would you fill this?

[radio frequency]

Do you even read; stop jumping into threads without reading everything. No one is saying they can't write for it. They can write for anything. The debate is should we dispense it. That's OP's question. Scroll up and read. OP is asking if he should dispense it. He's not asking if the doctor has the authority to write for it. OP says hes uncomfortable with dispensing it. Many of us agree. There are a couple here who's given him beef for possibly refusing it because they feel he shouldn't be refusing a legitimate script, or any script, from an MD with authority to write for it.

Have a lorazepam.

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[Lnsean]

Have a lorazepam.

why the personal attacks now? kinda uncalled for.

 

[steveysmith54]

Here's the other problem with this prescription: it is a hazardous drug product and it is concentrated. If he IS compounding it at home, he certainly isn't using proper precautions and could easily be exposing himself and anyone else who lives with him to repeated chemotherapy exposure. We also have no idea if he is using a safe concentration or if he is mixing it incorrectly resulting in an unsafely high concentration. If he isn't, that's even more likely to cause exposure. To me, that is very high risk in regards to dispensing liability. I have compounded several chemotherapy topical or oral products and would never do it outside of a vertical flow hood with chemotherapy precautions. Would you? There is a reason we do it that way, and it is because of safety.

I think that's the most intelligent post in this thread. As pharmacists, it's our duty to assess if the medication is safe for use the way it's prescribed... Sometimes it's as simple as if the dose is too high, etc. In this case, it's way more complex. If there is no literature stating that it's safe to use this injection topically and mix without vertical flow hood, forget it then... This is the main concern. I don't think some know what the definition of "prescribing outside of scope of practice". Oldtimer and others explained it well, so I won't go into it.

 

[TheBlaah]

I think Lnsean just doesn't realize that "scope of practice" applies to all healthcare professions, pharmacists and physicians included. And that it does describe prescriptive authority in a physician's case.

To quote wikipedia, "The Scope of Practice describes the procedures, actions, and processes that a healthcare practitioner is permitted to undertake in keeping with the terms of their professional license."


But I'd probably deny it anyway if I was not given specifics regarding its use.

 

[Lnsean]

I think Lnsean just doesn't realize that "scope of practice" applies to all healthcare professions, pharmacists and physicians included. And that it does describe prescriptive authority in a physician's case.

How does "scope of practice" describe or even define a doctor's prescriptive authority when it has been established that an MD is legally licensed to prescribe anything that can be legally prescribed? Don't cite wikipedia. Cite a law or regulation where scope of practice defines or limits an MD's prescriptive authority. You won't find any.

The scope of practice used in OP's situation to refuse a prescription is one where court cases have cited that it's part of a pharmacist's duty and thus, his liability, to express due diligence when medications are prescribed outside of normal practice. I'm thinking some people here are too concerned with the term "scope of practice" regarding the perspective of the MD. We're not here to limit a doctor's prescriptive authority. That's against current regulations. The term is mainly used as way to hold pharmacist liable for dispensing medications that would be out of the doctor's normal practice and that is unsafe. This term is directly related to our own liability as pharmacists. It has no bearing on the MD. As far as the doctor and the law are concerned, he wrote a legitimate script. Scope of practice doesn't apply to his authority. Some of the MDs who have commented in this thread have stated as such:

That's nonsense.
You know exactly what he's using it for.
If he has a valid license to practice medicine, why would you deny the prescription?
My medical license doesn't limit my practice nor does it require me to not use off label drugs, etc. If it did, I'd be out of business as many common anesthesia drugs are off label in pediatric patients.

In the end, the law or court cannot go after an opthamologist for prescribing fluorouracil outside of his scope of practice because there is no such thing. The opthamologist can write for whatever he wants. The court will, however, go after you for choosing to dispense it, if it ends up that he has harmed someone in the process, and you failing to realize it was outside of the doctor's scope of practice and thus unsafe. That's the difference some of you are not understanding.

For the record, I feel that MD's should have unrestricted prescriptive authority as they do now, but since pharmacists are liable for what we dispense, "scope of practice" is more relevant to us and is a part of our decision making process. On the other hand, "scope of practice" has probably never even crossed this opthamologist's mind once or is even a topic of debate on the MD forums.

 

[TheBlaah]

How does "scope of practice" describe or even define a doctor's prescriptive authority when it has been established that an MD is legally licensed to prescribe anything that can be legally prescribed? Don't cite wikipedia. Cite a law or regulation where scope of practice defines or limits an MD's prescriptive authority. You won't find any.

That's a physician's scope of practice. Whatever can be legally prescribed.

But anyway, I agree with radio frequency. Not all state boards of pharmacy require pharmacists to look at "normal scope of practice" in determining appropriateness of the prescription. Depends on your state.

 

[Gosondth]

For those that feel physicians are immune to "scope of practice", ask yourself if you would have dispense propofol as ordered to Conrad Murray (a licensed cardiologist)?

Granted there was no legal repercussion (as far as I know) to the dispensing specialty pharmacy (Applied Pharmacy Services), but I'm sure it's not the kind of attention they wanted.

