WhiteCoat

Greedy or Necessary?

Mrs. WhiteCoat had a patient issue and doesn’t know how to proceed, so she asked me to post the case for other people to comment upon.

A patient came to her practice 2 years ago with thyroid problems. She had been seeing an endocrinologist for several years before seeing Mrs. WhiteCoat and even the endocrinologist was having problems controlling the patient’s thyroid using medications. On the first appointment, Mrs. WhiteCoat performed an exam and found a thyroid mass which ultimately turned out to be cancerous. She referred the patient to an ENT surgeon for thyroid removal. The patient never followed up with Mrs. WhiteCoat after that.

A few days ago, the patient sends Mrs. WhiteCoat an e-mail saying that she is doing well and asking Mrs. WhiteCoat to call in a refill of the patient’s thyroid medications. Mrs. WhiteCoat wrote her back and said that she had not evaluated the patient since having her thyroid out almost 2 years ago, that she has no idea what the patient’s latest thyroid labs showed, and she doesn’t even know the patient’s medication dose. She stated that she wouldn’t call in a refill without seeing the patient in the office, examining her, and going over the patient’s labs with her.

The patient wrote back that she had “normal” thyroid labs in February and has been on the same dose of thyroid medications for the past year. She couldn’t afford to miss work any further, doesn’t want her thyroid to get out of control again, and appreciated Mrs. WhiteCoat’s understanding in calling in the prescription.

There are two ways of looking at this.

One one hand, the patient is probably stable after having her thyroidectomy and most likely will be continued on the same dose of medication if she does come in for evaluation, so an office visit would likely be low yield. That being said, when things go wrong, nobody thanks you for cutting corners to save them money. If the thyroid cancer returns, or if there are signs of metastasis somewhere and they are missed, then what happens?

On the other hand, some people may think that requiring patients to come to the office under circumstances like this is just being “greedy.” Mrs. WhiteCoat has student loans, office workers, office lease, malpractice insurance, and a dozen other expenses that she has to pay in order to keep the office running. If she provides free telephone services to all patients, then soon there may no longer be an office for patients to call for their refills.

I suggested that if another doctor is ordering lab tests on her, that doctor should be refilling her medications.

We kind of touched on this issue in a previous Open Mic Weekend, but now it’s a real situation.

What should she do?

40 Responses to “Greedy or Necessary?”

  1. My vote:

    1. Offer to fill a week’s prescription if the patient provides a copy of most recent labs. This way the thyroid won’t get out of control.

    2. For a prescription beyond that, the patient would have to come in for an office visit.

  2. Erica Rose says:

    I work in Family Med, and there’s no way she’d get a refill in my office. If she was making her come in for monthly f/u’s despite normal labs, yes, that would be greedy and wrong. But 2 years?! That is a long time. Pt needs to be seen, end of story.

  3. it's just me says:

    There is no way on the planet I would refill her meds without seeing her and doing new labs. It would be malpractice in my book, not to mention indefensible in court should there be any kind of negative outcome.

  4. Cienna says:

    As a fellow thyroid patient:

    You call the doctor that has been ordering the labs and prescribing the medicine. Not a doctor you saw 2 years ago. If you want the doctor from 2 years ago to fill the prescription you must first re-establish care. Also if the labs are more than 6 months old and not ordered by this physician, expect labs to be ordered.

  5. PJ says:

    I like Reflex Hammer’s solution. February labs faxed to the office and reviewed, one week’s prescription (assuming Mrs. Dr. WC can see her within that timeframe). I would also make a require of the office visit that there be new labs drawn and resulted/available before the office visit.

    I say this as someone who is not a physician, but who works extensively with physicians. I will occasionally seek medical advice/guidance (such as when I took a machine-pitched softball to the right testicle a few months ago) from these colleagues, but would never dream of asking for any kind of prescription without a proper office visit, which is always done through my PCP.

  6. peter says:

    I can’t see how this person would want to risk missing another cancer. I’d explain to the patient that with her history, she has to come in and be examined and tell her I personally don’t want to take the risk of missing a cancer that could kill her.

    Mrs. WC has no way of knowing what’s going on with this patient, and without that information, how does she know that the meds are working(plus the bad business aspect).

  7. Liz RPh says:

    I tend to agree with you – that the doctor that ran her labs is the one that should be refilling her medications. And, if that doctor isn’t available/etc., I’d be curious to know why not.

