Wondering what to do with my clozapine patients when I leave my current job.

[deleted1100659]

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Short version, ill be going to a new job soon, pretty far from my current job in a couple of months. Im at the largest community health facility in the region, by far, and im the only clozapine prescriber. Theres only one person on my clozapine pt list I think could actually do ok off it, the rest it seems highly unlikely. I really have no idea who I could even refer them to as they would likely be a few hours away. There is a psych residency here (smaller program) and they have no one who does it. It seems as the person they're trying to bring in to replace me once I head out only does telehealth and does not prescribe clozapine.

1. I slowly switch to high dose zyprexa +mood stabilizer, maybe even a little haldol and hope that works. Seems pretty unlikely based on my experience, fairly high chance they would just decompensate.

2. I continue them on it for the next couple months till I leave and give them the closest clozapine prescribers info. Im leaning more towards this option,

not really sure of any better options. For treatment refractory patients, usually trying things besides clozapine is a shot in the dark.

 

[nexus73]

Is there another doc in the current clinic? They need to get REMS certified.

 

[deleted1100659]

Is there another doc in the current clinic? They need to get REMS certified.

only one other doctor, she stopped prescribing it and refuses to use it. rest are midlevels

 

[Ironspy]

only one other doctor, she stopped prescribing it and refuses to use it. rest are midlevels

NPs can prescribe clozapine in many states. I find it shocking that you can be a psychiatrist at a community mental health clinic and refuse to prescribe clozapine.

 

[deleted1100659]

NPs can prescribe clozapine in many states. I find it shocking that you can be a psychiatrist at a community mental health clinic and refuse to prescribe clozapine.

unsure if they can in mine. my state requires NP supervision and NP has to have a delegating physician, though im not sure if they could do clozapine regardless of the delegating doctor. However if the delegating physician who replaces me doesnt do it then im skeptical he would allow the NPs to.

im also not super into the idea of the average NP prescribing clozapine, most have zero knowledge/experience with it.

However, I have made a concisse 4 page handouts on word with charts/tables including a 14 day titration guide, therapeutic levels/dose, interactions with smoking 1A2, side effects to monitor for, what to do for those side effects, etc that i keep posted in the lab. So in theory i have idiot proofed it as much as possible...but still...

 

[ObsequiousAplomb]

Does the residency program nearby not want to use clozapine, or they just don't have anyone that does it currently? It's a pretty major component of reasonable psychiatry residency training to get exposure to clozapine prescribing. I remember residents fighting over who got to take the clozapine referrals. IIRC the prescribing resident would be able to do this independent of the attending being in the REMS. Regardless, it would be the type of thing at least one of their attendings ought to be willing to register for, unless it's one of those residency clinics that don't treat psychosis.

If you call the pharmacy you have the clozapine filled at (as long as it's not in your current clinic) they should be able to give you a list of other clozapine prescribers in the area.

If I were in your shoes I would continue with the clozapine. I would rather they decompensated because the new psychiatrist refused the clozapine than to risk them decompensating right before I left.

 

[deleted1100659]

Does the residency program nearby not want to use clozapine, or they just don't have anyone that does it currently? It's a pretty major component of reasonable psychiatry residency training to get exposure to clozapine prescribing. I remember residents fighting over who got to take the clozapine referrals. IIRC the prescribing resident would be able to do this independent of the attending being in the REMS. Regardless, it would be the type of thing at least one of their attendings ought to be willing to register for, unless it's one of those residency clinics that don't treat psychosis.

If you call the pharmacy you have the clozapine filled at (as long as it's not in your current clinic) they should be able to give you a list of other clozapine prescribers in the area.

If I were in your shoes I would continue with the clozapine. I would rather they decompensated because the new psychiatrist refused the clozapine than to risk them decompensating right before I left.

nearby program is pretty small, not a lot of attendings is the issue. They're a newer program so they dont seem to have a lot of faculty or sites.

