Patient comes into clinic. Has a medication list (AMAZING). Is on a mess of medications. A mess. Three pills for the same problem, nothing for another problem, two that interact, at least three he shouldn't be on, a couple that should be replaced with better alternatives. So I talk to my attending and we decide to clean up the med list, get him on the right set of pills... and he asks the very legitimate question: WHY SO MANY CHANGES?
And the very legitimate follow-up-- "Did my last doctor screw up?"
Now, fortunately, there doesn't seem to be anything bad that happened because of the less-than-optimal medication regimen. So, fortunately, his questioning is more out of curiosity than any real demand for answers.
It's true that I don't even know if I have an answer for him. I don't know if he's taking the medications he was told to take, and only the ones he was told to take. I don't know if he brought his full med list to his last visit. I don't know if he's still ordering refills on things he should have stopped, until the refills on the prescriptions run out. I don't know if he might have described different symptoms in the past. I don't know if other doctors know more than I do or have had different experiences with different medications.
But I do have a strong feeling that, yes, someone probably screwed up, or at least failed to think about the full medication list. So do you tell that to the patient, or do you glide past the question, and decide that since you don't know for sure, and there don't seem to be any repercussions, the more responsible thing to do is to not throw another doctor under the bus?
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I always err on the side of not throwing another doctor under the bus, in part out of professional courtesy and in part because, like you said, you don't always know the circumstances behind what the doctor has done. I've certainly had patients where I've given detailed instructions about stopping certain medications and starting others, only to have them come back with some odd combination of medications that bears no resemblance to what I prescribed.
ReplyDeleteOn the one hand you don't want to "throw another doctor under the bus", but on the other what if the patient was completely honest with you and it was the doctor's fault? I guess it falls to whether or not you'd be comfortable with that patient going back to that doctor.
ReplyDeleteI think in any profession, you protect colleagues, especially when you don't have their side of the story. You may not have the whole story. You just don't know at the time. Clients (and patients) have been known to withhold vital information or are just plain confused about the facts. When you do have the facts, and find out that, indeed, your colleague is a dumbo, then you whistle for the bus!
ReplyDeleteNot a doctor, but it seems like you could say, "It's really important to go over your full med list with everyone who treats you - because it looks like you've been prescribed several medications that do the same thing, here. I'd bet that someone assumed you'd know to stop A when you started B, but that you went on taking both, which could have been dangerous." Put the responsibility back on the patient.
ReplyDelete@Amy Austin - it's not the patient's responsibility to know that he should stop A when he started B. That is the previous physician's responsibility to make that absolutely clear to the patient.
ReplyDeleteI don't agree at all that the responsibility should be put back on the patient. He was trusting that his doctor knew what medications he was taking and following his doctor's orders. That doesn't mean the previous physicians should be thrown under the bus, but trying to put the blame on the patient is even worse.
@ Amy Austin – I’m sure glad you’re not a doctor.
ReplyDelete@Ian – You are spot on. Patients didn’t go to medical school for umpteen years the way their doctors did. Even the few patients who are aware enough to ask questions rarely know what to ask. It’s up to the physician, who is trained (and paid) to be aware of these issues and to communicate them to their patients. To put the onus back on the patient is irresponsible and reprehensible.
But there’s a bigger issue here. This problem of tracking prescriptions is rampant. I know of a place that holds public events where people can bring in their meds and have a pharmacist evaluate the lot of them for interactions, redundancies, etc. The line is ridiculously long. Why do these people feel they can't do this with their physicians? There’s a clear breakdown in the doctor-patient relationship here.
Part of the reason for patients' losing trust with their physicians is because the docs protect each other - it's more important to protect other physicians (because you might need protecting someday) than to protect the patients. One of the reasons given for not having more formal oversight of physicians is that physicians can police themselves. Here, proof positive, they cannot.
ReplyDeleteDoctors do protect each other to the detriment of patients. Reporting agencies are run by doctors. Criminal acts against patients are covered up, sand bagged and protected by their professional community. Surgeons enjoy a benevolent protective society. Their zealous protection of each other is universal and unquestioned.
DeleteConsequently, another avenue is needed to obtain health care that allows making an end run around doctors.
Until this is changed, people needing health care are held hostage to a corrupt system.
It's just your opinion. Give it honestly, the way you'd expect a mechanic to tell you the last guy forgot to screw on the oil filter. Yes, the customer can take that opinion back to the first mechanic and ask for his money back, but that's the only protection non-expert consumers have.
ReplyDeleteFeel free to leave the caveats in, like "Someone in the chain somewhere screwed up, could've been a pharmacist or the nurse who collected the drug history, who knows." But hedge because you're really unsure, not because you're protecting your colleagues at the expense of the patient.
If the patient were asking you to testify in court, I'd worry about your opinion doing more harm than good, but not before.