Med changes over the phone

[MedMan80]

Working in a rural clinic seeing kids/adolescents. Since the beginning i'm getting bombarded with calls with patients expecting med changes/adjustments. "xyz kid is not doing well and so change a med", often times can't get the kids in sooner due to fuller schedule. The times i do get them in earlier they are 50% no-show. I take it PP mostly does not allow any med changes without appointments but wanted to see how the community handles such requests? PS: i was stricter in the beginning, but this was not palatable to many patient's.

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[wolfvgang22]

I will tweak dose and frequency of medications a patient is already taking over the phone if the patient is generally adherent to their treatment plan and I know the patient well. I will generally not start new medications without seeing and evaluating a patient.

Separately, I don't renew prescriptions for patients who no call/no show, even though I receive pressure to do so from admin. When I'm booked out 6 months in advance that means the organization needs to hire another prescriber. There are always going to be a few patients who don't like things I do. Those patients usually are not committed to treatment.

 

[calvnandhobbs68]

Working in a rural clinic seeing kids/adolescents. Since the beginning i'm getting bombarded with calls with patients expecting med changes/adjustments. "xyz kid is not doing well and so change a med", often times can't get the kids in sooner due to fuller schedule. The times i do get them in earlier they are 50% no-show. I take it PP mostly does not allow any med changes without appointments but wanted to see how the community handles such requests? PS: i was stricter in the beginning, but this was not palatable to many patient's.

Depends on the patient. Like above, I'll do it sometimes, especially if we've already talked about it (ex. if you can't tolerate this stimulant, we'll try Strattera for example).

I certainly will never give in to people "demanding" anything. If they don't like it they can go see the other open child psychiatrists....oh wait. Especially with kids when a large proportion of things are due to the social situation. You're also doing the family a disservice because many of them will then get into this idea that meds fix everything if you do a med change over the phone for every temper tantrum that's thrown. It can also instill a sense of calm into the family and kid that they have the ability to handle symptoms on their own without needing a "med change" every time things aren't going so well.

If they're no-showing, next time they call I'd let them know that if they had shown up to their appointment (which are at a premium apparently given your schedule), we could have discussed this then. Feel free to schedule an appointment and actually show up to that one so we can talk about this then.

I upfront let people and staff know that I generally do not do med changes in between appointments and this should not be an expectation. Sometimes its a function of setting expectations because a prior doc would change meds willy nilly. My fellowship there was a child neurologist who fancied treating psychiatric problems who was notorious for this (like changing meds every week when parents would call their nurse line) and actually seeing the patients like once every 3-6 months and then sending them to our clinic when they were "too much" for them...then the parents would expect we'd do the same thing. Nope.

 

[comp1]

If you have time to be doing these phone calls with parents, why not make it a real telehealth encounter?

 

[wolfvgang22]

If you have time to be doing these phone calls with parents, why not make it a real telehealth encounter?

That could be a good idea. Receiving a bill for every phone call sounds like a way to help patients moderate calling for frequent med changes.

 

[calvnandhobbs68]

That could be a good idea. Receiving a bill for every phone call sounds like a way to help patients moderate calling for frequent med changes.

Yeah only problem is since this is a rural clinic, bet a large proportion of these kids are on medicaid. So they won't get billed anyway for a telemedicine visit and then you're just now giving them positive reinforcement that when they call in between appointments they'll get a telemedicine visit.

Basically your "no-show fee" in these situations is the refusal to do anything in between appointments which will incentivize people to actually show up to their appointments, since they can't be charged actual no show fees for these either.

 

[MedMan80]

Yeah only problem is since this is a rural clinic, bet a large proportion of these kids are on medicaid. So they won't get billed anyway for a telemedicine visit and then you're just now giving them positive reinforcement that when they call in between appointments they'll get a telemedicine visit.

Basically your "no-show fee" in these situations is the refusal to do anything in between appointments which will incentivize people to actually show up to their appointments, since they can't be charged actual no show fees for these either.

Bingo! The path of least resistance I've found is doing some sort of nominal change to keep them happy/not complain, without doing a real change which can positively reinforce them to keep calling till my ears fall off!

 

[Candidate2017]

Bingo! The path of least resistance I've found is doing some sort of nominal change to keep them happy/not complain, without doing a real change which can positively reinforce them to keep calling till my ears fall off!

Ah yes.

Parent: Johnny keeps talking back and smoking crack, I don't think the Risperdal is working. Can we try the Vraylar we saw on TV?
Child Psych: Maybe try dosing the Risperdal at night for 30 nights, keep a diary, and see how that works.