 

[Dr Wario]

I really am not so sure physicians should not be limited in their scope of practice (or at least held liable if going outside of their scope causes a patient harm.) Many of these laws were put in to the books when barely over a handful of drug substances had been classified, now there are tens of thousands of medications available with a substantial number requiring very specific use, dosing and monitoring as to not cause harm. There is just too much out there for 4 years of professional education and 3 years of on the job training to make you an expert on the use of every facet of medicine.

When facing a decision about filling a questionable prescription, I typically consider how the DEA has mandated that pharmacists have a corresponding responsibility in the dispensing of scheduled drugs, and a part of that is to insure that the script is written for a LEGITIMATE purpose and in the USUAL COURSE of the prescriber's practice.

I recently had an out of town doctor who self proclaimed to be an addiction specialist write 28mg of klonopin/day for a patient that he said was trying to detox from heavy previous BZD use. I had no history of this patient at our pharmacy, and had never heard of the doctor before (as he was over 50 miles from our location) and it my professional judgement (and because the FDA max dose of klonopin is 20mg/day) a dose this high should be only given inpatent so that the patient can be correctly monitored. I informed the doctor that I did not have experience with this high of a dose and because I am not familiar with the doctor or the patient, I would not be filling this script. I suggested the patient take the script to his usual pharmacy where they may be more familiar with his history and doctor, but it was at this point I was of course threatened to be sued and given many nonsensical insults.

The point of this story is, just because someone has a MD/DO after their name does not give them all power over my logic and judgement as a pharmacist. If they want to directly dispense their concoction to the patient, let them, but when I am involved in the process my opinion also has merit, and that is why I am paid more than a technician.

 

[owlegrad]

In the end, the law or court cannot go after an opthamologist for prescribing fluorouracil outside of his scope of practice because there is no such thing. The opthamologist can write for whatever he wants. The court will, however, go after you for choosing to dispense it, if it ends up that he has harmed someone in the process, and you failing to realize it was outside of the doctor's scope of practice and thus unsafe. That's the difference some of you are not understanding.

You are right that I do not understand the difference. You literally say there is no such thing as being outside a doctor's scope of practice and then say that there is something outside the doctor's scope of practice.

 

[Ackj]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2991444/

Also, if a general practice NP can write for either of these, why can't an ophthalmologist?

That's a different circumstance, because if he's prescribing according to that study, it would be within specialty. The OP clearly states that the ophthalmologist is writing for something outside of the specialty, hence the debate. Obviously this whole discussion is about specialists prescribing for other things, but congratulations on being so smart to find an article where ophthalmologists prescribed something besides eyedrops in their practice.

So back to the question, which I apparently have to further clarify: Would you fill a prescription for a retired ophthalmologist attempting to treat themselves for RA or psoriasis with self-prescribed methotrexate or Humira?

 

[Lnsean]

What baffles me is that some of the people on here who has a problem with OP refusing this script for scope of practice would turn around and refuse it for some other bs reason. A few pharmacists on here would flat out lie to their patients and tell the doctor that they can't order it or don't have it in stock. I mean, if you're that uncomfortable with the script to the point where you have to lie your way out of dispensing it then you should man up and refuse the script outright. Every time you run into a difficult script, you're just going to tell people you can't order it? lol...what a joke.

Another user commented on how they wouldn't refuse it for scope of practice but would refuse this on the basis of "inappropriateness of therapy." I mean really? What if the ophthalmologist told you he's treating his wife's cancer...would that make the therapy appropriate now?

I'm just appalled at the reasons that some people here would make up to refuse this script rather than admitting the real reason: they're uncomfortable because it's an ophthalmologist prescribing a chemo agent.

 

[radio frequency]

That's a different circumstance, because if he's prescribing according to that study, it would be within specialty. The OP clearly states that the ophthalmologist is writing for something outside of the specialty, hence the debate. Obviously this whole discussion is about specialists prescribing for other things, but congratulations on being so smart to find an article where ophthalmologists prescribed something besides eyedrops in their practice.

So back to the question, which I apparently have to further clarify: Would you fill a prescription for a retired ophthalmologist attempting to treat themselves for RA or psoriasis with self-prescribed methotrexate or Humira?

Depends. On a weekend trip, been on it for years and forgot it at home for a one time fill? Yes. New start? No.

 

[Old Timer]

Well you have the right to refuse any prescriptions in my state. I refuse to fill pain pills all the time.

Yes, but you have to have a legitimate reason. If the patient were to go to the State Board or sue you because their therapy was delayed, you better have a good reason or you could be held responsible. I refuse things all the time too, but not usually because "I don't want to."

 

[Old Timer]

For those that feel physicians are immune to "scope of practice", ask yourself if you would have dispense propofol as ordered to Conrad Murray (a licensed cardiologist)?

Granted there was no legal repercussion (as far as I know) to the dispensing specialty pharmacy (Applied Pharmacy Services), but I'm sure it's not the kind of attention they wanted.

