A Country Doctor Writes:

This is a request I am getting electronically more and more often from pharmacies. I usually turn it down. Let me explain why.

For medications the patient is already on, I pretty much always refill them for a whole year in 90 day increments. Some people get their medications bubble packed in 4 week increments, and then I do the refill for 28 days with 12 refills.

But the reason I turn down the electronic requests I get from pharmacies to change my 30 day script to 90 days is that I have issued a new prescription that requires some kind of monitoring.

New starts of furosemide will require a potassium level and possibly a creatinine before the first 30 days are up. The same is true for spironolactone, in this case because it can raise potassium levels and carries a greater risk for causing kidney damage. The same is true for lisinopril, an ACE inhibitor, as well as the newer angiotensin receptor blockers. I had my own near miss with lisinopril more than 10 years ago, chronicled here.

A new start of a modern antidepressant, like the SSRIs, requires a clinical followup within a few weeks to make sure the patient isn’t getting suicidal or hypomanic. Even a 30 day script without followup is pushing your luck. 90 days in a non compliant patient missing their followup is medicolegally indefensible.

The other day I increased a PTSD patient’s prazosin for nightmares from 1 to 2 mg and sent in a 30 day script for the new dose. She still had some 1 mg capsules left. I neglected putting “FILL WHEN CALLS” on the “Sig” of the script. Boom, instantly the pharmacy shot off a “Patient requests 90 day script” refill request. You can’t split a capsule in two if, after a little while, you decide the higher dose doesn’t agree with you. In this case I authorized the 90 day script ONLY if they didn’t fill it until the patient had used up all her 1 mg capsules at two per day and knew that this dose agreed with her.

My bottom line is:

I am the doctor. I know what I’m doing. I work hard to save my patients money, and look up costs and copays every time I prescribe a new medication. Just like I carefully choose the medication and the dose, I deliberately choose which amount is appropriate for the situation.

So often, I note that my middle aged patients slowly gain weight between visits. It is a recurring topic during routine physicals. I call it the middle age creep and I make a big deal of it. I warn my thirtysomething male patients with budding potbellies that this doesn’t get any easier to get rid of later in life.

People often assume that our metabolism slows down in middle age, but that is not the case. And middle age creep isn’t always a case of decreased physical exercise. It is usually, quite simply, an excessive caloric intake. This was demonstrated recently in a big study published in Science. I read about it in my Swedish morning paper.

There are many reasons we take in more calories than we need. We may snack, we may indulge in sweet treats, we may drink caloric beverages that we desire, from juice and soft drinks to beer. And we may eat “fast foods” that generally contain more calories than a home cooked meal.

Judging from the cars idling in the right hand lane of Bennett Drive in Caribou, waiting to pull into McDonald’s at supper time, it’s not just people bringing their kids for a Happy Meal who eat their dinner this way.

I often bring up the concept of stewardship along with the middle age creep. Call me paternalistic, call me moralistic, but if we can talk of how our behavior and consumption are causing global warming, we must also be allowed to talk about how our behavior and consumption are causing ill health and disease.

Age 34 with Spaniel

Age 68 in Alabai shirt

I see my role at this point in my life and career – technically beyond the statistical middle years of a man’s life – to speak of the perils of middle age health denial. I can even refer to the fact that I was getting pretty pudgy myself in my mid-to-late thirties. I turned it around, as I described in my video “As a Vegetarian, I Gained Too Much Weight”. I didn’t think I ate badly, but instead blamed my metabolism at first.

https://hansduvefeltmd.com/2021/05/01/as-a-vegetarian-i-gained-too-much-weight/amp/

CONDITIONS was published July 4, 2020 and IN PRACTICE September 5. In order to mark the one year anniversary of the beginning of my series, which will have more installments in the future, I am lowering the price of my full length ebooks from $9.99 to $5.99. International pricing follows the US, and I believe this price decrease will help make my books more widely read not just in this country but also in other markets, served by Amazon, where my blog readership is growing steadily.

https://www.amazon.com/Country-Doctor-Writes-CONDITIONS-Circumstances-ebook/dp/B08B67NR7K

IT GUY: Hey, Doc, don’t make up workarounds, use the EHR the way it was designed.

DOCTOR: Listen, your whole EHR is a workaround itself – around the way medicine is practiced.

– Hans Duvefelt, MD

This was a tweet I posted a while ago. I expected it to either go viral among doctors or catch the ire of administrators and IT folks. Neither happened. So I’m back on my soap box:

Imagine creating a computer simulation or video game that people expected to prepare them for or refine their skills in any given sport. Then, assume that this game altered the rules of the game – using a volley ball instead of a hockey puck, scoring goal attempts rather than goals, rewarding slowness rather than speed and so on.

Then, imagine you, the programmers/code writers, went to the team owners and proposed athletes and coaches should abandon the time-honored rules of the game and instead play like it plays out on the pixelated imitation you just created. And just to be clear: You, the programmer, actually never played the game yourself.

You’d get shown the door and sent back to the digital drawing board.

But that’s not what is happening in medicine.

FIRST: Is finding the clinically relevant information easier than, or at least as easy as, the regulatory information? (The cumbersome ways we have to enter information is a big topic, better covered separately.)

Here’s a silly example: One of the EMRs I work with displays prominently that the smoking assessment requirement has been satisfied, but I’ll be darned if I can see whether the patient smokes or not. Whom does the Holy Grail serve here?

SECOND: Why is it that EHR interfaces are so far removed from how doctors think?

Show me a lab result and imagine what I would need:

– The prior value?

– The current medications?

– The current vital signs?

– A quick way to order medications?

– The patient’s next scheduled appointment?

– A quick way to make sure the patient gets a followup?

– The patient’s phone number?

– A quick way, on the same screen, to order more labs?

– And more…

Any EHR can do these things, but our gripe is that many interfaces are rudimentary and require countless clicks. Then, when you get to the next screen to do what you needed to do, you can’t see the screen that prompted your action, and so on.

I also object to how my (Greenway) EMR doesn’t understand that when I prescribe a medication, I am doing it righ now (it asks me what date I’m doing it) and what type of “encounter” this is (a “medication” encounter, what else?).

More Greenway gripes: A patient is on losartan. I decide to stop it. I click “discontinue”. While doctor-think is that the medication list at the beginning of the visit note includes the losartan and the PLAN includes an AUTOMATIC notation that I stopped that particular drug. (After all, the patient had that particular drug in his bloodstream after already taking their morning dose). There is also an automatic notification to the pharmacy to stop the (often automatic) refills of the drug.

BUT, in Greenway’s INTERGY, if I just stop the drug, it disappears from the top of the visit as if they weren’t on it when they walked through the door. And there is no automatic comment below that this drug was stopped. So, my workaround, and common doctor logic, is to stop the drug TOMORROW. (I then have to MANUALLY type “STOP LOSARTAN”.) I mean this is what the patient will actually do, right? But when I choose a future date do stop the drug, the system claims to be unable to notify the pharmacy. So I then have to pick up the phone and let them know.

The programmer in this case obviously has NO IDEA how doctors, patients and pharmacists think.

Imagine if you had $1,500 in the bank and took out $1,000 today, and your statement showed only that you had $500 without mentioning that here was a transaction at all today. Wouldn’t that seem confusing?

So, don’t be too hard on me for using workarounds. I’m just trying to do my job with tools made for some other occupation than being a doctor.