 

[deleted1100659]

If serious issue with medication, sure. Otherwise they need to make an appt. If theyre making the appt for an earlier time and they're a no show to that appt, then that is on them. Medicine is a team effort. Also for peds patients, im usually careful listening too much to what a caregiver says, id want to see the patient and see what the full story is, usually theres more to the story.

 

[Ironspy]

I don't work for free. Things come up for everyone but there is a subset of patients who want me to prescribe without engaging in care. These "quick calls" for med issues add up, and if I don't enforce boundaries, I'd be doing 2+ hours of free work daily while having admin hounding me about "low productivity" as none of these unscheduled "quick calls" are billable. This is a recipe for burnout

My boundaries-
All med changes require an appt especially if a patient is not doing well. Only exception if this was something that was discussed in a prior session ie let's see how the sertraline is working in 1 month and decide to titrate v continue same dose with follow up scheduled 6-8 weeks out. These calls are <3 min or are a quick EMR message, are for simple issues and only for patients I see regularly.

Medicaid in my state reimburses phone telepsych at the same rate as video so people can schedule a phone telepsych appt which I tell them to do when they call with med requests. Scheduled phone appts are billed to insurance and count towards my productivity. I can usually see patients within one month. If they cannot wait for the next appt because it's an emergency, I refer them to the local psych ED. If they no show and reschedule they get a refill of meds they are currently on to get them to their next appt. If they are on controlled substances I do this more rarely.

 

[dl2dp2]

I take it PP mostly does not allow any med changes without appointments but wanted to see how the community handles such requests? PS: i was stricter in the beginning, but this was not palatable to many patient's.

Au contriare. In PP because of the smaller volume you are able to respond better and change meds more frequently as you see the patients more often anyway and have more time.

In community-based practice, in general you don't return phone calls. Refill calls are handled by front staff. If patients needs med change they should come in for appt so you can appropriately bill and collect.

 

[deleted1100659]

In community-based practice, in general you don't return phone calls. Refill calls are handled by front staff. If patients needs med change they should come in for appt so you can appropriately bill and collect.

this is my setting and this is pretty accurate for me. The one exception being if im starting them on a newer medication and were not able to get them covered then I may call and switch to an alternative I had in mind.

 

[Merovinge]

You could be doing a real disservice makes these changes at the parents bequest without seeing or hearing from the actual patient. If you actually are hearing from the guardian and the patient, that's way too much work to be doing without an actual visit. There's a reason we see patients instead of having parents enter symptoms into a computer and hope that it poops out a med change...

 

[MedMan80]

You could be doing a real disservice makes these changes at the parents bequest without seeing or hearing from the actual patient. If you actually are hearing from the guardian and the patient, that's way too much work to be doing without an actual visit. There's a reason we see patients instead of having parents enter symptoms into a computer and hope that it poops out a med change...

I'm of this mind also. Unfortunately my predecessors have set the example that meds can be changed over the phone. Also there is 0 triaging happening and i always get a message "please call the patient". Exciting to see that other's aren't facing this problem.

 

[calvnandhobbs68]

I'm of this mind also. Unfortunately my predecessors have set the example that meds can be changed over the phone. Also there is 0 triaging happening and i always get a message "please call the patient". Exciting to see that other's aren't facing this problem.

Ohhh no you gotta have someone at least taking down what the message is about. I don't think I could take that...I'd be telling admin that either secretaries start at least giving me an idea of why people are calling/getting specific refill-med requests or I'm not wasting my time at that clinic anymore.

 

[Ironspy]

Ohhh no you gotta have someone at least taking down what the message is about. I don't think I could take that...I'd be telling admin that either secretaries start at least giving me an idea of why people are calling/getting specific refill-med requests or I'm not wasting my time at that clinic anymore.

I had this when I started. I would ask them to call the patient back and ask what they needed help with. If it’s an emergency go to the ED. If scheduling that’s admin, if Med questions schedule a follow up appointment. Did this politely and persistently for a few months and they realized it’s less work for them to ask the patient the first time than send 3-4 clarifying emails/EMR messages to me only to have to call the patient back in the end

 

[Merovinge]

I'm of this mind also. Unfortunately my predecessors have set the example that meds can be changed over the phone. Also there is 0 triaging happening and i always get a message "please call the patient". Exciting to see that other's aren't facing this problem.

Previous or other "providers" practicing bad medicine is never a reason to practice bad medicine. It does not hold up in court and it shouldn't hold up to your own personal responsibility being the sub-specialist trained physician looking after a child's healthcare. You can make changes to the way things are run if it comes from the place of doing the right thing for the patient.

 

[MedMan80]

Previous or other "providers" practicing bad medicine is never a reason to practice bad medicine. It does not hold up in court and it shouldn't hold up to your own personal responsibility being the sub-specialist trained physician looking after a child's healthcare. You can make changes to the way things are run if it comes from the place of doing the right thing for the patient.

