I hate this topic. I really do. But Abel started it this time. Over at Terra Sig, the good pharmacologist brought up the issue of pharmacists behaving badly. I’ve dealt with the ethical implications of conscience clauses ad nauseum but Abel’s discussion raised some important points.
A brief recap: a patient with a valid prescription for morphine was denied her medication by a pharmacist. The reason given was “that [the patient] should find some alternative pain relief”, presumably one that does not involve opioid analgesics. I won’t bother with my usual rant about the responsibility of pharmacists, because I’ve said it all before. From the discussion, here are some points I’d like to highlight:
First, while it is true that opioids are often diverted, there are fail-safes in place, and if someone like the patient in the post clearly has a valid prescription and a history of filling the same prescription regularly, there is essentially no reason to suspect diversion.
Second, the patient mentioned a “pain contract” that she signed, which basically prevents her from going to another pharmacy. I, too, use such contracts, for the protection of both me and the patient. It basically says that I will treat her pain adequately and that she will not behave inappropriately. In recognition of the addiction and diversion danger, it requires the patient to stick to a particular pharmacy, to avoid inappropriate phone calls asking for meds, and to receive pain pills only from me. Violation of the contract allows me to discontinue prescribing narcotics for the patient. These contracts can be burdensome to both parties but they are usually necessary, unfortunately.
Finally, I was very disappointed by Ms Red Deer’s doctor. The physician seemed, per Ms Red Deer, unconcerned by the pharmacy’s actions. This is where I start to lose my shit.
As a physician, my job is not only to walk into a room and prescribe medications. It is to listen to patients, to assess their needs, to advocate for them. If, for example, my patient is being abused by her boyfriend, I have an obligation to listen and to provide resources for help, even though I’m “just an internist”. If my patient was told by their gynecologist to get a hysterectomy, and the reason is not clear to me, I am obligated to speak to the doctor and get her a second opinion if necessary. If a pharmacist denies my patient a valid prescription I have written, I am personally insulted and angry. But more important, I have to show the patient that I am angry on her behalf, as this is one way of showing compassion.
When my patient is happy, I should share some of that joy. When she is sad, I should share the sadness. Empathy is an important part of the glue of the physician-patient relationship. If you cannot develop an nice helping of righteous anger on behalf of your patient, the level of trust is going to drop a notch. Listen to your patients. Insulate yourself to an extent, but show some emotion, show you get it. It’s part of what we do.