    I don’t think it’s unreasonable to require that the patient be seen for any prescription – although the week supply is a possible compromise. Of course, I’ve also seen patients try to refill their old dose – because the new dose “doesn’t work right” – even though their doctor specifically adjusted their dose in response to their labs.

    Anyhow, yes, I’d be curious to why _why_ this patient is unable to see her PCP to handle this issue, on top of everything else.

  8. Snarky Scalpel says:

    Refill without an exam? After two years? Hell no.
    Around here, you can get a prescription for up to a year’s worth of meds, but only for certain classes of meds and only if you meet certain criteria regarding how stable your disease is. Why not others? Oh, I don’t know, maybe because you actually need supervision to be taking meds? Because things change and it takes your doctor to notice that and adjust meds -appropriately-?

  9. Jordan says:

    People seem to forget that patients have a responsibility in the doctor-patient relationship as much as the doctor does. That responsibility includes keeping regular appointments and managing your supply of medication (and not leaving it until the last minute).

    As a pharmacist, I commonly have encountered this scenario at the dispensing end – “can’t you just refill it this once?” There are true emergency scenarios that probably dictate bending and doing the right thing. This isn’t one of them!

  10. Placebogirl says:

    I have a different solution. If the issue is that the patient cannot miss work, then offer to see the patient outside her work hours. This way Dr. Whitecoat (Mrs) can see the patient and satisfy herself that the patient is doing well, and the patient’s needs are also met. If the patient cannot find a time outside work hours, then perhaps she needs to find a doctor closer to her work.

  11. Tanja says:

    If she is on the same meds for a year, that means Mrs WhiteCoat isn’t even the one that set the meds, as she last saw the patient 2 years ago. I agree with giving a short refill (1-2 weeks) to enable the patient to find a time that works with her schedule, but for more than that, she’d need to come in.

  12. susanders says:

    I am a clinical medical librarian who works with physicians and students in a hospital. Who ordered the February labs? Pt “should” know better, and request refill from the physician who has been following her for the past 2 years. Hammer’s solution sounds safe; however, it’s not likely any of my physicians would go out on a limb that way, and if I were Mrs. WC, I would not either.

  13. JustADoc says:

    There isn’t even a debate. Pt has to be seen.
    Pt can call the doc who ordered the labs in Feb or pt can come in.
    Pt has had a major change in the condition she wants treated since last seen.

  14. GUy Fogel MD says:

    Patient must be seen to get meds. Doctor’s family has to eat too. Dr. doesn’t make anything by calling in Rx. Dr. doesn’t make anything for phone calls, emails, blog posting, and worrying about this stray lamb anyway. I postulate that the patient is suing the initial dr for missing the cancer and has developed a laisse faire attitude about all doctors. Just saying…

  15. Raf says:

    Agree with all: pt has got to be seen. Invite pt to pick up repeat ‘scrip in person and do a quick once-over, maybe? “I appreciate how busy you are but I really can’t prescribe for someone I haven’t seen in almost/exactly/over 2 years”. Offer any solution that might make it easier for the pt to get seen: evening clinic, first appointment of the day, lunch-time slot.

  16. Jaime says:

    No medical person here, but I would not fill the prescription. One, if on the rare chance something was out of the norm and no one caught it, Mrs. WhiteCoat would probably be held responsible, not to mention feeling guilty (I would at least.)

    The bigger question is if another doctor order lab work, why hasn’t that doctor filled the prescription? Ask for the lab results, and consult with the other doctor to see what’s going on.

  17. CD says:

    I’m a thyroid patient, not a doctor. No reasonable patient would expect a refill in these circumstances. Now, if the patient comes in once a year for a few years and is stable on the same dose, the issue would be different.

  18. SonoTek says:

    My veterinarian won’t even prescribe a de-worming pill for my cat if she hasn’t seen her in the past 6 months.
    Wonder why she is not contacting the prescribing physician?

  19. Vagabond Rx says:

    Here’s the pharmacy POV: tell the pt to call her pharmacy. Pharmacy can then fax the original prescriber for a refill or, if the physician doesn’t do faxed refills, the pharmacist can do a one-week supply at the last known dose to give the pt time to make an appointment to see the Dr. In my (Canadian) pharmacist’s opinion, this doesn’t need to be the physician’s headache at all, especially the physician who hasn’t seen the pt in 2 years.

