Scope of Practice Question

Discussion in 'Podiatric Residents & Physicians' started by APharmacist, Dec 9, 2008.

  1. APharmacist

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    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?
     
  2. 215512

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    if you have to ask then yes
     
  3. Feli

    Feli ACFAS Member
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    First, I have no idea how a pre-pod student would know anything about this issue.^

    ...I think it's certainly a fair question and there should be no issue with your asking the doc for details and explanations on an atypical Rx.

    I've seen a fair number of foot surgeons who will write sedative hypnotics for post-operative patients, but it's typically just for the first week or two and in conjunction with narcs, NSAIDS, Abx, etc as you suggest. The only application of long term hypnotics that I could imagine for foot and ankle might be painful diabetic neuropathy. However, I think that you're definitely correct that it is not something most DPMs would prescribe long term as a solo Rx. We had a patient in my attending's office today who received a Lunesta one week supply post-op, and she was asking for a refill. She was given one more week and told that she will need to follow-up with her PCP or a neurologist for those Rx if the sleep difficulty continued. I'd say that's about the norm based on my limited observation as a clinical pod student.
     
  4. diabeticfootdr

    Podiatrist 10+ Year Member

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    If it is a validly written prescription by a doctor who has an unlimited license to prescribe drugs, then you are obstructing a patient who is attempting to fill a legitimate prescription - which is illegal in most states.

    You can not tell the doctor how to practice medicine. If he believes the Ambien is necessary to treat something in his scope of practice, then he has the right to prescribe it.

    Your only recourse would be to turn him into the state board of podiatry on suspicion of practicing out of scope, but I'll tell you that he probably has a more valid claim against you to your state board of pharmacy for your failure to fill the script.
     
  5. 215512

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    um with all due respect, same to only a podiatry student...neither of us know and can just give/not give an educated guess
     
  6. air bud

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    wow. you are an absolute moron. how would you have any knowledge of this situation?
     
  7. JEWmongous

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    Well Feli is in his clinical years (I believe 4th) and has rotated with residents and various doctors (DPM, DO/MD). So yea, I would listen to him on a number of things. Of course hearing info from current residents and practioners is the best, but Feli does have useful input.
     
  8. APharmacist

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    So, diabeticfootdr, is it your position that if the pt was anxious because of her foot problems you could prescribe valium indefinetly or if she was depressed because of her foot injury you could prescribe prozac? I'm not questioning the drug as much as the length of therapy. Chronic insomnia would not seem to be a disease of the foot or ankle. If I believe that a script is outside a prescribers scope of practice I'm not obligated to fill it. I've no problem involving my board of pharmacy in this matter, in fact I think I'll give them a call Weds. I'll let you know what they have to say.
     
  9. diabeticfootdr

    Podiatrist 10+ Year Member

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    You have no right to question the length of therapy. So valium for 1 week for foot spasms is okay, but for 1 year is out of scope. The reality is that you have no idea why the doctor wrote the medication, perhaps it was off label as a brand new treatment for plantar warts?

    You were presented with a valid Rx. You don't know what it was for, really. You refused to fill it. If you were a pharmacist dealing with my patient you'd get an angry call from me too.

    Prozac? How do you know the reason that any doctor is prescribing any medication. SSRIs can be used for painful diabetic neuropathy, as can tricyclics. Viagra and statins can be used for PAD. Antihypertensives can be used for Raynaud's. You are not the prescribing doctor. Your job is to fill prescriptions.
     
    #9 diabeticfootdr, Dec 9, 2008
    Last edited: Dec 9, 2008
  10. 215512

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    hey so whens ur date?:love:
     
  11. APharmacist

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    PRN INSOMNIA thats what the rx stated. Nothing off-label or brand new in that. Just because a prescriber writes a prescription doesn't mean its valid. I don't decline to fill very many prescriptions and I don't do it lightly. We filled ambien from this Dr. in good faith and the patient still has some medication. By the pts own admission she isn't taking any pain meds and is using this to get some sleep, and it doesn't work very well for her. I didn't just look at the rx and say DPM + Ambien = no fill.
     
  12. 215512

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    :clap::bow:
     
  13. APharmacist

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    I conducted an unscientific survey and 5 out of 6 pharmacists said they wouldn't fill the prescription, thats why I asked the question here.
    Called the state board today, had to talk to 3 people before I could get an answer, bottom line if the doctor says its related to the feet its good. I called the Pt and the Dr and humbly offered my apologies for my ignorance. Pt was cool, Dr. may still think I'm a jerk, couldn't really tell.