100% the frustrating part comes when patient's have been conditioned to call to ask for changes and my resistance is perceived as me not caring or bad customer service, then having to deal with the blowback..patient after patient..

 

[Merovinge]

100% the frustrating part comes when patient's have been conditioned to call to ask for changes and my resistance is perceived as me not caring or bad customer service, then having to deal with the blowback..patient after patient..

I've dealt with that doing rural CAP outpatient work as well. Please don't let it get to you. While there may be a more diplomatic way to phrase "I really need to see your child to provide them the best care", I ended up having to repeat that ad nauseum when I started my clinic. People are used to PCPs or NPs who will adjust meds with a 1 line direct message, so this comes up even if you aren't replacing a CAP who does this.

I will say that when you really do get to spend time with these patient's/families and they see you really are doing the best care for their children, most of them come around. A few won't, I had one man scream "Mother fuking shrink, cok fuker" at the top of his lungs, but you can't win them all.

 

[robellis]

I've dealt with that doing rural CAP outpatient work as well. Please don't let it get to you. While there may be a more diplomatic way to phrase "I really need to see your child to provide them the best care", I ended up having to repeat that ad nauseum when I started my clinic. People are used to PCPs or NPs who will adjust meds with a 1 line direct message, so this comes up even if you aren't replacing a CAP who does this.

I will say that when you really do get to spend time with these patient's/families and they see you really are doing the best care for their children, most of them come around. A few won't, I had one man scream "Mother fuking shrink, cok fuker" at the top of his lungs, but you can't win them all.

Why was that gentleman upset

 

[Ironspy]

100% the frustrating part comes when patient's have been conditioned to call to ask for changes and my resistance is perceived as me not caring or bad customer service, then having to deal with the blowback..patient after patient..

Patients deserve to have my undivided attention for med changes and I cannot do this in a 3-5 minute phone call that's sandwiched between other commitments. I emphasize that I want to provide them with the highest level of care and to ensure that I can do this they need time on my schedule.

 

[Merovinge]

Why was that gentleman upset

I redirected him from calling his 10 year old Caucasian son "fcking n-word", on the second occasion within 5 seconds, when I was sure I heard him right, I told him he was not allowed to continue to be in the exam room.

 

[MedMan80]

Patients deserve to have my undivided attention for med changes and I cannot do this in a 3-5 minute phone call that's sandwiched between other commitments. I emphasize that I want to provide them with the highest level of care and to ensure that I can do this they need time on my schedule.

I tend to put it on the clinic, "clinic doesn't give me more than a few mins on the ph" and most patient's are okay with this

 

[sloop]

This all kind of depends on many factors, but my primary and overarching principle is always whether making the med change would be good for the patient. I don’t really care much about what they want me to do. At the same time, I try not to let the fact that it’s annoying when patients are calling and bugging me about med changes influence my decisions too much.

If the medication change is likely to benefit the patient, sure. But there’s no way I’m going to make a med change if I’m just shooting blind.

In general, this effectively resulted in a policy of making truly urgent med changes over the phone, but insisting that patients see me for an appointment for routine changes. And obviously, anyone whose medication I changed over the phone was also expected to come in for a follow up as soon as was feasible.

 

[clausewitz2]

This all kind of depends on many factors, but my primary and overarching principle is always whether making the med change would be good for the patient. I don’t really care much about what they want me to do. At the same time, I try not to let the fact that it’s annoying when patients are calling and bugging me about med changes influence my decisions too much.

If the medication change is likely to benefit the patient, sure. But there’s no way I’m going to make a med change if I’m just shooting blind.

In general, this effectively resulted in a policy of making truly urgent med changes over the phone, but insisting that patients see me for an appointment for routine changes. And obviously, anyone whose medication I changed over the phone was also expected to come in for a follow up as soon as was feasible.

This strikes me as the reasonable position. It also depends for me a bit on how much of a habit this is for the person on question.

Some patients I hear from enough that I make a point of delaying response until the outside of the window i promise because otherwise they would just message continuously.

Some patients I hear from so rarely that if they are expressing a worry about medication they are probably one step away from hospitalization. It all depends. Phronesis and all that.

 

[milesed]

We can't charge for no shows and can't charge for anything done by phone. I can't usually see someone back in less than 2 mos so do encourage them to call if having issues. I don't mind making small changes by phone, but have a reliable RN who can call and get details I ask for before I do anything. If they are frequent no show patients or it's too complicated, they have to wait until seen.

 

[ridethecliche]

If you have time to be doing these phone calls with parents, why not make it a real telehealth encounter?

My thought as well. The same time on the phone could be spent doing a televisit where you could actually lay eyes on the patient.