  20. Leslie says:

    I have no medical education but I am a levothyroxin user due to an irradiated goiter 12 years ago. My doctor requires that I have my TSH levels tested once a year. I get a 90 day + 3 refill prescription which lasts the year.

    I would never expect a doctor, who hasn’t seen me in 2 years, to prescribe a medication of any sort for me.

    Dr. Mrs. White Coat should stand firm in her stance of proper prescription practice. No patient should ever compromise her standards.

  21. ndenunz says:

    The second you call in a prescription you have now re-established the Dr./patient relationship and you are now on the hook for anything and everything. So, in my opinion, no prescription until the patient makes an appt. and keeps it.

  22. hashmd says:

    Our state’s prescribing laws basically say that a good faith exam MUST occur prior to providing a prescription.

    The simple writing of the prescription will presume an ongoing doctor-patient relationship. Should the patient sue for ANYTHING, even unrelated to the prescription, Mrs. Dr. Whitecoat will be named in the suit.

    The first question her malpractice insurer will ask is, “When did you last examine this patient prior to writing that prescription?” Her answer of “Two years” will prompt an immediate attempt to settle, as her prescribing was indefensible. They may even drop her coverage.

    Then our Medical Board would step in, after being clued by the suit, and either reprimand her or suspend her license for improperly prescribing without a good faith exam. They will multiply it by all the other times she wrote ANY script without a prior exam, making it appear as multiple counts of improper prescribing.

    Then more dominoes start falling…she will lose her hospital privileges, she will then lose most if not all her insurance contracts including Medicaid and Medicare.

    She will then be without a livlihood…

    All for writing a presciption in the situation being discussed.

    THAT IS WHY WE MUST INSIST ON AN OFFICE VISIT AND DOCUMENT IT. It is not greed, it is the only way to make the action defensible in court! A “quick lookover” while picking up the prescription is not defensible either. Only a formal, full-fledged office visit with vitals, weight, etc. is acceptible in the court of law.

    That is how lawyers make everything more expensive and formal for all of us.

  23. throckmorton says:

    This patient had thyroid cancer. It is essential that she be on the correct dose of thyroid medication and further needs to be carefully followed. It must be firmly established who is following her for her cancer and she needs to be certain that the patient is having follow up. The patient is calling around trying to get someone to call in a script. I would bet she has called the ENT, endocrinologist, and every other doctor that she has ever seen. I would tell her that she needs to be seen by whoever is following her for her cancer.

  24. WhiteCoat says:

    Wow. I didn’t think this many people still read my blog.

    A little more of the back story based on the comments –
    apparently the ENT doctor has been treating the patient and writing thyroid meds up until this point. Now, after deeming the patient “stable” and cancer free, he recommended that the patient follow up with her family physician and return if any problems.

    Thanks to everyone for all the insight. Many comments made both of us laugh while reading them.

    It’s good to be able to do a reality check once in a while.

    Hmmmmmm. This worked so well that I may continue doing it for other topics …

    If you have a decision like this, e-mail me with the details and I’ll post it for discussion.

    • hashmd says:

      I’m surprized Matt has not ripped me a new one for my comment, like he does when you make comments about the legal profession.

  25. Ardosa says:

    First question – who ordered the lab or did she walk into a ‘pay and get your labs done’ place.

    second – who has been the one on the script for the last year (or two!)

    There are enough physician offices with ‘off shift’ style hours (mine has appointments some days as early as 6 some days as late as 8) just to help with these kinds of patients.

    She’s opening herself up for too much liability by refilling the script, in my humble, pharmacist’s opinion

  26. Essay says:

    It’s a no-brainer for me. As a veterinarian I can lose my license if I prescribe without a valid doctor-patient-client relationship. That means that I need to have seen the patient in question at least once in the last twelve months and need to have discussed the situation with the animal’s owner. No visit, no script. Making an exception even once, even for some regular medicines like insulin or levothyroxin only opens the door to further expectations and potential abuse. I assume it’s the same for “real” doctors, except that patient and client tend to be the same individual, which would make life a tad easier. It just isn’t worth building expectations for repeat scripting from the client, and it sure isn’t worth my license.

  27. T. Hunt says:

    WOw! I’m just a 62 yo retired mechanic and I know the answer to this one without even breathing hard. What is absolutely incredible is that you even ask the question. Both you and Mrs WC went through medical school and all that, right? I mean, you didn’t get your diplomas on the internet did you?

    Of course the woman has to come in! Or she should be advised that she should contact her current physician for refills.