    Let the beating commence.
     
  14. 215512

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    :diebanana:(hey you asked for it...you are the banana lol)
     
  15. justtesting

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    why do you even post? you never have anything beneficial to say. i just roll my eyes every time i read your comments.
     
  16. JEWmongous

    JEWmongous Member
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    Thank you!
     
  17. GetnMyFtNtheDor

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    Originally Posted by justtesting [​IMG]
    why do you even post? you never have anything beneficial to say. i just roll my eyes every time i read your comments.

    Amen brother! I thought I was the only one...
     
  18. APharmacist

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    I see a scenario with this guy where he writes a bad order/script, the adverse event happens, and the person who carried out his wishes to the T will be immediately thrown under the bus by him.

    I hope I'm wrong but thats the way he comes accross on this board.
     
  19. j0ez0r

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    theta has got to go....
     
  20. jonwill

    jonwill Podiatrist
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    You were doing what you thought was right. No apology needed.
     
  21. JEWmongous

    JEWmongous Member
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    If only this place was like survivor....
     
  22. 215512

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    thats for your useful post as well
     
  23. justtesting

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    if for no other reason than to bring to your attention that no one appreciates or respects your opinion, my post was useful. This post is now way off topic so don't expect another responce from me
     
  24. UW66

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    understatement of the year, good god.

    Minus theta-boys 'contribution', this was a fun read though.

    My fathers ran his own small town pharmacy for going on 25 years now and he gets to deal with this stuff all the time. If he gets a script he thinks is fishy, he just makes a call to the drs offices to confirm dosages, refills, medmixing etcetc. He's saved more than a few dr.s butts over the years. In fact most docs love pharmacists and consider them an extra safety net in case they make a booboo!
     
  25. GymMan

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    Ain't a "fun" thread til I'm in it. Got a prob with that? :p:laugh:
     
  26. air bud

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    count me in thinking that ThetaChi has nothing useful to add. It takes a "special" kind of guy to use as many smilies and stupid icons as much as he does.
     
  27. 215512

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    you all are just too nice thank you so much and I am very pleased that you enjoy my contributions how wonderful :p in any event does anyone know how to delete an account? just curious (yay everyone else) because the only thing i have gotten from this forums was information about where the interview feedback was and 8000 "what are my chances" threads along with tons more about random things that are not important so...awesome
     
  28. j0ez0r

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    dont let the door hit you on the way out :laugh:
     
  29. dpmPOD

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    :thumbup:
     
  30. ohhyourgod

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    How about you guys carry this conversation to the Pre-Podiatry thread/create a BULLSH$T thread for attacking Theta and let's resume the normal Podiatric Residents and Physicians thread? :D :p
     
  31. air bud

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    i agree 100 percent. Just like there are some threads about taking the USMLE and jobs and stuff in the pre-pod forum that are unneccessary. However, and this cannot be stressed enough...ANYTHING that could potentially drive thetachi away and stop contributing his 0 cents is worth it.
     
  32. 215512

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    seriously can you just knock it off with the attacks at me? stop taking yourself and the podiatry forum so seriously and treating me with such disrespect you dont know me and are being incredibly rude
     
  33. meister

    meister Senior Member
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    This is false. Pharmacists are not robots who are forced to do the bidding of a prescriber, in this case a podiatrist. Furthermore, the question of scope of practice regarding podiatrists is a complicated question. You say that the prescription is written by a "doctor who has an unlimited license to prescribe drugs," but this is not true. Medical doctors have unlimited scope and privilege, the same cannot be said for podiatrists. Podiatrists have DEA numbers that give them full privileges to prescribe narcotics, however, this does not give them the authority to prescribe birth control, asthma medication or other medications which are wholly outside their scope of practice. In this particular instance, the podiatrist was within his scope if the Ambien therapy is related to a podiatric diagnosis and the proper course would be for the pharmacist to inquire as to the length of the therapy. If the pharmacist is not satisfied with the podiatrist's response, then he is legally able to refuse to fill the prescription and return it to the patient for the patient to have it filled elsewhere.

    I'm going to ignore your straw-man that this pharmacist was somehow telling the podiatrist how to practice podiatry. The podiatrist certainly does have a right to prescribe it, but the pharmacist certainly does have a right to refuse to fill the prescription if in his professional judgment it is better that he not. A good course of action would be for the pharmacist to contact the podiatrist to inquire as to the reason for Ambien therapy for an extended period of time.