Is there a law in your state that says only certain doctors can order Propofol? Do you not understand the concept of scope of practice? There are many grounds you could use to refuse to fill this order, scope of practice is not one of them. Advancing your training to specialize DOES NOT preclude you from practicing medicine outside of your specialty. Scope of practice applies to the degree and the license. There is not separate degree or separate license for an ophthalmologist in any state that I am ware of. (bad grammar I know). An ophthalmologist has the same degree and the same license as a cardiologist. pulmonologist, gastroenterologist, gynecologist, or a GP. They can all order the same drugs.

Would I have filled Propofol for sleep? NO, because it is not safe or efficacious for insomnia. He has a right to prescriber the drug as long as the drug is indicated by law or clinical studies to be safe and effective for the condition being treated.

 

[steveysmith54]

Oh man. Oldtimer just schooling people. This is vintage

 

[zelman]

...Would I have filled Propofol for sleep? NO, because it is not safe or efficacious for insomnia...

I'm pretty sure that it is efficacious.

 

[zelman]

...I'm just appalled at the reasons that some people here would make up to refuse this script rather than admitting the real reason: they're uncomfortable because it's an ophthalmologist prescribing a chemo agent.

I think the fact that they're retired is an equally large issue.

 

[Old Timer]

That's a different circumstance, because if he's prescribing according to that study, it would be within specialty. The OP clearly states that the ophthalmologist is writing for something outside of the specialty, hence the debate. Obviously this whole discussion is about specialists prescribing for other things, but congratulations on being so smart to find an article where ophthalmologists prescribed something besides eyedrops in their practice.

So back to the question, which I apparently have to further clarify: Would you fill a prescription for a retired ophthalmologist attempting to treat themselves for RA or psoriasis with self-prescribed methotrexate or Humira?

Maybe. I would have to have a conversation to if he/she knew WTF they were doing. In P.A. retired doctors can prescribe for themselves or their family. I also advise any MD prescribing for themselves or their family to keep medical records. If they do or don't, it's up to them. I wouldn't decline it outright.....

Outside the practice? Why does anybody not understand scope of practice? It might not be safe to use. It might not be indicated for the listed condition. All good reasons to refuse. Outside the scope of practice, not a good reason to refuse, since it IS NOT OUTSIDE THE SCOPE OF PRACTICE.

 

[Old Timer]

I'm pretty sure that it is efficacious.

Since the patient died, I would not say this is safe or effective, nor is their literature to support the safe and effective use of propofol as a hypnotic.

I think the fact that they're retired is an equally large issue.

Like I said, not in PA.

What if I want to retire and maintain my license?

Retired physicians should consider renewing their license as “active retired.” This allows you to continue to treat and write prescriptions for immediate family members without the burden of maintaining professional liability insurance coverage or meeting the CME requirement.

Like a regular license, the cost to renew an active retired license is $360 for MDs and $440 for DOs. They must be renewed every even-numbered year on the same schedule as a regular license.

P.A. Medical Society

 

[steveysmith54]

Maybe. I would have to have a conversation to if he/she knew WTF they were doing. In P.A. retired doctors can prescribe for themselves or their family. I also advise any MD prescribing for themselves or their family to keep medical records. If they do or don't, it's up to them. I wouldn't decline it outright.....

Outside the practice? Why does anybody not understand scope of practice? It might not be safe to use. It might not be indicated for the listed condition. All good reasons to refuse. Outside the scope of practice, not a good reason to refuse, since it IS NOT OUTSIDE THE SCOPE OF PRACTICE.

To be honest, I don't either. In my law class, our professor used the phrase "scope of practice" to describe dentists trying to prescribe birth control. Optometrist trying to prescribe Lisinopril. But, not in another context.

 

[Rukn]

Going to have to disagree with Old Timer here, even though he seems to usually be right

 

[zelman]

Since the patient died, I would not say this is safe or effective, nor is their literature to support the safe and effective use of propofol as a hypnotic.

N=1
And I don't consider it safe. Only effective.

Like I said, not in PA.

P.A. Medical Society

There is a similar legal situation in MA. However, just like the fact that this is probably something he has zero professional experience with since his specialization as an ophthalmologist decades ago (which everyone else is bringing up), there's also the fact that he is no longer involved in the medical community on a professional basis. I did not mean to imply that he could not write for any med, just that I would be concerned about appropriate use for this reason, as well.

 

[Ackj]

Maybe. I would have to have a conversation to if he/she knew WTF they were doing.

That is exactly the entire point. I am doubtful that a retired ophthalmologist is competent in chemo. Similarly, I wouldn't expect an ID specialist to be managing their own heart failure, a psychiatrist to manage their dialysis, a pulmonologist to manage their foot ulcer, etc etc. Are there some that could? Sure. But they most likely don't have the extensive training and experience in that area, especially given that they are retired and may not be up to date on everything. Every poster opposed to filling this is trying to make that exact point. We doubt they know WTF they are doing and that their general MD training from 50 years ago is going to cut it.

What would they need to tell you in the conversation? I can't foresee the doctor saying anything other than "Yeah, yeah, I know what I'm doing, give it to me."

