White Coat Underground

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.

Comments

  1. #1 MikeMa
    March 13, 2009

    Most pharmacists do not own their pharmacy I think. Wouldn’t a call to the owner have some impact when presented as you do with the contract stipulations? If nothing else it would imply a loss of business if not the more oppressive loss of compassion.

  2. #2 Elissa
    March 13, 2009

    It may be part eleventy – but it clearly still needs to be said.

  3. #3 Mike
    March 13, 2009

    Mikema: Who is the owner you are going to call if a CVS pharmacist refuses to fill a prescription? If it is a small non chain pharmacy there is a good chance that the pharmacist is the owner or co-owner.

    About the OP: The company culture of pharmacists varies between stores. Walgreens informally encourages their pharmacists to contact police and catch as many fake scripts that they can. In contrast Target pharmacists are prohibited from contacting police over a fake script. In certain pharmacies, multiple fake script for controlled drugs are received every day. This puts all prescriptions for controlled drugs under a cloud of suspicion. But after a call to a doctor to confirm that the script is legitimate, the prescription should be filled.

  4. #4 JLK
    March 13, 2009

    No offense to the profession as a whole, but my question is – how do I find a primary care doctor like you who actually Gives A Shit?

  5. #5 Abel Pharmboy
    March 13, 2009

    Gotta say I’ve learned something from my pal, PalMD, and my commenter, Ms Red Deer. I had not known about “pain contracts.” Sounds like a really good idea to keep these issues from arising.

    My bigger concern, perhaps bc I’ve lived in big cities and very rural areas, is what is a pt to do when the next pharmacy is 30-60 miles away?

    @JLK, there are some great internists out there who are as caring as PalMD. Outside of moving to his town, I’d suggest you look at your “Best Doctors” category of your local indy rag or regional magazine. But I’d move to Pal’s town.

  6. #6 leigh
    March 13, 2009

    i don’t frequent pain management specialists like i used to, but as far as i have heard the pain contract is pretty common for chronic opioid therapy.

    the one that my husband entered into included a psych evaluation for personality traits that may lead to drug misuse and randomized drug testing to occur at any of his appointments. also, a strict record of doses taken, and finally all remaining pills were to be brought to the clinic for all appointments. any of these requirements being unmet led to the patient having their narcotics revoked and they also got handed some scripts for the withdrawal symptoms.

    that’s some serious stuff, afaik the dea is able to go after doctors when their patients distribute the drugs.

  7. #7 Whitecoat Tales
    March 13, 2009

    I’m a med student, can I conscientiously object to pre-rounding at 5 in the morning? I think its ethically wrong to wake to poke and prod them that early in the morning…

    … Or does the fact that poking and prodding them in the morning leads to better medical care supercede that?

    You know what else leads to better medical care? Pharmacists filling out the prescriptions they’re given. If a doctor is doing something irresponsible or dangerous, call the doctor. But if not, I could care less about your morals. Like the situation in the original article, life is far more complicated than “ooh morphine, shes a drug seeker, MORALS CLAUSE”.

    This is grossly irresponsible. Pharmacists do alot of good by checking doctors mistakes, often suggesting better alternatives, catching polypharmacy, and a variety of other ways they improve patient care. But they cannot make a diagnosis, and without knowing one, they should not be dictating care.

  8. #8 Donna B.
    March 13, 2009

    The problem with finding a doc like PalMD is that he’s not covered by my insurance. I’m stuck with whoever I’m assigned to and, thankfully, most of them have been as good as PalMD.

    I happened to be sitting in my doc’s office when he took a call from a pharmacy asking about conflicting medications. He had prescribed both, explained his reasoning about this particular patient to the pharmacist and thanked him for his diligence.

    That’s the way it’s supposed to work, isn’t it?

    I’m wondering if the Scott Reuben fraud is relevant here… have I misunderstood that his work on NSAIDs being as effective as opiates in post-surgical pain relief is now null and void until real studies can be done?

    Did his work contribute to the attitude that Tylenol works just as well as morphine?

  9. #9 DuWayne
    March 13, 2009

    This has me mad as hell and scowly.

    I am really sick and damned tired of hearing this crap. It makes me this angry when it’s birth control too, but this is just getting scary.

    I am taking drugs now, that a lot of folks think are just Evile and should never be used. I am also slowly but surely getting my head right, with medication and cognitive therapy. The main reason I got the script for Xanax, was so I could deal with my Friday therapy sessions. It also helps with mediating my moods, but has unfortunately not really stabilized them the way we were hoping (I don’t take it every day). So I am going on Seroquel (rather than the Depakote my doc initially recommended), starting tonight. And I’m already on Ritalin too.

