Search Results for 'Interaction '



I Hate to Encourage Pharmacy Shopping, But I Have to

In a perfect world, patients have one primary care doctor who knows what their specialist doctors are doing, prescribing and recommending, and one pharmacy that watches out for interactions between their treating physicians’ prescriptions.

But sometimes I just have to tell my patients to shop around for their medications, even though that creates some risks.

I have many patients without prescription insurance. Some of them are on our sliding fee program and also qualify for free drugs from the pharmaceutical companies. We call that prescription assistance. A coordinator within my organization helps patients apply for this and they may get several different brand name drugs from different companies. It is obviously up to me to make sure there are no interactions between the drugs I prescribe. But if such a patient fills a new medication at the pharmacy from an emergency room or specialist doctor, there is no one watching over this, because no one has that kind of information.

The other day I saw a new patient who had quit his job and moved to Maine. Six months from now he will have Medicare, but right now he is without insurance. He is a diabetic and takes half a dozen medications. He uses Walmart, which made sense to him as he was moving from one state to another and was able to transfer his prescriptions. But one of his latest prescriptions was an expensive diabetes medication. Alogliptin was one I had never heard of, but because sister drugs usually end with the same syllable, I deducted that it was a generic in the same family as Januvia.

This drug costs over $300 per month at Walmart. The discount website GoodRx has coupons for different pharmacies. The Walmart coupon brings the cost down to $160.63, but there is a better deal at $94.57 with Walgreens.

So I refilled his metformin and glipizide at Walmart and sent the alogliptin to Walgreens. The next day I got a call from the Walgreens pharmacist, asking why I had a diabetic on such a fancy drug as monotherapy instead of something more basic like metformin or glipizide. I told him the patient was on both, but at Walmart.

Continuity of care isn’t just a provider issue. It is also a pharmacy issue. We sometimes forget that. But it can come with a cost to the patients because of wide variation in drug prices. And this isn’t just for people without insurance. Medicare patients regularly end up in the benefit gap we call the doughnut hole, when their Medicare D prescription benefit is exhausted partway through the year. Those people, too, will find the best deal they can with competing pharmacies.

The Healing Power of Even Virtual Human Connection

Almost two years into this new age of varying degrees of self quarantine, I am registering that my own social interactions through technology have been an important part of my life.

I text with my son, 175 miles away, morning and night and often in between. I talk and text with my daughter and watch the videos she and my grandchildren create.

I not only treat patients via Zoom; I also participate, as one of the facilitators, in a virtual support group for family members of patients in recovery.

I have reconnected with cousins in Sweden I used to go years without seeing; now I get likes and comments almost daily on things that I post. I have also video chatted with some of them and with my brother from my exchange student year in Massachusetts 50 years ago.

I have stayed in touch with people who moved away. And I have made new friends through the same powerful little eye on the world I use for all these things, my 2016 iPhone SE.

Members of my addiction recovery group stay in touch with each other via phone or text between clinics. They constantly point out the value of the social network they have formed, even though they only meet, many of them via Zoom, once a week. The literature has supported this notion for many years and is very robust: Social isolation is a driver of addiction.

It is also a driver of cardiovascular risk and is thought to be a risk factor of the same magnitude as smoking.

But, do new, online friendships mean as much for our health? This is probably a question that is too new to be answered. How many of these relationships can transition and deepen over time and through different stages of life? Suzanne Degges-White, PhD, writes cautiously about this in Psychology Today.

In 2017, pre-pandemic, Frontiers in Psychology reported that people who spent a lot of time on the Internet were more lonely than people who used the Internet less. But that was in a different era, when in-person relationships were a more practical and safe option than they are today. Back then, the heavy users of the Internet were possibly a self selected group for entirely different reasons than today’s high utilization demographic.

But with the fragile state of affairs, exemplified by the revolving door of new coronavirus mutations – of which Omicron is unlikely the last one – we probably need to make the most of whatever means we have to stay in touch with family and friends. Not so much that we neglect the necessary solitude we all need for introspection and self care, but enough to feel connected in some way to the human race.