 

[IlDestriero]

That is exactly the entire point. I am doubtful that a retired ophthalmologist is competent in chemo. Similarly, I wouldn't expect an ID specialist to be managing their own heart failure, a psychiatrist to manage their dialysis, a pulmonologist to manage their foot ulcer, etc etc. Are there some that could? Sure. But they most likely don't have the extensive training and experience in that area, especially given that they are retired and may not be up to date on everything. Every poster opposed to filling this is trying to make that exact point. We doubt they know WTF they are doing and that their general MD training from 50 years ago is going to cut it.

What would they need to tell you in the conversation? I can't foresee the doctor saying anything other than "Yeah, yeah, I know what I'm doing, give it to me."

I'm not sure why you think he's using this for chemotherapy. He's almost certainly using it for benign actinic keratoses and is too cheap to just order the solution or cream that is likely not covered by his cheap insurance, so he's ordering the injectable solution which is likely covered.
And someone commented above about not dispensing it because he has to compound it under a hood, etc., he doesn't. It's essentially the same as the 5% topical solution that you all dispense all the time to old gomers with AKs.
Perhaps he doesn't even know he's ordering the wrong solution, but the OP made a big deal about him being cheap, so he's probably trying to get around the drug plan payment.
So knowing that he wants 5% injectable solution vs 5% topical solution for his or his wife's AKs, would you now see that as reasonable and dispense it? Or would you say he needs to have an Nurse Practitioner see him in a derm clinic visit for a prescription for the non covered 5% solution first?
PS in case you don't know, anybody with reasonable vision and minimal knowledge can diagnose AKs and monitor them for cancerous progression. I did a few months of derm in medical school and internship and could diagnose AKs from day 1 of the first rotation.

 

[Old Timer]

That is exactly the entire point. I am doubtful that a retired ophthalmologist is competent in chemo. Similarly, I wouldn't expect an ID specialist to be managing their own heart failure, a psychiatrist to manage their dialysis, a pulmonologist to manage their foot ulcer, etc etc. Are there some that could? Sure. But they most likely don't have the extensive training and experience in that area, especially given that they are retired and may not be up to date on everything. Every poster opposed to filling this is trying to make that exact point. We doubt they know WTF they are doing and that their general MD training from 50 years ago is going to cut it.

What would they need to tell you in the conversation? I can't foresee the doctor saying anything other than "Yeah, yeah, I know what I'm doing, give it to me."

That's your opinion. It's not the law in any state of the union. Scope of practice has nothing to do with specialization. It has to do with liscensure. If he has license, he can prescribe it. You may decide not to fill it, but it's not because of scope of practice.

 

[Lnsean]

That's your opinion. It's not the law in any state of the union. Scope of practice has nothing to do with specialization. It has to do with liscensure. If he has license, he can prescribe it. You may decide not to fill it, but it's not because of scope of practice.

We're not debating if they can write for it. We're debating if a pharmacist can refuse the script based on scope of practice. Jesus. Here, you are using scope of practice to assist you in a clinical dispensing decision. This use of scope of practice is for you only...it doesn't concern him at all. You are not using it to limit his prescriptive authority. He can still write for whatever he wants.

You're quoted as refusing this particular script based on "appropriateness of therapy." ? What if he had said he's treating his wife's cancer. Would that be appropriate therapy then? You're going to tell him that you cannot order it? I think you're just so adamant on being right you're making up silly reasons to refuse this script just to save face.

The case is simple. You have an ophthalmologist prescribing a chemo agent outside his scope of practice. If you refuse the script, it's mostly definitely for this reason not because you cannot order it or because the therapy isn't appropriate...or whatever other reasons some of you guys are making up (you mean your wholesaler doesn't stock it either? what a joke). If you're making up silly reasons to refuse it...then you are already uncomfortable with it. Don't be a weasel.

If you choose to fill it then that is your call.

 

[Lnsean]

I'm not sure why you think he's using this for chemotherapy. He's almost certainly using it for benign actinic keratoses and is too cheap to just order the solution or cream that is likely not covered by his cheap insurance, so he's ordering the injectable solution which is likely covered.
And someone commented above about not dispensing it because he has to compound it under a hood, etc., he doesn't. It's essentially the same as the 5% topical solution that you all dispense all the time to old gomers with AKs.
Perhaps he doesn't even know he's ordering the wrong solution, but the OP made a big deal about him being cheap, so he's probably trying to get around the drug plan payment.
So knowing that he wants 5% injectable solution vs 5% topical solution for his or his wife's AKs, would you now see that as reasonable and dispense it? Or would you say he needs to have an Nurse Practitioner see him in a derm clinic visit for a prescription for the non covered 5% solution first?
PS in case you don't know, anybody with reasonable vision and minimal knowledge can diagnose AKs and monitor them for cancerous progression. I did a few months of derm in medical school and internship and could diagnose AKs from day 1 of the first rotation.

OP is assuming liability based on someone's words. Would you?
"oh yeah judge, I didn't know he exposed all his family member to this agent. I trusted him."
"oh you mean...everyone is going after me for compensation and liability too? He told me he knew what he was doing. I trusted him"

 

[Old Timer]

Going to have to disagree with Old Timer here, even though he seems to usually be right

Please explain scope of practice. Also, show me your state law that says a specialist can only prescribe in his specialty.

