Just saying no to drugs.

[BlueDevil,DNP]

What are your techniques for saying "no" when asked for inappropriate prescriptions patients have been given by other providers in the past? I am not referring only to narcotics.

I saw a Phys. Assist. (as a pt) the other day whom is transferring her care to me due to an insurance change. She asked me to write for a bottle of 100 tablets of doxy 100mg tabs to keep at home. She takes them prn. This has been her habit to ward off infection whenever she has a sniffle b/c "I have asthma and everything always goes to my chest." She just takes one or two, and Voilà, she doesn't get a life threatening pneumonia. Who knew?

This would not surprise me coming from Jane Citizen who read about it on her Mommy message board, but a PA? Yes, I'd expect her to know better. When I expressed hesitation, she told me her old provider, "a MD" (yes, with emphasis -the clear implication in her tone was that someone who is smarter and better educated than I am thought it was a great idea) did it for her all the time.

I told her that I am not familiar with any literature that supports this as a sound practice, and if she could find me any, I'd be happy to do it for her. I even gave gave her my work email address, which I would ordinarily never do for Jane Citizen, lol. She said she would probably not be making me her PCP since I wouldn't continue the plan of care that had been working for her up until now.

I don't feel bad when junkies get mad and leave threatening to go someplace else (I pray they actually will, they just seem to wait until after hours and try to pull one over on whomever is on call- as if they have never heard of EMRs, lol) but I did feel disappointed by this encounter. She seemed like a nice person, and normal in all other respects, and losing her means I probably lost her whole family as well, since they were all my schedule for next week.

How would you have handled it? I asked a doc I work with and he just shrugged and said he gives crazy nurses, docs, PAs and NPs whatever they want (as long as it isn't really dangerous) as part of the "cost of doing business." Do you think that's true? Are there different rules for colleagues?

[angelalala]

My kneejerk reaction was to think "oh, it really wouldn't hurt anything to just give her what she wants" but. . .she's a new patient, right? Who knows if she'll try to push her weight around to try to get whatever she wants in future visits.

Plus, the MD thing would've rubbed me the wrong way and I would've thought, "Just get your MD to do it, then."

[prairienp]

as an aside, i was taught never to utter the words "i am not comfortable," with the rationale that it makes the speaker appear incompetent or to be lacking confidence. it reportedly does not inspire respect in the listener.

i agree, although "never" is too strong. i have used i am "uncomfortable", especially with narcotics, especially patients i know well.

i would have responded to the pa pt almost exactly as you did. i may have asked her to please update me on the treatment protocol as you want to be able to help other patients in your practice with the same condition. i have learned from patients about new treatment options, but i want to verify with ebp before i implement with my other patients. by asking for validation you are acknowledging her preferred treatment option, as a healthcare provider she should be able to provide you with valid ebp.

[reeya]

I know when I did my women's health rotation at a busy OBGYN owned private practice (2 MD, 1 CNM, 1 PA), it was OK to give Minocycline or Doxycycline as a PRN Abx for PRN acne flare up in women with adult onset acne. The pt. would just take 1 or 2 for flare up and voila control it before it became severe. That was my first encounter with PRN Abx regimen. They would prescribe about 50 tabs and that would last pt about 6 months or even longer. These pt. were among those who were aggresively treated with Abx previously for long time but after discontinuing, acne would come back. The rationale they gave me was if they dont take Abx when it just started to flare up (adult onset only), the acne would become so severe needing another longer tx of Abx for months..which they certainly want to avoid.

I also remember, when I did adult health rotation with a MD (Int. Med), if dermatologist or OBGYN had prescribed PRN Mino or Doxy, he would refill it, for acne of course.

Not exactly asthma case but I was surprised too.

[Tinabeanrn]

I agree with practicing Evidence based medicine too. If she goes somewhere else then that is even better. Its too much resistance as is. And antibiotics are not indicated for Asthma unless there is actually an infection. So why cant she come in and be examined when she starts having symptoms and let you examine her just like anyone else would have to do? I think it is sorta wrong to put someone on the spot and ask an ongoing prescription on the first visit. Actually all together. She should put herself in your shoes. Would she do the same? Just because her last provider did it doesn't make it right. I think she will respect you more in the end for sticking to what you know is right and practicing within the guidelines. I understand it has worked for her before, but there is a reason she is switching providers...she will probably be asking for controlled substances on the next visit ya know? I think you did the right thing.

[wowza]

Minocycline treatment results in... [Allergy Asthma Proc. 2008 May-Jun] - PubMed - NCBI

[TX RN]

Actually, my point was more about how you deal with people when you aren't going to give them what they are asking for, be it 100 doxycycline tablets to pop 1 or 2 whenever they sneeze, or 100 oxycodone tablets because it hurts when they sneeze. And further, are you more flexible if the patient is a health care provider?

You know, I like the question you ask.

"Are you more flexible if the patient is a health care provider?"

I have had this happen to me, health care providers ask for unreasonable prescriptions. And yes, the abx thing is the most typical.

My answer usually goes like this.

"I'm not in the habit of doing that so I won't start now. If something changes and you need to be seen, call the clinic, I'll make sure to work you in."

That answer usually tells them YES I'm willing to work with you, but right now all you're getting is NO.

[studentdrtobe]

Yea, I don't really see what the prior MD was doing wrong here. Especially considering that there is some evidence supporting that practice (depending on the patient's situation of course...and we don't know the whole story here). It's a bit ridiculous to suggest someone who asks for antibiotics will ask for controlled substances on the next visit; quite a leap there.

Also, while it's admirable that so many of you are advocating for EBM, keep in mind the limitations associated with EBM. The vast majority of medicine is still a gray area where you need to extrapolate data from studies to treat a particular patient. Not all patients meet the criteria used in controlled studies and not all studies answer the question of how you should manage a particular patient.

[TX RN]

^^^It's "clinical discretion," that drives decision making in conjunction with EBM or the lack there of.

[nursetim, NP]

Before wowza's post I would have handled it as you did. The study didn't bowl me over visa vie risk Vs benefit.Something we nurses have a hard time saying is NO. The prison gave me a lot of practice.