How do you prescribe ABX in a retail clinic? - page 2
I am a FNP student 8 weeks into my first practicum rotation. I'm mostly in a busy clinic office, but twice I was asked to go to a retail clinic. The clinic is staffed by one NP and a receptionist in... Read More
May 15, '11This is an interesting thread. I find that an overwhelming amount of patients are very receptive to being told that they are sick with a virus; starting an antibiotic is a HUGE risk that could expose them to an allergic reaction and inevitably they lead to stomach cramps and diarrhea...and if that occurs you gotta keep taking them, etc. Most of them just want someone to validate that they ARE sick and there is a valid reason.
For the others who INSIST on an antibiotic, I find they also do well with the above discussion, and an open invitation to call me if they aren't better in 4-5 days and I will Rx an antibiotic. Occasionally, I will give them a written RX to have (especially for ones who are about to travel, etc.) and give them the same schpiel. It is AMAZING how many come back in a few months for an entirely different reason and say "hey, I never even cashed in the antibiotic. Thanks for taking the time to talk to me about viruses..."
Also, a sure fire way to anger a patient is to say "it's JUST a virus." It minimizes their feelings, insults them and makes them feel incompetent for even coming in. Validate their feelings, validate they they ARE sick and then take a few minutes to talk to them about the risk of antibiotics, etc.
May 15, '11I explain the why they don't need abx, I validate their feelings but parents can be adamant about needing a abx, and they frequently tell me well dr x always gives a abx when he has a runny nose
May 15, '11I have also had WONDERFUL results explaining about C.Diff in the community now and why we are starting to see new cases in non-nursing home patients who have recently been on antibiotics. The "weeks of diarrhea, fever and pain" part really seems to drive the point home.
Jun 12, '11I typically explain that it is viral in origin and that at times viruses can be "worse" than bacterial infections since abx dont help or make you feel better. They tend to LOVE the fact that I am validating their illness and understand how terrible they feel.
Jun 12, '11What I've been saying all week is, "The bad news is, you have a viral infection. The good news is, you won't need antibiotics so there's no need to worry about possible allergic reactions, diarrhea, or vaginal yeast infections. You're going to feel really lousy for the next few days, so try to take it easy. Rest, fluids, Lifetime Movies, etc... but you'll be much better by this time next week."
Jul 3, '11When I was at one clinic doing a rotaion we would give antihistamines and decongestants and robitussin for viral symptoms. I would tell my patients if I give them medicine the cold would be gone in a week, if I gave them nothing, it would be gone in 7 days. Some people got this, others opted for the week solution. In a retail setting, if viral, I would recommend an inexpensive solution for their symptoms and tell them if they do not feel better in 11 days to call and I would call in an antibiotic so it would not cost them any more than their original visit. I would not send them with a script to be filled later as it would most certainly be filled immediately with few exceptions.
Jul 4, '11Interesting thread. I too saw the behavior described in practices other than retail outlets (In fact, I have no experience with ROs at all, either as practitioner, student ro pt). I also so one provider undermine another when pts/parents c/o about a tx plan they didn't like. I'm far too new this gig to have any wisdom to share. All I can say is that I plan to take my time finding a position that provides a true collaborative relationship, and then practice and learn to the best of my ability. Still, I am certain these things will come up, and then all we can do is fall back on what we know, and what we believe we should be doing.
Peds, my heart really goes out to you.
Jul 6, '11I am finishing graduate school in about a month and was assigned to a retail clinic a few semesters ago. The one I was at totally did not follow that practice. If it was a URI you were told that you need symptom relief that did NOT require antibiotics. We educated them on the entire virus/bacterial thing and drug resistance. I had every patient ok with my explanation except for one who was furious, and we still denied her antibiotics. We told her she could go to her PCP or another clinic, but they would say the same thing we just did.
It is worrisome to hear you say that they are giving out antibiotics like candy. I know every clinic wants to make money, but there are much bigger problems down the road if you prescribe anyone antibiotics who do not need them.
I would bring this up to your professor who makes out the clinical assignments to inform her of this. This is NOT what they are teaching us in school and what all of the data and research is saying about practicing. Good luck with everything.
Jul 11, '11"I suppose one could refund their money if they do not Rx an ABX. This would satisfy the customer monetarily and increase trust in the clinic, but then the NP is not making the clinic money, and less business income means over time equals closed doors and unemployment lines."
I realize that the above quote is highly unlikely but just want to warn that this type of thing would just be reinforcing the public's belief that they are paying for a script. They are paying for an educated, knowledgeable, experienced assessment and diagnosis NOT a script. If the assessment of nasal discharge and congestion revealed a tumor that had to be referred to a surgeon would you refund money because they did not need abx? No, you are being paid for your assessment and diagnostic skills, not a script.
Jul 14, '11"I will likely end up working in one of these clinics at some point, but will I compromise my clinical work ethic for the sake of a having a job?"
I would recommend not working in a retail or UC clinic, if you want to practice evidence based medicine.
I have been doing locums and am becoming more and more frustrated with being told "how" to practice. Basically I am told to give the patients what they want. If i don't then I don't have a job. If the patient is unhappy for any reason, I am the problem, and I am the one they will get rid of.
I got "talked to" by the non-medical office manager at one clinic because I had 2 patients one right after the other that left angry.
Pt.1 had URI which I gave her OTC/URI instructions, she was mad b/c she had pd cash, UC clinic and did not receive antibiotics.
Pt.2 had a painful umbiliical hernia and was mad b/c his insurance told him he could go to this clinic and get everything done. He was mad because I referred him to a surgeon and would not perform the surgery myself in the clinic.
So i got reprimanded.
They called Pt.1 back and the next doc went overkill gave her steroid shot and antibiotics. The non-medical office manager then "believes" I did the wrong thing because the MD "Gave a SHOT" so she must have been super sick and i was just too dumb to see it...
The MD told me I did the right thing and he was just trying to suck up as well.
My experience has been if the patient is paying cash or they are upper class you better give them what they want or you won't have a job.
Practicing evidence based medicine is becoming less and less because its become a drive through McDonalds type based medicine in the US. The customer (yes they really are becoming just customers) come in, and tell you what they would like to order. If you don't get the order right, they will find another fast food restaurant that will meet there needs.
Its all about business, its really sad.. not many places care anymore..
Jul 14, '11Dont you just love a person with zero medical knowledge telling you how to practice. I had a lab report come back last week where the WBC was elevated and the office clerk on handing it to me said dont you think she should be on antibiotics. ( the pt was already) I looked her straight in the eye and asked her what license she was practicing with other than her drivers license.