 

[Lnsean]

Please explain scope of practice. Also, show me your state law that says a specialist can only prescribe in his specialty.

omg dude...no one is saying the ophthalmologist can't write for it. We're debating if OP should dispense it. Do you have that much problem with reading comprehension? I feel like you know you're wrong but you lack the integrity to admit it...so now you're trying to twist or change your original argument. Lack of honor among men.

 

[Old Timer]

omg dude...no one is saying the ophthalmologist can't write for it. We're debating if OP should dispense it. Do you have that much problem with reading comprehension? I feel like you know you're wrong but you lack the integrity to admit it...so now you're trying to twist or change your original argument. Lack of honor among men.

As usual, you can't read. I said multiple times you can refuse for a number of reasons, just not for scope of practice. I'm not chnaging anything I said. Many people are saying he can't write for it since it is out of his scope of practice.

 

[Lnsean]

As usual, you can't read. I said multiple times you can refuse for a number of reasons, just not for scope of practice.

Sure you can. This has nothing to do with the doctor. Since you're so keen on laws, cite me a law that says pharmacist are not allowed to do so.

I'm not chnaging anything I said. Many people are saying he can't write for it since it is out of his scope of practice.

But many people aren't saying that. People are discussing the dispensing of such a script...not the actual writing of the script.
Yes, you are changing your argument. You've changed your argument from OP being unable to dispense due to scope of practice to now saying that the doctor can write for it. Of course, he can. He's a doctor. He can write for anything. Can't go wrong if you're arguing for the obvious.

 

[IlDestriero]

OP is assuming liability based on someone's words. Would you?
"oh yeah judge, I didn't know he exposed all his family member to this agent. I trusted him."
"oh you mean...everyone is going after me for compensation and liability too? He told me he knew what he was doing. I trusted him"

How is his family exposure with this solution any different from the 5% topical solution (Effudex is available as a cream or solution) that he could have ordered. It's not in any significant way. You are aware it's the same concentration right? The solution doesn't have any special properties other than being a sterile injectable. It's a liquid. Just like the IV form. The cream may be more dangerous as it doesn't dry and can wipe off and expose the public to this horrible dangerous solution. Apply, air dry, get on with your life. Do you also not dispense any topical solutions due to concerns about family exposure? That's not a valid argument.
If he ordered Efudex 5% topical solution, that his insurance wouldn't pay for, you wouldn't give it a second thought and this thread wouldn't exist, and he would have had the same thing on his AKs.
The whole incident could have been avoided by simply telling him that he had to order the 5% topical solution instead, and then when he whined that his insurance company wouldn't pay for it then you say that you've never heard of an ophthalmologist crying poor before, and he should probably look into getting better insurance. Then, he would write for the most expensive cream available just to show you that he's still a big dog, while adjusting the time on his solid gold Rolex Day Date.

 

[wagrxm2000]

I know an ophthalmologist who prescribes birth control for his daughter.

 

[IlDestriero]

I know an ophthalmologist who prescribes birth control for his daughter.

I bet his daughter will sue you for her DVT and PE...

 

[wagrxm2000]

I bet his daughter will sue you for her DVT and PE...

Don't worry she doesn't smoke.

 

[Lnsean]

How is his family exposure with this solution any different from the 5% topical solution (Effudex is available as a cream or solution) that he could have ordered. It's not in any significant way. You are aware it's the same concentration right? The solution doesn't have any special properties other than being a sterile injectable. It's a liquid. Just like the IV form. The cream may be more dangerous as it doesn't dry and can wipe off and expose the public to this horrible dangerous solution. Apply, air dry, get on with your life. Do you also not dispense any topical solutions due to concerns about family exposure? That's not a valid argument.
If he ordered Efudex 5% topical solution, that his insurance wouldn't pay for, you wouldn't give it a second thought and this thread wouldn't exist, and he would have had the same thing on his AKs.
The whole incident could have been avoided by simply telling him that he had to order the 5% topical solution instead, and then when he whined that his insurance company wouldn't pay for it then you say that you've never heard of an ophthalmologist crying poor before, and he should probably look into getting better insurance. Then, he would write for the most expensive cream available just to show you that he's still a big dog, while adjusting the time on his solid gold Rolex Day Date.

This is unreal....i'm sure the liquid form of the drug would be more volatile than something that was safely stabilized in a cream....but that's another topic.

What if he's not going to use it topically? So if he treats his wife's cancer it's okay? I'm off the hook? I get that you want to defend your MD friend but this isn't about your liability. If there comes a day when we're not jointly liable, i'll dispense whatever script is written at face value.

Calling OP out for refusing this script and claiming his reasons as "no sense" is unprofessional. I think that working in healthcare you would understand this. OP has every right to be concerned and uncomfortable with dispensing this script. Like you said, the situation is some type of insurance fraud at the least...it's the ophthalmologist who is being unprofessional. I wouldn't fill this rx if he personally signed a letter of accountability...and I know many in here wouldn't fill this rx either except they'll make up some lame reason like they can't order it or something.