    And there is no one who cannot miss work. Not for this kind of thing.

    I read blogs and websites like this one because I think that the people writing them are smarter than I am, so I stand to gain a little something. I can think of a lot of reasons not to write the perscription. What I can’t think of is ANY reason why you would.

    Tom

  28. Emily says:

    I agree with everyone else. No way.

    Mostly I wanted to comment to because it made me smile when you noted that you were surprised that this many people still read your blog. I’m not much of a commenter or participator, but I just wanted to tell you that your blog is a must-read for me and I get bummed if I go more than a few days without a WhiteCoat update. I learn a lot here. Keep writing! Long live WC!

    P.S. – Also not a physician. ED nurse.

    • it's just me says:

      Agree…I am more of a lurker, but I read every post. Some things drive me out from my cave every now and again.

  29. Cray says:

    Thyroid patient here. Glad the situation was resolved, but anyone who has been seeing a doctor (or doctors) for their thyroid for 2+ years should know this type of request is asinine. A doctor unfamiliar with your thyroid will (almost) never write a script without examining the patient first. Pt should have offered to have their specialist consult with your wife, at the very least.

    Looking forward to more posts like this! Very enjoyable!

  30. pat says:

    if this were for a controlled substance you’d not be asking this question i’m guessing? that is a bit different but not really. or substitute some other drug that requires frequent monitoring, warfarin, etc. , add to that need for good faith exam, i think the answer is “no”. no one WANTS to take time off work for appts but….. her history now includes a significant event not previously documented in her records at your wife’s practice.

  31. Chris says:

    I’m not a lawyer, just a paralegal with 20 years experience working for a med-mal attorney – NO SCRIPT, no way, without an office visit. Way, way too much liability. You have absolutely no way of knowing what, if any, treatment/meds this patient has had in the last 2 years.

  32. MamaOnABudget says:

    I’m one of the thyroid patients who has asked about this in the past. My issue was that I had to go in to see a doctor to get a labs prescription to then go back for a second appointment to discuss the labs/get prescription. I didn’t think the first appointment was necessary – but I’d NEVER question the labs discussion/Rx appointment at all.

    Who prescribed the labs earlier this year? That’s who she should be calling. If that doc wants her to come back in, she could ask your wife to call in lab orders, but not a prescription at this point.

    • Cape Cod Stepmom says:

      As a patient I’ve had labs callled in or have a standing order. No appointment needed. Now I must go in to discuss he results and sometimes it leads to future labs….

  33. eqvet2015 says:

    YES I still read your blog; in fact, I used to have much more time to read medblogs (darn vet school and studying), and yours is now one of only a couple that I check on regularly. I like reading about things are on the other side of the species divide. Some topics are applicable to non-primates, and others are important to me as a citizen and consumer of healthcare.

    Not much to add here, but if a physician (or veterinarian) can’t charge for their medical expertise, cognitive abilities, and time spent considering a patient’s case to come up with the proper diagnosis (as needed) and treatment plan, how ARE they supposed to make a living? And, as mentioned above, it would be both unethical and illegal to write a prescription without a physician-patient relationship for the problem being addressed.

    • DefendUSA says:

      Hey EqVet…I’ve got a question for you…I pay bills for a client. This dog gets 100mg of Tramadol daily…it’s a smallish dog probably 25 pounds…If I didn’t know better, I would say that Diego’s mama is stealing from the pooch…because I had a medium grade sprain and I barely got 25mg for five days!!

  34. Emergencyfltdoc says:

    No visit, no refill.

  35. DefendUSA says:

    In this case? No way. 2 years with no contact at all is a long time. Maybe a consult with the ENT could have sufficed for a temporary week’s worth, but nope. That is different than being seen and monitored by the same physician who would not prescribe meds unrelated to blood tests that were needed.

  36. Teresa says:

    I would not even give her the 1 week as some have suggested. This is a totally ridiculous request.

    Oh, by the way, patients don’t need doctors to order labs. We can order some of them for ourselves now.

    In any event, there is no question in my mind that greed has nothing to do with this.

    Mamaonabudget, you should not normally need 2 visits for something like this. My doctor will see me, do the exam, and order the lab on one visit. Then he gets the results and, if necessary, calls in a prescription for me. I don’t have to go back to discuss the results, and if I have a question, I can get an answer from him through his nurse. Normally all of the discussion takes place in a single visit.

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