illegal or just unethical?

[Gary F]

We've established what your recommendation is, we have already established that is not going to happen. Now, what do you do NEXT, or do you just keep repeating over and over that they should see a doctor? A doctor patient relationship is like any other, you don't always get what you want. The question is what do you do then? That is what defines character, what you do when you don't get your way.

If you call the ambulance leaving that person no option but to go to the hospital, or refusing because they can't pay the bill and they are still stuck with an ambulance charge of a few thousand dollars for it showing up, do you pick up the bill? If not, where did you suppose you had the right to incurr debt for someone else against their wishes?

If they call my office they are stuck with what I consider to be my best judgement. We will not call an ambulance unless they agree or we suspect that the patient is incapacitated. Usually when we call an ambulance we have received a notification from their implanted device that something really bad has happened.

 

[Henning]

If they call my office they are stuck with what I consider to be my best judgement. We will not call an ambulance unless they agree or we suspect that the patient is incapacitated. Usually when we call an ambulance we have received a notification from their implanted device that something really bad has happened.

So you'll just tell them, "Do what I tell you or call someone else"?

 

[Gary F]

So you'll just tell them, "Do what I tell you or call someone else"?

I give them my recommendation and document it in the record. If they don't agree they have other options including, but not limited to:
1. Ignore it and do nothing.
2. Go somewhere else (Internet) or to another person or provider for advice this time.
3. Fire me and get a smarter, more compassionate physician.

 

[Henning]

I give them my recommendation and document it in the record. If they don't agree they have other options including, but not limited to:
1. Ignore it and do nothing.
2. Go somewhere else (Internet) or to another person or provider for advice this time.
3. Fire me and get a smarter, more compassionate physician.

So no way in hell are you gonna call in that script for Cipro or whatever?

 

[Gary F]

So no way in hell are you gonna call in that script for Cipro or whatever?

It is very unlikely that I would call in a script for an antibiotic over the phone. I don't ever remember doing that. I have been known to switch medications (due to allergy or other problems) and adjust dosages over the phone.

 

[Henning]

It is very unlikely that I would call in a script for an antibiotic over the phone. I don't ever remember doing that. I have been known to switch medications (due to allergy or other problems) and adjust dosages over the phone.

What would be the reason for your refusal?

 

[Gary F]

What would be the reason for your refusal?

If they really need an antibiotic they should be seen for a proper evaluation. If they don't need it then they are risking complications with no benefit.

 

[Henning]

If they really need an antibiotic they should be seen for a proper evaluation. If they don't need it then they are risking complications with no benefit.

That is in a perfect world, unfortunately we do not live in one so often we have to make choices. In this situation you are the person with the ability to help or not and you choose not. My question is why not? It is clear the person will not be getting an evaluation, so there are two potential complications, one is pneumonia and death and the other is a complication from antibiotics (at 70 we can leave out 'building resistance to antibiotics' from the complication list, agree?). Which of those choices is more likely to create an adverse reaction? Would you consider either or both actions to be in conflict of "Do No Harm" or do you not consider an act of omission to be harmful?

 

[Gary F]

That is in a perfect world, unfortunately we do not live in one so often we have to make choices. In this situation you are the person with the ability to help or not and you choose not. My question is why not? It is clear the person will not be getting an evaluation, so there are two potential complications, one is pneumonia and death and the other is a complication from antibiotics (at 70 we can leave out 'building resistance to antibiotics' from the complication list, agree?). Which of those choices is more likely to create an adverse reaction? Would you consider either or both actions to be in conflict of "Do No Harm" or do you not consider an act of omission to be harmful?

It is not an act of omission not to prescribe any medication without what the provider sincerely believes is an inadequate evaluation. I also believe that I have an ethical obligation not to prescribe antibiotics inappropriately and that is much more likely based on a phone consult. It is not a money issue. I do all sorts of stuff for free.

 

[Henning]

It is not an act of omission not to prescribe any medication without what the provider sincerely believes is an inadequate evaluation. I also believe that I have an ethical obligation not to prescribe antibiotics inappropriately and that is much more likely based on a phone consult. It is not a money issue. I do all sorts of stuff for free.