“I Thought I’d Wait Until My Appointment”

It happened again. A sick patient needed to be double booked this morning. Looking at my schedule, I saw Gordon Plourde had his six month diabetes visit today. He is well controlled, takes as good care of his health as his impeccable lawns and gardens.

“Have her come when Gordon is here, he’s usually a quick visit”, I told Autumn.

As soon as I walked through the door I knew this wasn’t going to be a quick visit. Gordon had lost a lot of weight. His blood sugars were up and he started telling me about all the symptoms he’d been having the past couple of months.

“My wife kept bugging me to call you, but I figured I’d wait for my appointment”, he said. “I probably should have listened to her.”

“Probably”, I answered. What more could I say?

His visit ran over, as did my double booked patient who had done what I wished Gordon would have done. It took a few hours before I caught up. But I did, and everybody was understanding.

Tonight, over barn coffee with the animals, my random thoughts returned to this morning’s patients.

Some people have a rigid view of when they need to see us – every so many months, whether they feel well or very ill. That is not good. Have we, as a profession, fostered such an inflexibility? Or is it procrastination, or maybe for cost reasons, although so many of my patients have Medicaid or Medicare with supplemental insurance and virtually no copays.

I have experimented with letting patients decide when to come back and often seen that this doesn’t work.

I have said “Come back in three months, but if all your blood sugars are good, you can push your followup out to six months. That just seems to confuse people, so I almost don’t do it anymore.

If we had more staff, and if we were capitated (payment per member per month) or paid for outcomes (although risk -possibility of losing money – isn’t something a small group or clinic might dare to get involved with), perhaps we could reach out to patients with chronic conditions and see if they needed to come in or not.

Even though I like the old fashioned, patient centered interaction once I’m in the room with my patients, the surrounding clinic routines can seem old fashioned in a bad way.

The “Patient Centered Medical Home” was supposed to fix all that, but the rules were stilted and ultimately counterproductive. For example, you HAVE TO use the EMR for things like educational handouts, even if the old fashioned preprinted handouts have better information. And you get credit for keeping open same day slots but not for squeezing people in, like I did today.

So, since I can’t change the system, I’ll have to work harder at reminding patients that three or six months until the next appointment is the plan AS LONG AS THERE IS NOTHING NEW GOING ON.

PCMH Certification and Designing the Perfect Car

Three Challenges in the Art of Prescribing Warfarin

The blood thinner we have used for so many years is gradually being replaced by the novel anticoagulants, which don’t require laboratory monitoring and have fewer interactions. But for some indications, warfarin is still preferred and for many patients, it is still by far the more affordable anticoagulant.

Dosing warfarin has always been an art and it seems to be less often mastered than it used to be. The three challenges are drug interactions, food interactions and dosing schedules.

DRUG INTERACTIONS

Just the other day, I was covering for a colleague and got an urgent message that her patient had a supratherapeutic INR – too much thinning of his blood. I asked the medical assistant to find out if the patient was taking any new medications, like ciprofloxacin, that might interact with the warfarin. I just threw that drug name out because it is such a common and overlooked interaction. Sure enough, somebody else had prescribed ciprofloxacin two days earlier for a urinary infection.

I played detective and tracked down the urine culture, which showed the coli bacteria were resistant to ciprofloxacin, but sensitive to nitrofurantoin (safe) and Bactrim (unsafe). I messaged the prescribing provider, who changed the patient’s antibiotic to nitrofurantoin, so I just ordered the warfarin held for two days.

Many providers seem to be unaware or less paranoid than I am about drugs that interact with warfarin. I once had a patient end up in the intensive care unit with critical internal bleeding because I prescribed levofloxacin with plans to check her INR every couple of days during her antibiotic course. That was clearly not cautious enough in her case.