 

[Old Timer]

I bet his daughter will sue you for her DVT and PE...

On what grounds would they sue?

 

[Corpseman]

As usual, you can't read. I said multiple times you can refuse for a number of reasons, just not for scope of practice. I'm not chnaging anything I said. Many people are saying he can't write for it since it is out of his scope of practice.

You guys are all arguing over semantics. No, you should not refuse the drug based on the prescription alone, the doctor can absolutely write for whatever he wants.

You can reject it for appropriateness and liability.... This is where you, gasp, talk to the doctor.

 

[IlDestriero]

On what grounds would they sue?

The same ones the guys above seem so afraid of I suppose.
Or not...

 

[IlDestriero]

This is unreal....i'm sure the liquid form of the drug would be more volatile than something that was safely stabilized in a cream....but that's another topic.

Note to self, make sure you just order Efudex 5% topical solution for your AKs. It will save everyone a lot of drama.
On second thought, maybe he wants to inject it into his recalcitrant genital warts?

 

[Lnsean]

Note to self, make sure you just order Efudex 5% topical solution for your AKs. It will save everyone a lot of drama.
On second thought, maybe he wants to inject it into his recalcitrant genital warts?

it's unethical of him to write for such a script, from a practice standpoint to an insurance stand point...almost anyway you slice this situation. I don't think any pharmacist would fill such a script and many here will agree with me. I don't think there is one pharmacist in here that would fill this script...it was just a debate on the reason for rejecting it. I don't think you can find 1 single pharmacist in here that had said yes they would fill this script...not 1.

If you want to defend him with sarcasm then I can't stop you. People will judge you for the way you carry yourself...if you want to be unprofessional then that's how you will come across. If you don't respect your prescriptive authority then no one will: the way the each profession in healthcare has deteriorated saddens me but it's people with this laxed attitude on something they've given their oath to uphold....that's why you have NPs and PAs with 2 year degrees prescribing things now....but I went off tangent. Continue on with your sarcasm.

 

[IlDestriero]

Judge all you want, I don't write any prescriptions at all, and I'm not too cheap to see a Derm for AKs, so you won't have any problem with my scripts.
If you find my debate and benign sarcasm unprofessional, you wouldn't have lasted long as a physician.
And as noted on page one, the nonsense I referred to was asserting that his being an ophthalmologist was a valid reason to not fill this rx.

Out of the scope of his practice. Denied.

And it's an odd argument as not only being factually incorrect, I doubt you know or check the specialty of many or any of the hundreds of prescriptions passed over the counter every week. This particular one caught the OPs attention because it was an unusual and off label use. Another thing that happens every day in the real world. When I used to write for things long ago, it had my name, ID number, contact phone number, the Rx and a generic hospital header on a small pale blue slip. I could have been the resident, the chairman, or a retired Professor Emeritus of family medicine or pathology. They all got filled. The computer generated ones may print some kind of department title, but I doubt it. It's not like they come on the department letterhead with all the faculty noted on the side. The ones I can take out of the Pyxis were completely blank generic forms. I had to do that once for some out of system lab test and couldn't use the computer system for that particular patient.

There are other reasons, plenty of them- fraud, not believing he was using it topically, not wanting to dispense IV meds as topical solutions, maybe not dispensing something off label without some discussion or lit search, etc. but not because he was an ophthalmologist. Many in this thread clearly believe that his specialty choice is a valid reason to limit his med options and deny dispensing it. Then they back it up with extreme examples, that may not be valid either really. I'm not making that up, it's right here in the above posts.
I use IV midazolam orally all the time at work for people allergic to red dye. Ketamine as well. We all do. No problem. Same drug, same concentration, just in sterile water and not tasty fake sugar syrup.
PS I agree that it's stupid to write for IV meds for topical use, and it probably is attempted insurance fraud.
Would you dispense topical 5FU cream to him? Without a second thought I imagine. And no staying up at night worrying about exposing his children, etc.
People get radioactive iodine treatments and are released into the world. I think their urine is a much bigger threat.
The fear of litigation in pharmacy for filling valid prescriptions is an interesting angle. Is this a real concern outside of grossly inappropriate use of opiates/benzos or more theoretical?

 

[Old Timer]

Sure you can. This has nothing to do with the doctor. Since you're so keen on laws, cite me a law that says pharmacist are not allowed to do so.

Really, You must have failed reading comprehension. There is no other conclusion that can be drawn. I am the one saying over and over it has nothing to with the doctor. It is within his scope of practice to prescribe it and you should not refuse on those grounds. I will say again. Scope of practice comes from your education and liscensure. Your license allows you to prescribe. Once you have a medical license and you choose to specialize, you do not lose any privileges and therefore an ophthalmologist can prescribe this item legally. I have never said anything differently. If you do refuse on this ground and a complaint is filed with the State Board you will be sanctioned. If the delay in therapy damages the patient, you could be sued. Furthermore in Pennsylvania a retired doctor may keep his license in a Active-Retired state that allows him to prescribe for himself or his immediate family, so the retired part does not come into play in Pennsylvania.

