Friday, March 7, 2008

Sometimes you just have to talk to the doctor directly.

When I walked into the pharmacy on Thursday, I wasn't in the best mood. I had a crappy day on Wednesday; a transformer blew and our whole street loss power for 4 hours on Wednesday morning. By the time the power was restored, and we could get back to normal business, we were well behind. By late afternoon, we finally were just about caught up when suddenly our computers went down for an hour. It was a frustrating mess.

Therefore, it's understandable that I wasn't too thrilled to be walking into work the next day. The first thing I did was check our voice mail, which had 7 prescriptions just waiting for me. One prescription was left by a local doctor, who I'll call Dr. Smith. Dr. Smith called in Voltaren for this certain 94 year-old patient of ours. Once I heard "Voltaren" come out of his mouth, I immediately thought it was a terrible drug to prescribe to someone her age. I checked her profile and saw that she was on a bunch of heart medications as weel as Coumadin.

Voltaren (and NSAIDs in general) are terrible drugs for the elderly. It is well known that NSAIDs are affect platelet aggregation and can damage the mucosal lining of the GI tract, which in turn can cause GI ulcers. A bleeding ulcer is certainly not a good thing to have in someone taking Coumadin. In addition, NSAIDs can decrease renal function, which is already decreased in the elderly population. NSAIDs can also increase blood pressure, which isn't a great idea for someone taking a lot of cardiac medication. Finally, a little known thing about NSAIDs is that studies have shown that they actually increase the rate of falls in the elderly. The reason isn't quite clear, but there is a definite statistical link. For all these reason (especially the patient being on Coumadin), I decided to call the office to inquire about the doctor's choice of drugs in this patient.

I figured Dr. Smith simply wasn't aware she was on Coumadin when he prescribed Voltaren. Granted, it still wouldn't be a great choice of drugs for her, but without the Coumadin, he could make some kind of risk vs. benefit case about why he prescribed Voltaren. I spoke to a nurse at the office and told her I was questioning Dr. Smith's choice of drugs in this elderly Coumadin patient. The nurse put me on hold to ask the doctor about it. When she came back, she told me that Dr. Smith didn't want to change the drug because "she wouldn't be taking it that often anyway."

I wasn't satisfied by this answer, so I requested to speak to the doctor himself. Begrudgingly, she got the doctor for me.

(As a side note- Why is everyone at these offices so damn afraid to ask the doctor about stuff? Are doctors really so mean and unapproachable that no one dare question their decisions? Every time I ask to speak to the doctor directly, I get someone telling me, "He's going to be mad." I think it's pretty ridiculous. When a customer calls to speak to a pharmacist, I'm expected to personally answer that phone call regardless of whether the situation actually warrants a pharmacist.)

Anyway... The doctor got on the phone, and I explained to him my concerns. He told me that he wasn't the least bit concerned about her being 94 years old. He then asked me what I was worried about with the Coumadin. I was kind of dumbfounded by the question. Was he really asking me why NSAIDs and Coumadin are a poor mix? "Well, my concern is that she can develop a GI bleed that won't stop bleeding, and she can die," were my exact words to him. I guess the possibility of death got to him, and he changed the prescription to Ultracet (the patient had some kind of back pain), which while not being great, is a considerably better choice than Voltaren.

I felt pretty good about myself for actually talking to the doctor himself to get him to change the drug. I felt even better about myself when the patient came in for her prescription. Everyone at the pharmacy is very familiar wiith her. She's been using our pharmacy for over 20 years. She's a cute old lady, couldn't weigh over 90 pounds, and about as mentally alert as a 94-year old could be. She always comes in with her daughter, who helps take care of her. This was her first time seeing Dr. Smith, so when he gave her the prescription, she immediately called her primary care doctor to ask him if it was OK to take with her other medications. Her doctor, like me, told her that she should not take Voltaren along with her Coumadin. After relaying all this information to me, I assured her that I had already called Dr. Smith and got the medication changed to something that was safer for her to take. She was pleased.

I walked away to let one of our techs ring her out. After she walked away, the tech came back and told me that her and her daughter kept on saying what a "nice, young pharmacist" I was. That was my little victory for the day, and moments like that make my job worthwhile. Perhaps, changing therapies and catching interactions happens a thousand times a day for hospital and other more clinical pharmacists, but how often do they get to see the patient's appreciation of their efforts? This is a big part of the reason I like retail better than the other areas. You get to develop personal relationships with the customers, and in doing so, you build up a level of trust. I'd like to think that most of my customers know that I work hard for them, and they trust me enough to know that when I say I'll do something (i.e. call a doctor, call an insurance company, etc.), I actually do it.

Like I said, that was my little victory for the week. Maybe that's not enough for some people, but it's OK for me.


pharmacy chick said...

Those are the things that keep us coming back arent they? Those few people who say thanks because they really mean it and need us because so few people are in their corner. I have this family whose drug bill exceeds 21,000 per year. we got them from a competitor because they never felt cared for, only felt they were a bother. Sure they are a little high maint, who wouldn't be with those kind of health issues, all legit and very complicated. But I do it and they are very grateful, they said once that for the first time, they felt they dont have to worry about pharmacy matters any more because they know somebody cares and will take care of stuff.

Silliyak said...

You get a virtual pat on the back from me! Good job.

rphgirl said...

Kudos to you for taking an initiative for doing this very important intervention in order to act in the patient's best interest and not being afraid of questioning MD's authority and expertise. Even though you may feel unappreciated by your customers most of the times, it is those small victories of yours that will make your day worthwhile.

Gary said...

congrats on that mike. i feel the same way as you do about how those relationships with the patients make retail worth it all in the end. granted i am still just a student nothing gives me greater satisfaction than putting a smile on an old persons face.

Anonymous said...

Nice work, Clinical Pharmacist Mike! Sometimes it does help to use single-syllable words with certain people, like "die" for example, then a lightbulb goes off above their head and next thing you know you've prevented another NSAIDs/elderly statistic. Strong work. I ALWAYS like to talk to the doctor. A medical assistant cannot properly interpret what you're trying to get across. Helpful tip: use BIG words with the MA, and tell her to write them down. Use words like "creatinine clearance" and "ankle edema" and "pulmonary edema" or "hypertension leading to increased stroke risk" or "gastrointestinal bleeding". Always use the generic name for drugs. Of course, you'd never talk like this to the doc, because he'd think you were being an ass (which would be true.) However, you will likely frustrate the MA and more likely be turned over the physician for a personal interaction. Anyway, my hat is off to you for being an exemplary model of why pharmacists are a necessary component of excellent health care.