I have seen great variability in how much other drugs affect the effect of warfarin, especially azithromycin, amoxicillin-clavulanate and also acetaminophen and prednisone, both of which in most people doesn’t seem to cause much trouble. But I worry about all of them, plus sulfamethoxazole, metronidazole, fluconazole, NSAIDs (obviously) and new starts of amiodarone, sertraline, carbamazepine and many others. Over the counter agents to worry about include fish oil, ginkgo biloba and St Johns Wort.

This is not a complete listing, and since most of us have EMRs that warn us of interactions you would think close calls like this would never happen. The problem here is the multitude of basic warnings providers know in their sleep, so that the less famous issues drown among the unnecessary alerts (see my posts about Alarm Fatigue).

I end up using epocrates’ interaction checker on my iPhone to double check sometimes, but, as I said, I’ve been burned so I know this stuff know.

FOOD INTERACTIONS

Warfarin interferes with the role of vitamin K in the coagulation process. Therefore, if you flood your system with foods rich in vitamin K, which is the pharmacological antidote to warfarin, you decrease the effectiveness of warfarin. A week before my ciprofloxacin case, one of my own patients suddenly had a low INR. “Ask him if he’s been eating fiddleheads”, I told Autumn. Sure enough, this Maine spring delicacy was the culprit. The season is short and he wasn’t going to have more, he said, so I didn’t change his dose schedule.

A lot of people are under the impression they cannot eat green vegetables while on warfarin. I tell them that’s like saying you can’t open your windows in the winter if you heat with wood. Imagine you know how many logs to put in the wood stove at certain outdoor temperatures. Then imagine you decide to open a window now and then. You would then have to adjust your fire whenever you opened the window, compensating for the heat loss. If you instead decided to leave a crack open all the time, you would quickly figure out your new firewood budget.

So I simply tell my patients, “eat all the greens you want, but be sure to keep the amount the same every day”.

DOSING WARFARIN: DON’T DRIVE LIKE YOU’RE MR. MAGOO AND PLEASE LEARN FROM YOUR MISTAKES

Mr. Magoo is like me without my glasses. If I were to drive in a snowstorm without my glasses, I would only see a couple of feet in front of me and I would be turning my steering wheel a lot more than necessary. I wouldn’t be able to tell if I was entering a small or a big curve, for instance. If I could see further ahead, I would make smaller corrections. Many providers will look at the current INR value and the previous one, and the current warfarin dose. Then they change the dose. Unless you have a flowsheet that tells you that the last time you made that change, bad things happened, you will make the same poor choice again. On paper, such flowsheets are easy to maintain, but – believe it or not – in many EMRs it is just too darn cumbersome to do.

I have a three ring binder with all my warfarin patients’ flowsheets. It helps me avoid Mr. Magoo type errors and it also serves as a low tech way of making sure no warfarin patients fall off my radar screen. Autumn or I sometimes just flip through the binder to make sure our flock doesn’t wander off, so to speak.

An old fashioned method of managing an old fashioned medication…

The Parallel Realities of Health Care: Ratio and Intellectus

Every patient is unique, with some common basic and measurable features and parameters. For a couple of decades now, healthcare has professed to be patient centered. But the prevailing culture of “quality” (and the reality of getting paid for what you do) has us spending at least half our time documenting for outsiders, who are non-clinicians, the substance and value of our patient interactions. That means our patients get half of our attention and others get half.

But of course, if you really wanted to be patient centered, you’d have to ask what patients actually care about, like their blood pressure or their cholesterol, their anxiety or their sore knees. Their answers may not align with the payers’ priorities. And then what…

Parents raise their children and never have to file any reports on how they do it. I believe clergy can still counsel their parishioners without filing reports. But doctors, nurses, nurses aides and physical therapists are trapped in the tyrannical dichotomy of “If you didn’t document it, it didn’t happen”, which actually forces us to do less for our patients just so we will have time to document what we did do. We are, to varying degree, robotniks in a big, inhumane corporate and federal healthcare billing machine these days.