A pharmacist may decline to fill or refill a prescription if the pharmacist knows or has reason to know that it is false, fraudulent or unlawful, or that it is tendered by a patient served by a public or private third-party payor who will not reimburse the pharmacist for that prescription. A pharmacist may not knowingly fill or refill a prescription for a controlled substance or nonproprietary drug or device if the pharmacist knows or has reason to know it is for use by a person other than the one for whom the prescription was written, or will be otherwise diverted, abused or misused. In addition, a pharmacist may decline to fill or refill a prescription if, in the pharmacist’s professional judgment exercised in the interest of the safety of the patient, the pharmacist believes the prescription should not be filled or refilled. The pharmacist shall explain the decision to the patient. If necessary the pharmacist shall attempt to discuss the decision with the prescriber.

049 PA Code § 27.18. Standards of practice. Section C

But many people aren't saying that. People are discussing the dispensing of such a script...not the actual writing of the script.
Yes, you are changing your argument. You've changed your argument from OP being unable to dispense due to scope of practice to now saying that the doctor can write for it. Of course, he can. He's a doctor. He can write for anything. Can't go wrong if you're arguing for the obvious.

Really, you truly cannot read at all. People are saying you can't dispense the prescription soley because the prescriber is not allowed to write the prescription as it is out of his scope of practice.

Out of the scope of his practice. Denied.

You even liked that post.



I have argued constantly in this thread that it is within the scope of practice for the physician to prescribe the medication and the pharmacist should not refuse on those grounds. I have NOT changed my position one iota. As per PA Law stated above the pharmacist may refuse if in his professional judgement the prescription as ordered is not safe for the patient.

And one more thing. If it was out of the scope of his practice, such as a dentist prescribing blood pressure medicine, it would fall under the same section of the law since the order would be unlawful.

 

[steveysmith54]

IlDestriero,
thank you for sharing your knowledge and rationale. I appreciate your calm, non arrogant, and professional tone. I find this very shocking coming from a physician

 

[Lnsean]

Really, You must have failed reading comprehension. There is no other conclusion that can be drawn. I am the one saying over and over it has nothing to with the doctor. It is within his scope of practice to prescribe it and you should not refuse on those grounds. I will say again. Scope of practice comes from your education and liscensure. Your license allows you to prescribe. Once you have a medical license and you choose to specialize, you do not lose any privileges and therefore an ophthalmologist can prescribe this item legally. I have never said anything differently. If you do refuse on this ground and a complaint is filed with the State Board you will be sanctioned. If the delay in therapy damages the patient, you could be sued. Furthermore in Pennsylvania a retired doctor may keep his license in a Active-Retired state that allows him to prescribe for himself or his immediate family, so the retired part does not come into play in Pennsylvania.


049 PA Code § 27.18. Standards of practice. Section C






Really, you truly cannot read at all. People are saying you can't dispense the prescription soley because the prescriber is not allowed to write the prescription as it is out of his scope of practice.
You even liked that post.



I have argued constantly in this thread that it is within the scope of practice for the physician to prescribe the medication and the pharmacist should not refuse on those grounds. I have NOT changed my position one iota. As per PA Law stated above the pharmacist may refuse if in his professional judgement the prescription as ordered is not safe for the patient.

And one more thing. If it was out of the scope of his practice, such as a dentist prescribing blood pressure medicine, it would fall under the same section of the law since the order would be unlawful.

Dude, you said pharmacist aren't allowed to refused a script on scope of practice. I asked you for a specific law...it seems you cannot find one so you quoted a different law and inject your own opinions in there. wtf? lol

You keep asking others to quote you laws but when asked so yourself...you're unable to provide one. Cite me a law that says pharmacist cannot refuse on scope of practice (this is your argument).

I said multiple times you can refuse for a number of reasons, just not for scope of practice.

Cite me a law that says pharmacist aren't allowed to do so. Very simple here. Jesus. Like is it hard to deliver on what you constantly ask of others here?

 

[Lnsean]

Judge all you want, I don't write any prescriptions at all, and I'm not too cheap to see a Derm for AKs, so you won't have any problem with my scripts.
If you find my debate and benign sarcasm unprofessional, you wouldn't have lasted long as a physician.
And as noted on page one, the nonsense I referred to was asserting that his being an ophthalmologist was a valid reason to not fill this rx.

And it's an odd argument as not only being factually incorrect, I doubt you know or check the specialty of many or any of the hundreds of prescriptions passed over the counter every week. This particular one caught the OPs attention because it was an unusual and off label use. Another thing that happens every day in the real world. When I used to write for things long ago, it had my name, ID number, contact phone number, the Rx and a generic hospital header on a small pale blue slip. I could have been the resident, the chairman, or a retired Professor Emeritus of family medicine or pathology. They all got filled. The computer generated ones may print some kind of department title, but I doubt it. It's not like they come on the department letterhead with all the faculty noted on the side. The ones I can take out of the Pyxis were completely blank generic forms. I had to do that once for some out of system lab test and couldn't use the computer system for that particular patient.