    This is not a simple question and certainly it does not have a simple answer as you seem to think. You should pause for a couple seconds to consider how in your first sentence you say the prescription was written by a podiatrist with unlimited scope for prescribing drugs and now you say that the pharmacist could report the podiatrist for practicing out of scope. Think about that.

    Wow, you sure are coming off as condescending. The right of a pharmacist to deny filling a prescription varies in each state, but in California a registered pharmacist cannot be forced to fill any prescription. It is called professional discretion.

    Again with the condescension. It's obvious you have little idea what it is that pharmacists do. If a pharmacist feels in his professional judgment that there is something wrong with a prescription, he is well within his rights to call the prescriber and ask for a diagnosis or refuse to fill the prescription outright. The rest of your posts are straw-men attacking this pharmacist for trying to force the podiatrist to practice podiatry a certain way, which the pharmacist never did.
     
  34. confettiflyer

    confettiflyer Did you just say something?
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    lol @ ignorance :laugh:
     
  35. UNMorBUST

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    In my state a pharmacist is allowed to deny a perscription for a variety of reasons. Pharmacists are interested in safety of the patient as well as their own hide in case of something going wrong. Why are you faulting them for that?
     
  36. 165007

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    http://forums.studentdoctor.net/showthread.php?t=586579

    check out what the pharmies are saying about this topic. LOL

    didnt you guys know MD = unlimited scope of practice?

    some of them are saying that, they will fill prescriptions from specialized MDs for meds that are supposed to be prescribed by PCP.

    I guess I should tell my cousin (a cardio) to fill my friend's birth control, next time. :laugh:
     
  37. All4MyDaughter

    All4MyDaughter SDN Mommystrator
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    Well, in my state, MD/DO's have unlimited scope of practice. So a cardiologist *is* legally entitled to write for birth control or eye drops or whatever. Whether a valid doctor/patient relationship exists, or whether that physician SHOULD write for meds outside of his/her scope of practice, is another matter. So when we see something that is unusual, or seems inappropriate, we can contact the prescriber for clarification. If it doesn't check out, there is no obligation to fill.
     
  38. meister

    meister Senior Member
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    Your cousin could write for your friend's birth control and it would be filled probably without question. Medical doctors do indeed have unlimited scope when a valid doctor-patient relationship exists, this is not news. Determining if said relationship exists is pretty much only in the power of the board of medicine to determine.
     
  39. jonwill

    jonwill Podiatrist
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    I always find these theoretical debates funny. As a resident, I work with a lot of docs in all specialties. They are all very specific as to what they will write for and what they won't. It all comes down to liability. And in today's wonderful litigious society, specialists will only write for those drugs specific to their specialty because they don't want to assume the liability. The fact that they are an MD and have an "unlimited" license to prescribe drugs won't save them in a court of law.

    It's like the old theoretical pissing match that comes up every 6 months or so between pre-meds/beginning med students vs pre-pods/beginning pod students about an MD's "unlimited" scope of practice vs a pod's "limited" scope. Everybody's scope is limited. It's limited to what you are trained to do. And no one steps outside of their scope because they don't want to get sued!
     
  40. WVUPharm2007

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    Wow...just...wow. :laugh:
     
  41. WVUPharm2007

    WVUPharm2007 imagine sisyphus happy
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    Yeah...but the difference is that if an MD or DO specializing in some random specialty that isn't OBGYN wrote a script for birth control, I'd still fill it. If a podiatrist wrote a script for birth control, I'd chuckle and void the prescription.

    Of course I am a clinical pharmacist, so I don't deal with prescriptions as much, anyway...meh.
     
  42. meister

    meister Senior Member
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    It's not so much a pissing match as an important legal nuance. You are entirely correct, WVU, of course.
     
  43. IamMDMBA

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    You are an idiot, MD's do have unlimited scope. Your cardio cousin could write for the birth control, insulin, migraine meds and it would be filled unquestioned. Go read a book. Honestly, why would you question what they are saying in the pharmacy thread....that's their field, don't you think they would know more than anyone who can prescribe what????
     
  44. 165007

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    Sarcasm anyone?

    Did i forget to add my icons?

    lol
     
  45. 165007

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    I guess these pharmies couldnt read under the line.

    but thanks for writing it out for me. :laugh:
     
  46. dpmPOD

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    So if a nephrologist writes a script for an antipsychotic specifically to treat bipolar disorder it makes sense to fill it? I understand the nephrologist has "universal scope" but when the patient can't possibly be managed appropriately by that provider (a nephrologist vs. say a psychiatrist) you still fill the script anyway? I'm not saying such a scenario would happen, but since we're all about hypotheticals tonight...
     