I never thought it was a money issue, just trying to discern the decission process. I'm not really faulting you for the decission even if I don't agree with it as there are several good and legitimate reasons for the choice as well as against it.

 

[denverpilot]

If you call the ambulance leaving that person no option but to go to the hospital, or refusing because they can't pay the bill and they are still stuck with an ambulance charge of a few thousand dollars for it showing up, do you pick up the bill? If not, where did you suppose you had the right to incurr debt for someone else against their wishes?

When did Doctors or Nurses get in the transportation biz? They don't call ambulances. When I said Karen has helped someone do it, it was at the patient's specific request, and her neck is sticking out pretty far doing it.

If the problem is cost, the patient can call a cab, they're cheaper. We could discuss how even city-funded ambulances already purchased and operated by government, charge $300 or more to stuff an O2 mask on someone's face here too, if we're going to speak of ethics...

 

[jbarrass]

MDVIP.com

My wife uses an MDVIP doctor and swears by it. It's a good program (NB: her doctor is not old and does have hospital privileges)

 

[Gary F]

I never thought it was a money issue, just trying to discern the decission process. I'm not really faulting you for the decission even if I don't agree with it as there are several good and legitimate reasons for the choice as well as against it.

Everything boils down to the risk benefit equation. Most medical decisions are based on probability. Over time a physician usually becomes better at medical decision making based on his or her experiences and those of colleagues. I am happy with my performance record and I believe that the vast majority of my patients are as well. I spend a lot of time explaining my medical decisions process to patients and they agree or migrate to a physician with a more compatible philosophy.

 

[Henning]

When did Doctors or Nurses get in the transportation biz? They don't call ambulances. When I said Karen has helped someone do it, it was at the patient's specific request, and her neck is sticking out pretty far doing it.

If the problem is cost, the patient can call a cab, they're cheaper. We could discuss how even city-funded ambulances already purchased and operated by government, charge $300 or more to stuff an O2 mask on someone's face here too, if we're going to speak of ethics...

I was responding to his reply where the doctor calling an ambulance was given as an option.

 

[Jthamilton]

Wow, I figured this would have petered out by! At least it should have

 

[Gary F]

I was responding to his reply where the doctor calling an ambulance was given as an option.

Rarely done.

We can get screwed by lawyers if something bad happens after a patient calls a physician for advice or treatment. A lady called a physician who told her to go to the ER. She didn't and got real sick from septic shock and lost hands and feet. She won a lawsuit because the physician did not explain adequately enough to convince her to go to the ER.

 

[weilke]

I have never called an ambulance.

I have sent the sheriffs office for a 'welfare check' a couple of times, but not for 'cough and a runny nose'.

 

[Gary F]

I have never called an ambulance.

I have sent the sheriffs office for a 'welfare check' a couple of times, but not for 'cough and a runny nose'.

I hope nobody construed that I recommended that option for the sniffles.

 

[Doggtyred]

Not this one. One day you can teach me how it is done. You are truly a Renaissance man.
Less true than in the past due to Clostridium Difficile which is being diagnosed with increasing frequency. For the non medical types here, C. Diff. is a possible complication of antibiotic use. Normal bacteria in the intestinal tract is often severely depressed by certain antibiotics allowing the bad actor bacteria C. Diff. to take over. It can be hard to eradicate and can be passed on to others. It can be fatal.

Clostridium difficile is an anaerobic, gram-positive bacillus that can cause considerable disease, including diarrhea, colitis, and septicemia, resulting in death (1). C. difficile–associated disease (CDAD) primarily affects persons >65 years. Risk factors include residence in hospitals and long-term care facilities and the use of antimicrobial medications (1–3). Incidence of CDAD has been increasing, and severe cases are becoming more common http://wwwnc.cdc.gov/eid/article/13/9/06-1116_article.htm

Good point, Doc.. and C-diff has been found to occur with single rounds of some abx, like Clinda...