The city itself is not very desireable, so chances are if someone is going to do a community health setting (which already is a tough sell for a lot of psychiatrists) they sure as heck wont choose this area. A lot of crime and substance abuse problems in the city and the location definitely pushes people away.

Reality is with the huge shortage of psychiatrists, the obvious question becomes why go to a crappy city to live unless the job is amazing? I explained that to admin at one point, but most dont seem to get it.

 

[Celexa]

I think you need to present options 1 and 2 to your patients and let them tell you which they want to pursue. Rock and a hard place either way but it's their right to decide if they want to stay on the medication knowing they'll need to travel far to see their psychiatrist or roll the dice on trying different meds. I agree with you risk of decompensation is going to be very high.

 

[SubzDoc]

nearby program is pretty small, not a lot of attendings is the issue. They're a newer program so they dont seem to have a lot of faculty or sites.

The city itself is not very desireable, so chances are if someone is going to do a community health setting (which already is a tough sell for a lot of psychiatrists) they sure as heck wont choose this area. A lot of crime and substance abuse problems in the city and the location definitely pushes people away.

Reality is with the huge shortage of psychiatrists, the obvious question becomes why go to a crappy city to live unless the job is amazing? I explained that to admin at one point, but most dont seem to get it.

I did residency at a smaller program, in a small city very much like the one you describe, split between community hospitals and agencies (although there was an academic affiliation). Even so there were a number of faculty members prescribing clozapine. They didn't always broadcast this and some of them complained that their outpatient partners were stonewalling, not registering for the REMS. Agree with posters above, it would be at least worth asking the pharmacy or someone in the know in the residency. Hard to imagine this isn't available in a training program although, if you are community, no guarantee your patients are covered in the other clinics. Best wishes with the new job.

Update: "The Clozapine Risk Evaluation and Mitigation Strategy (REMS) registry provides contact information for prescribers or pharmacists who are registered with REMS in specific regions: 1-888-586-0758."

 

[whopper]

So long as you refer them out and do the appropriate termination procedures legally you are okay. Inform your organization of the situation cause this could put the flame under their butts to find a new psychiatrist willing to prescribe Clozapine. The Registry will provide you and your patients with contacts. That doesn't mean there's anyone out there that can take them within a reasonable distance and even if so that they are taking new patients. They could be screwed. I don't like it one bit but you are not ethically bound to keep onto a job because of this situation. This is also a problem that is not your fault but the fault of the system that creates a nationwide shortage of psychiatrists.

 

[deleted1100659]

Well what the hell, I just called clozapine REMs this morning and they told me they have no way of searching for clozapine providers by region.

 

[whopper]

They do. Just means they don't feel like doing it or their software didn't allow for them to do so in an easy manner, and they don't care enough to help you. Their software might not parse people by region. Again that doesn't mean they can't do it but that they don't feel like doing it themselves.

As I've said before, the REMS website ahem, sucks.

 

[SubzDoc]

In all fairness, I did not pull that directly from the REMS website although the source seemed reasonably reputable. I am sure the REMS has the information.

SMI Adviser - A patient is moving to a new location and needs to find a new prescriber or pharmacist for clozapine. What information is available on this?

"

A patient is moving to a new location and needs to find a new prescriber or pharmacist for clozapine. What information is available on this?​

The Clozapine Risk Evaluation and Mitigation Strategy (REMS) registry provides contact information for prescribers or pharmacists who are registered with REMS in specific regions: 1-888-586-0758. Other possible contacts for more information are local academic medical centers, local NAMI chapters, or local psychiatric societies.

Type: Knowledge Base
Answered by:
Alexander S. Young, MD, MSHS, SMI Physician Expert - University of California, Los Angeles
Date Answered: November 12, 2021
Topic: Clozapine,
Tags: Clozapine,
"

 

[deleted1100659]

im going to call them again today and maybe this next person will be more helpful. The REMs program is annoying, if anything