Stop telling doctors what to do

I enjoy a fairly small private practice and a manageable telepsychiatry side job with good support staff. But even the small scale of my outpatient clinical practice doesn’t fully insulate me from the pain of unnecessary practices that I wish would become obsolete.

1. Preauthorization. The dance of preauthorization starts with the naivety on my part that I decide what medication my patient should be on. I spend precious time crafting a treatment plan with my patients and send in a prescription. Dear doctor, you are not done! Even in cash-private practices, the patient’s insurance will make known, who wears the pants in this relationship. It’s not the physician!! Try asking why a medication needs a preauthorization, and witness an unapologetic “deal with it” or “suck it up buttercup” attitude.

I always cringe when asked if I have considered sedative/hypnotics instead of non-addictive sleep medications or other “thoughtful” (read: inappropriate due to more adverse-effect prone, hence cheaper) medication for treating bipolar depression or anxiety.

The fact that my treatment decisions have to be scrutinized by an insurance company, whose goal is to save money rather than helping the patient, makes this interaction as pleasant as witnessing sideline coaching during soccer games by worked up parents.

My wish: If preauthorization is here to stay, physicians should be allowed to bill the insurance companies for the time we spent on these purely cost-cutting practices.

2. M&M and Skittles. Pharmacies now routinely request 90-day medication supplies or fill 90-days without consulting with the prescribing physician. Seriously, who in their right mind would want to wait and see if a medication would work or not?

As a psychiatrist, I have unique challenges of titrating up or tapering off many medications based on my clinical evaluation of the patient. Furthermore, many of the psychiatric medications like Lithium, Tricyclic antidepressants, and the like can be lethal in accidental or intentional overdoses. There is no way a pharmacy or the insurance company has the slightest idea of a patient’s various risk factors, as well as I do, yet they take upon themselves to make the supply decisions for my patients.

My wish: Insurance companies/pharmacies stop playing doctor or be liable for providing large quantities of pills to patients without physician permission and stop forcing physicians to write high quantity scripts regardless of safety.

3. Pharmacy blues. I could write a book about this one. In my experience, the big-chain pharmacies are the most problematic and worst offenders in this regard. I try hard to deal with local and small pharmacies to avoid big chain and their mail-order cousins, but once again, insurance companies strike. I have lost count of how often my prescriptions are lost or not filled on time (resulting in withdrawals and at times decompensation) and then be blamed for not sending the prescription.

Ironically, when I call (since I can see the transmission report on my end), the prescription is found with an appropriate number of refills. But I don’t have time to chase my prescriptions. I have gotten requests for refills for medications that I have discontinued and had sent orders to the effect. Complaining to pharmacy supervisors about multiple instances of their staff not checking PMP, and inappropriate controlled substances dispensing has its pitfalls.

Additionally, anecdotes of pharmacies refusing to fill scripts because of potential interactions make the issue even more groan-worthy. The attitude that a physician’s medication order can be refused, but over-enthusiastic reminders for refills are appropriate, is puzzling at best.

My wish: Please give my fax machine a rest. If you have concerns, don’t make treatment decisions for patients by not filling prescriptions but call the physician. We should continue to empower patients to take control of their medications by contacting their physician for refills or medication concerns.

4. Doctor who? Now I have to undo medical advice given by non-physicians. Even with the best of intentions, these interactions are problematic at best because they directly interfere with treatment decisions made by the patient-doctor dyad by excluding the physician.

Pharmacists, therapists, and psychologists can provide appropriate consultation to patients, without undermining the treating physician. Psychiatry is a complex art.

My four-year residency was grueling, and our fellowships are not irrelevant. It is my training that taught me the art of using an alpha-1 antagonist to combat nightmares in PTSD or an alpha-2 agonist being a valid treatment, especially in children for a variety of psychiatric diagnoses. When already anxious patients are told by others that their psychiatrist shouldn’t be prescribing a certain medication, they rightfully freak out; despite prior discussion about the rationale for use. Similar problems occur when well-meaning therapists and psychologists recommend medications to patients. As a result, psychiatrists are spending time retelling patients, why they can’t be on a benzodiazepine, or why they are on a mood stabilizer?

My wish: Please give the treating physician the courtesy of a phone call, if you are so inclined to discuss the prescribed treatment. But please, do not practice medicine without a license.

Our jobs are inherently and rightfully stressful due to the responsibility we have for patient safety. The burden is, however, increasing because there are multiple chefs in the kitchen without the understanding of the basic ingredient — medical education and training. We continue to carry the highest liability and risk regarding patient outcomes and safety, even when we are forced to practice otherwise.

We, as physicians, need to make alliances with our patients to put patient safety and care decisions back in the hands of the patient-doctor dyad with appropriate consultation from pharmacist, therapist, case manager, and insurance companies, etc., initiated from within the dyad and not the other way around. Physician-led care needs to be the norm, not the exception.

It’s high time to stop telling me, “Dear doctor: Do this.”

Najma Hamdani is a psychiatrist.

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