 

[Unregistered]

Update from the OP:

Halfway through the course, my mother developed problems with her right achillies (sp?) tendon. Apparently that is a possible side effect of Cipro. She was on her way to recovery at that point. We saw her regular doc, and she took my mom off Cipro, without prescribing another medication. But so far, things seem to be improving, both with her cold and with her tendon.

 

[Unregistered]

OK, I found this forum because one of my dad's old friends sent me the link. I don't fly, my dad worked in avionics and I am a nurse with CDC training. Good for GaryF 's comments...he sounds like a good physician. Cipro's side effects are well known. Calling in a prescription for ANY antibiotic for a runny nose is an absurd action to begin with. For the record, I am a former public health nurse epidemiologist who spent years tracking reportable diseases and conditions then worked as an STD Clinician and later as an Infection Control Practitioner.
Antibiotics do nothing for virus infections and present risks when given without due cause, especially for the elderly and very young.

If a practice I went to did this kind of thing...they would be history. I feel that calling in a prescription without knowing the patient and assessing them is really outrageous.

 

[Unregistered]

Gary sometimes its just not worth the waste of time. Face up to it, some nonphysicians just know more about medicine than physicians.

That is a bizarre statement. As a nurse who spent years in public health working with all kinds of diseases and conditions (acute and chronic...) I can tell you that there are some docs I wouldn't give a nickel for, but GaryF sounds like he is well versed in this matter.

Many of us nurses with advanced degrees know a lot about medicine...add in years of practice and we know that VERY few nonphysicians (sic) are more knowledgeable about "medicine" than physicians.

 

[bbchien]

If a practice I went to did this kind of thing...they would be history. I feel that calling in a prescription without knowing the patient and assessing them is really outrageous.

Everybody's a doctor, i guess including you. And you don't even have the guts to identify yourself. Throwing stones anonymously.

I'll start with, how do you know this practice didn't know the patient? Her history of Chronic episodes of COPD exacerbations? That the Son was unwilling/unable to bring her to the doc? That out here in the community the ratio of patients to MDs can be 4,500:1? That....oh just fuggedaboudit.

I have an infectious disease fellowship. I do think ideally everyone need be seen. Now LEAVE THE BIG CITY and do some engangement in the field, oh high and mighty anon pharisee.

And in the meantime, your comments get filed in the "almost a FP" column. Sheesh. And I have LOTS of initials behind my name. TWO residencies, a fellowship and FOUR boards.


To post #101, in our community, the infection control nurse is someone who ran to an admin job. because they couldn't hack it on the floors. There are SOME nurses I wouldn't give a dime for. Want to tell me about the bacteriology of lungs that have chronic COPD? How about the needless mortality of letting one of those go an excess # of hours without transient suppression? Or about the fact that a chest xay, CBC, and/or an exam, in this situation rarely changes the decision?

Did you, oh stone thrower even know that the major reservoir of resistant bacteria isn't even in humans? Want to guess where the reservoir is? I'll let you dangle for a while...I have just recently retired, and it's in part because of "experts" like this I.D. Control nurse.....if you wanted to speak with authority, you shoulda gone to medical school. You MIGHT have a hint of the global view of the situation, not just the narrow "the rate is such and such". Yes, those things require address. But not without the large perspective.

This sort of c_ap ****es me off enough, that you may take this as my annoucement of a POA holiday. I'll not be coming here again for QUITE a while. Thsoe of you who need/want to ask things, you know where to find me.

 

[Doggtyred]

That is a bizarre statement. As a nurse who spent years in public health working with all kinds of diseases and conditions (acute and chronic...) I can tell you that there are some docs I wouldn't give a nickel for, but GaryF sounds like he is well versed in this matter.

Many of us nurses with advanced degrees know a lot about medicine...add in years of practice and we know that VERY few nonphysicians (sic) are more knowledgeable about "medicine" than physicians.

It's called "sarcasm". That's what happens when you are new to a forum and don't know the players involved.

Thanks for playing.

Theres quite a few MD's on this thread. I'm not one of them.