it's in my scope because I **SAY** it is" business is a new one for me. :confused:
No one thinks this. All he's saying there is that if there is foot/ankle pathology he's entitled to treat it. Mentioning hypothyroidism with respect to podiatry is absurd. Apples and oranges and absolutely out of pod scope.
 

WVUPharm2007

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No one thinks this. All he's saying there is that if there is foot/ankle pathology he's entitled to treat it. Mentioning hypothyroidism with respect to podiatry is absurd. Apples and oranges and absolutely out of pod scope.
I think A4MD's issue was the use of the word "think". The idea that if he "thinks" it's in his scope of practice he can do as he pleases. I would certainly disagree with that. If he all of a sudden decides to "think" that he's qualified to prescribe LMWH for DVT prophylaxis, I'm not going to accept his script for Lovenox...

But, again, WE are saying that if there is a legitimate medical purpose, we are fine with it. However, using the original example, prescribing 30 Ambien falls out of common practice and is thus not a legal script. I guess we agree to appear to disagree when we actually agree..but semantics or something confuse the hell out of everyone?

F' it, I'm going to sleep.
 

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No one thinks this. All he's saying there is that if there is foot/ankle pathology he's entitled to treat it. Mentioning hypothyroidism with respect to podiatry is absurd. Apples and oranges and absolutely out of pod scope.
Sure, no one disputes that you can treat foot and ankle pathology.

So tell me, what foot/ankle pathology is a 30-day supply of Ambien intended to treat?


PS: I can think of a way to connect thyroid disease to the feet. Just like DM. Are we agreed that a podiatrist is not able to manage hypothyroidism or diabetes?
 
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Sure, no one disputes that you can treat foot and ankle pathology.

So tell me, what foot/ankle pathology is a 30-day supply of Ambien intended to treat?
I guess you missed the part in the other thread where I said this should be referred to someone else after a 7 day supply unless there is some off label usage there. I'm not aware of one, but then again I'm not the prescribing doctor so I suppose I don't need to be aware of one just yet.

PS: I can think of a way to connect thyroid disease to the feet. Just like DM. Are we agreed that a podiatrist is not able to manage hypothyroidism or diabetes?
This is just being ridiculous. I hope you're not being serious. If you are being serious, then yes, we're agreed. We can treat the manifestations in the feet but not the systemic disorder.
 

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So the patient is on a high dosage of Zocor....patient is given cimetidine...patient gets rhabdo...yikes.

I never have been able to understand why some professions aren't put under the same curtain as medicine...but, hey, that's just me.
If the rhabdo somehow touches something connected to the foot, then couldn't the DPM switch therapy?
 

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If the rhabdo somehow touches something connected to the foot, then couldn't the DPM switch therapy?
No, that is something the MD/DO should be doing. However, the DPM does have the right to consult the patient like stop the offending medication that you are taking.
 

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This is just being ridiculous. I hope you're not being serious. If you are being serious, then yes, we're agreed. We can treat the manifestations in the feet but not the systemic disorder.
Sure, the idea of a pod treating hypothyroidism or systemic diabetes is ridiculous. But we have someone who has stated that "if I think a condition is within my scope, I can prescribe medication for it," and who is now claiming to be able to RX oral contraceptives. That's ridiculous too.
 

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Yes, and meister, you made a good point about the pelvic exam. I believe it is the standard of care to administer a pelvic exam/pap smear before oral contraceptives are prescribed. I don't think a DPM could provide that care and therefore, should not be RXing OCP. Under any circumstances. Until, of course, we learn that Plan B cures foot odor. Then, IT'S ON!!!!! :p
 

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I don't think his malpractice insurance carrier would like to hear about all of this primary care he feels he's able to do...
These people are like cowboys in the wild west....and I'm pretty sure they are making up a bunch of this crap off of the top of their heads...a podiatrist prescribing Ambien for RLS....wow....:laugh:
 

WVUPharm2007

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WVU, I'm curious. Do you think podiatrists in expanded scope states (those that allow pods to treat the entire lower extremity) would be within their scope to treat RLS?
No. The etiology does not stem from the legs...it's a neurological disorder. The idea that they apparently do is a rather frightening precedent..and laughable. That's stretching their scope of practice to unbelievable levels. I wouldn't fill a script based upon that excuse. If they want to treat RLS, they should become physicians. Period. Given enough time, they can come up with excuses to prescribe anything under the sun. Sure, they will flame me...but I obviously don't care.

And who the hell uses Ambien for RLS? It's like 4th line therapy...and if it's gone that far without resolving, they REALLY need to see a danged neurologist.
 

All4MyDaughter

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I do wonder what other drugs were tried and failed before going to Ambien for RLS (in fact, I asked the same question in the other thread). It seems to me that there are equally effective, safer options that have less potential for dependence. Ambien is not something I would have connected to RLS on my own.
 

girllein

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So basically, they aren't treating the foot if they're prescribing metformin, because they're treating the diabetes that is causing the foot problems. It's an indirect treatment, which is out of scope even though it's "related".
For example, if I can't stop coughing, and no one can figure it out, then I might have to see a neurologist for a psychosomatic disorder. If the neurologist prescribes me an antipsychotic or whatever, then he is not treating the cough, he is treating the psychosomatic disorder. I think it's the same for podiatrists trying to treat diabetes and neuropathology.

Podiatrists should stick to the feet. What's wrong with treating toe cheese? Somebody has to do it. As a bonus, it would do society a lot of good if Uncle Joe's feet didn't make people pass out upon exposure.

This is a side point, but the field of podiatry should have been scrapped a long time ago. That's what MDs are for. The foot is an integral part of the body the last time that I checked, and it's not optional like vision correction or cavity fillings.
 

All4MyDaughter

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Seriously, it's totally optional. You can pull out your own teeth too if you feel like it, instead of getting fillings.
You may be jesting, but I have people in my own family who have done exactly that. WVU isn't the only person on this board who comes from a hillbilly/redneck background...
 

girllein

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You may be jesting, but I have people in my own family who have done exactly that. WVU isn't the only person on this board who comes from a hillbilly/redneck background...
Right. People do that sort of stuff on a regular basis. It's not rocket science to pull a tooth, but it should be studied by a professional for the sake of quality practicing.
I don't understand how podiatrists are excluded from surgery like dentists or optometrists without MDs. Is that what makes them think that they can prescribe whatever they feel like? It's like they think 'I can open you up with my scalpel, but I can't prescribe Ambien for a month??? Give me a break! Hahahaha!' Knife action does not equal unlimited prescribing rights. Scope is still scope.
 

girllein

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It's called a three year residency.
An oral surgeon has to have an MD, if you get my drift.
Podiatry is the only exclusion that I can think of that allows for a residency to replace medical school plus a specialty residency after medical school... If a podiatrist wants to prescribe systemically, then they should have gone to M-e-d-i-c-a-l S-c-h-o-o-l. I think its time for me to stop posting in this thread, because I no longer value podiatrists' training. What a sad outcome. :(
 
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