Perhaps the most striking example of the micromanaging and patient-uncentered mandates we are subjected to is the Medicare Annual Wellness Visit: Miss one thing, like offering HIV screening to 80 year old devout French speaking, monogamous Catholics in Van Buren, Maine and risk getting your payment retracted. But we are not mandated to ask about personal life goals or how to balance seniors’ independence with reliance on their children.

Which is more real? The work we do, face to face or even screen to screen, behind closed doors with our patients, or the EMR documentation we produce as a result of those encounters? I know many providers generate voluminous notes that don’t reflect in any way what happened in the visit. That is where the money is.

Right now I am reading a Swedish book by philosopher Jonna Bornemark, titled (my translation) RENAISSANCE OF THE UNMEASURABLE – battling the pedants’ world domination. Much of it is about how the professions of caring for others have been reduced to protocols and reporting systems that make it harder to do what we were trained and developed a passion for. It talks about how checklists and workflows devalue and discourage the powerful creativity that arises when professionals interact with their unique clients and with each other. She anchors all this in the writings of philosophers Cusanus, Bruno and Descartes. It talks about the unknowable, which is something pedants usually don’t want to think about.

Basically, according to Cusanus, there are two models of knowledge, Ratio and Intellectus. Ratio is the possession of measurable and definable information, which basically fits with generalizations we humans make. Beyond that is what is not known. Our modern way of thinking is perhaps that this is simply what we don’t know yet, but eventually can learn or understand. Intellectus is a form of curiosity that scans the horizon of the known or knowable. It asks “what is” and can thereby sometimes make classification and counting possible, but far from always.

People who have Ratio but completely lack Intellectus, Bornemark describes as pedants.

Pedant is a common word in the Swedish language, but not so common here. It means someone with superficial knowledge, focused on perfection of form rather than substance. Words like stickler, nitpicking and OCD reverberate with the notion of the pedant. The Intellectus archetype is what professionals have always strived to emulate.

(Bornemark has a few books available in English that I know of. She is the editor of one with a title that really intrigued me, EQUINE CULTURES IN TRANSITION – Ethical Questions.)

Henrik Sjövall, professor emeritus at Gothenburg’s department of molecular and clinical medicine (that sounds like the title of a man who knows both Ratio and Intellectus) writes:

Bornemark’s discussion of Cusanus’s concept of Intellectus centers on the distinction between the unknown and that which is not yet known. She notes that Ratio accepts only the latter, because according to Ratio, everything can be measured and weighed provided you have sufficiently good methods, which in principle can replace the “flummery” of Intellectus. Intellectus responds with the circle metaphor: a polygon will never be the same as a circle. Oh yes, it can be, provided there are enough of sectors, Ratio responds… Then tell me what a patient’s narrative weighs, says Intellectus. It simply consists of the answer to a lot of yes and no questions, Ratio retorts, and it is dead easy to measure.

He continues:

Bornemark writes that Ratio has, in principle, already won that battle and Intellectus is in retreat, as most people consider him difficult. A manifestation of this is all these algorithms and patient care plans with checklists that inundate us. Triaging in the emergency room is part of the same way of thinking, a rough sorting based on the outcome of a number of objectively measured vital parameters. The next step in that chain is, of course, the introduction of artificial intelligence as interrogator and information sorter, and maybe eventually as a decision-maker without the patient having to meet a doctor at all…

It would be cheap and good, right?

What are the counterforces to this development? I am active in the Swedish Association for Narrative Medicine (anyone interested is welcome to join), an association that wants to focus on something that cannot be measured and weighed, namely the patient’s story. We are making an effort to stop or ideally reverse this development. In other words, to train Intellectus doctors.

I read in the Wall Street Journal about a forthcoming book about living with autism – not being able to fully understand the nuances of facial expressions and intonation, for example. It seems to me that those things are exactly what good clinicians excel in. Such things make them Intellectus practitioners and elevate their work to a level beyond Ratio, the territory some hope will ultimately be the domain of Artificial Intelligence. I, for one, don’t think AI will ever move beyond Intelligence to Intellectus.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

BOOKS BY HANS DUVEFELT, MD

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