  47. WVUPharm2007

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    Sure would. Physicians are generalists by training...other professions are not. Plus, they have the legal and professionally recognized authority to prescribe as such. Using the original example a pharmacist could legitimately get in legal trouble for dispensing Ambien to a patient based upon a script from a podiatrist. ANY physician has no such legal or professional restrictions. The DEA would consider the aforementioned dispensing of Ambien prescribing out of scope of practice and, as such, would be an illegal script. That's just the law...and I ain't breaking it...
     
  48. dpmPOD

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    Ok, but is bipolar disorder best managed by a "generalist?" Does the one month clerkship + behavioral science class the nephrologist had say 10 years ago in med school qualify him to act as a psychiatrist? Let's imagine that the bipolar patient commits suicide and the family decides to sue--will that nephrologist not be sued for practicing outside his area of expertise and for mismanaging the patient? Should he not have referred the patient? I would imagine the psychiatrists would disagree with you here.

    As far as the Ambien thing goes, I understand where you are coming and I more or less agree, but I do think a short course would be appropriate post-op if the pt. is having trouble sleeping; anything beyond that needs a referral.
     
  49. diabeticfootdr

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    Firstly, I am well aware of my scope of practice, and I didn't say that podiatrists have an unlimited scope. Podiatrists have an unlimited license to prescribe drugs. You need to read more carefully.

    Secondly, I don't expect you to be a legal expert.

    Thirdly, I encounter these issues and I sit on our Podiatry State Board of Directors.

    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, regardless of it's FDA indication. That is what "off label" means. And you may not have any idea why I'm prescribing a certain medication. A phone call is fine to ask me why I'm prescribing a medicine, but ultimately I am the treating doctor. If you refuse to fill a legally written Rx, --- 1. I call your supervisor (which probably takes care of the issue), 2. I call your state board. 3. I direct my patients to a different pharmacy. Issue solved.
     
  50. WVUPharm2007

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    Sure they do...assuming they are for a legit medical purpose.

    Well, I just passed the PA and WV state law exams, which is a comprehensive examination on the prescribing and dispensing laws of the federal government and the aforementioned states. I'd suspect I'm much more of an expert than you at the very least.

    Yes, good for you. And maybe in YOUR state podiatrists can prescribe 30 days of Ambien without a medical license. In my state and every other state I know of...they can't.

    No, YOU are wrong. If it's for a legitimate medical purpose, I'm fine with it. Say cimetidine for warts...FINE. Granted, I'd triple check that they aren't on any CYP P450 3A4 substrate drugs before filling it because a physician didn't write the script...but I'd fill it because it's for a legitimate medical purpose. I know more about drugs and their off-label use than you could ever imagine. I'm a freakin' drug specialist. I hold a PharmD. Lordy. Please shush with the condescending blathering from your soap box about how you are the super-magical "treating doctor." I'm the "treating pharmacotherapist" who is equally as liable for drug misuse, thanks. And I likely already know full-well the drug you are using has an off-label use....and when it doesn't....and you're right I WILL call you one it if it doesn't.

    If it's something patently bizarre...such as a legitimate reason why a podiatrist would prescribe Ambien for 30 days pertaining to a SPECIFIC ankle/foot problem...then I'd ask for you have to back it up with a study, reference, or something as to why it affects the feet/ankles specifically. If it's prescribed without such a podiatry-specific use, then it is prescribing out of practice and I am OBLIGATED by state law (and in this case with a scheduled drug, federally obligated) to refuse to fill it. It's not that I don't want to, it's that I LEGALLY CAN'T. I will bust out the DEA Pharmacists' Manual and PA/WV rules and regs and show you the citation if you so please.

    So let's go number by number here.

    1) He'd agree with me because I'm legally correct. Case closed.
    2) They'd ask you why you were prescribing 30 Ambien to a patient as a podiatrist and call the DEA. Great idea. Plus, I can legally refuse to fill any script for any reason I want. I am not subservient to some dude in a white labcoat somewhere who writes words on little pieces of paper that can be exchanged for goods and services.
    3) A pharmacist that knows his law would do the same thing...unless they don't care...upon which they have broken the law and I guess it's their problem.
     
    #50 WVUPharm2007, Dec 16, 2008
    Last edited: Dec 16, 2008

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