There are other reasons, plenty of them- fraud, not believing he was using it topically, not wanting to dispense IV meds as topical solutions, maybe not dispensing something off label without some discussion or lit search, etc. but not because he was an ophthalmologist. Many in this thread clearly believe that his specialty choice is a valid reason to limit his med options and deny dispensing it. Then they back it up with extreme examples, that may not be valid either really. I'm not making that up, it's right here in the above posts.
I use IV midazolam orally all the time at work for people allergic to red dye. Ketamine as well. We all do. No problem. Same drug, same concentration, just in sterile water and not tasty fake sugar syrup.
PS I agree that it's stupid to write for IV meds for topical use, and it probably is attempted insurance fraud.
Would you dispense topical 5FU cream to him? Without a second thought I imagine. And no staying up at night worrying about exposing his children, etc.
People get radioactive iodine treatments and are released into the world. I think their urine is a much bigger threat.
The fear of litigation in pharmacy for filling valid prescriptions is an interesting angle. Is this a real concern outside of grossly inappropriate use of opiates/benzos or more theoretical?

I respect this non-sarcastic tone and your view on it. That doesn't change the fact that this script is unethical in many ways. Whether I checked all the other prescriber's specialty or not has nothing to do with you. That is a liability that I assume. If presented with the facts that OP has presented here, then he would knowingly dispensed a chemo agent written by an ophthalmologist for use that has no evidence/clinical support. That's a judgement each pharmacist has to make...and many here wouldn't dispense it.

As for liability, the victim/lawyers will go after whoever has the money. Sure, the MD will be mainly responsible but since he's retired I doubt he has insurance. Pharmacists have been liable for opiates and benzos but I won't get into that. Walgreens had to introduce a whole new protocol on dispensing opiates because of this (and scope of practice is one of the main reasons that walgreens reject opiates scripts). So, yes, you can reject for scope of practice. Walgreens is doing it everyday.

 

[northeast-southwest]

People use this stuff for planter warts.

 

[Lnsean]

Intersting topic. As a senior surgical resident, I'd be curious to know on what bases you are trained to reject a prescription? This thread seems to run the gamut from "scope of practice" (which several posters don't seem to understand) to "scope of training" (I'm not sure how that's even assessed) to "maybe I could get sued" to "you have to make me feel good that you know what you're doing."

Is it completely personal discretion? And are there no potential liabilities from refusing to fill a legally valid prescription because you don't feel good about it? I recall some controversy about birth control a few years ago that revolved around some of these issues.

Sure, there is potential liability for both rejecting and filling a prescription and that's the decision that has to be weighed. This is what's happening here. I think there's maybe 1-2 pharmacist in here that said they probably would fill in OP's scenario in consultation with the MD....most have said they would reject it.

I don't think it's personal discretion...more so professional discretion. Just like there is professional discretion among prescribers to not be frivolous with their prescriptive authority there is also discretion among dispensers to not be frivolous with their dispensing authority. There's an MD in here who commented that in OP's scenario with the opthamologist, it would be at the very least some type of insurance fraud...yet it still condones it...and then implies that pharmacists are unprofessional for refusing it? Really?

The birthcontrol thing? It's probably religious-based reasons for rejecting it and that's not professional. I don't think it had to do anything with scope of practice or the safe dispensing of medication.

 

[IlDestriero]

No, not exactly chief. We don't really know why the OP's physician wrote it the way he did, or what he said he was using it for. The OP never came back and filled in the blanks.
Maybe it has nothing to do with insurance fraud, though it's a possibility. And I've repeatedly said that you can refuse it for several reasons noted above, or because it's Thursday, or the guys cologne is offensive and you reserve the right to refuse service to anyone for any reason, but not because he's an Ophthalmologist and this drug is outside of his scope of practice.
Good luck with all your future NP scripts, there the ones you really want to second guess.

 

[Lnsean]

No, not exactly chief. We don't really know why the OP's physician wrote it the way he did, or what he said he was using it for. The OP never came back and filled in the blanks.
Maybe it has nothing to do with insurance fraud, though it's a possibility. And I've repeatedly said that you can refuse it for several reasons noted above, or because it's Thursday, or the guys cologne is offensive and you reserve the right to refuse service to anyone for any reason, but not because he's an Ophthalmologist and this drug is outside of his scope of practice.
Good luck with all your future NP scripts, there the ones you really want to second guess.

Of course a pharmacist can refuse it because an opthamologist is writing for a drug outside his scope of practice...it's part of our professional judgement and due diligence. It has nothing to do with his prescriptive authority. We do this all the time, especially for pain medications. If you're not a pain management doctor and you write for oxy IRs month after month, Walgreens will deny you for scope of practice. They'll even send out a letter saying they will no longer fill pain scripts written by you. I know CVS has sent out these letters as well near my area. How about that?

If it was as straight forward as you have said, OP wouldn't come on here to ask for everyone's input in making his decision. He would just fill it at face value.

And I've repeatedly said that you can refuse it for several reasons noted above,

This was not your original argument. If i scrolled up to the beginning of the thread, you were very adamant about the opthamologist's prescriptive authority and that his rx should never be refused because he has a "medical license" to write for anything.

If you're conceding that point now, then it's really all about semantics now at this point.