    So what the hell is to keep a pharmacist from deciding that they think the drugs I’m on shouldn’t be prescribed nearly so often as they are? What’s to keep them from deciding that they just don’t think I should be taking these scripts and refusing to fill them? I mean I’m pretty sure that at the Wal Mart pharmacy I use, because it isn’t as difficult to manage the cost there (no insurance), such a pharmacist wouldn’t likely be a pharmacist there for long. Not to mention they always have multiple working at any given time. But hypothetically, I could totally see this happening with the drugs I’m taking.

  10. #10 bob koepp
    March 14, 2009

    PalMD – I think you might be glossing over some important issues when you assimilate the present case to others where professionals have “appealed to conscience” to recuse themselves form providing certain services. But since I’m blinded by idiocy, maybe I didn’t notice where the pharmacist in question made a purportedly moral claim.

  11. #11 PalMD
    March 14, 2009

    Ethically, it doesn’t matter whether the pharmacist appeals to morals or to Great Baal or Jock Itch—if she refuses to fill the med, she’s wrong.

    That being said, in the case discussed, when the pharmacist mentioned finding another way to control pain, that was a moral judgment about opiates, no different from one about plan B or OCPs.

  12. #12 DuWayne
    March 14, 2009

    Bob -

    But since I’m blinded by idiocy, maybe I didn’t notice where the pharmacist in question made a purportedly moral claim.

    Since you brought it up – yes, you’re blinded by idiocy.

    I have some pretty severe neurological issues that are prohibitive to my academic and by extension, professional success. I have close friends who have explained to me that they to have similar problems that they managed to deal with without resorting to medication. They don’t like how often the drugs I am taking are prescribed and have tried to convince me that I should try different methods to deal with these issues. (one is no longer a friend, the other two figured out that I’ve been dealing with this shit my whole life and am not stupid – they finally got it)

    Do you not see the moral judgment in their position?

    It’s bad enough when it’s one’s friends taking these kind of moral stances. But one can choose their friends. When it’s that asshole licensed by the state to perform a certain function, they need to perform that function – regardless of their moral stance on a particular drug or type of drug.

  13. #13 bob koepp
    March 14, 2009

    I don’t recall defending the pharmacist who refused to fill Red Deer’s prescription. I did say that responsible commentary required more information, and more recently, questioned the relevance of this case to disputes about so-called “conscience clauses”. The moral and legal dimensions of these issues are more nuanced than our friendly host, who is not, however, an idiot, merely ignorant.

  14. #14 Joe
    March 14, 2009

    PalMD | March 14, 2009 10:33 AM “… if she refuses to fill the med, she’s wrong.”

    Consider the general case- some of your colleagues are less than competent and a pharmacist must refuse to dispense inappropriate medication.

    In this case, the pharmacist erred in not consulting the doctor before forming an opinion. That is a HUGE mistake.

  15. #15 khan
    March 14, 2009

    This is an issue I have been following for a long time.

    I have hereditary crippling arthritis (I’m sure there’s a medical term). I will need a caretaker in 10 or so years.

    The government (even in OR & WA) won’t allow the doctors to help me die because arthritis is not terminal. And now we have the dickhead ‘moralists’ saying people in severe/chronic pain have a moral failing?

    Is there a word for people who enjoy inflicting pain?

  16. #16 Steve Schonfeld
    March 14, 2009

    I’m wondering if the Scott Reuben fraud is relevant here… have I misunderstood that his work on NSAIDs being as effective as opiates in post-surgical pain relief is now null and void until real studies can be done?

    Did his work contribute to the attitude that Tylenol works just as well as morphine?

    Well, first of all, Tylenol isn’t an NSAID.

    Secondly, while Reuben’s work cannot be trusted, there is a whole body of good literature showing that NSAIDs are as or more effective than opioids for certain types of somatic pain. They are generally more effective and have fewer short-term side effects for pain relief in third molar (wisdom tooth) extractions, for example.

    You can do a Medline search (http://www.ncbi.nlm.nih.gov/sites/entrez/) on “third molar extractions and NSAID” and see for yourself.

  17. #17 Donna B.
    March 14, 2009

    Thanks for answering my question, Steve. We lay people tend to lump Tylenol with the NSAIDs available OTC as good for general pain relief.

  18. #18 Whitecoat Tales
    March 14, 2009

    Re: Joe

    “Consider the general case- some of your colleagues are less than competent and a pharmacist must refuse to dispense inappropriate medication. ”

    Thats not the general case here. There was no question made as to the medical reason for the prescription. There was no question about side effects, or compatability with the patients other medications – these are the things that pharmacists commonly know, and doctors commonly don’t.

    The pharmacist here either said “Opioids aren’t medically appropriate here” or “I morally disagree with using Opioids in this patient”. A pharmacist is not equipped to determine the former without extensive paperwork documenting the patients medical condition, and the latter is what we’re discussing here.

    I apologize if anyone takes offense at the “equipped” above, thats not the intent. Pharmacy school is not medical school. Even if it was, one cannot look at someone and decide what medications are appropriate, it takes a workup that the pharmacist in the article did NOT do).

  19. #19 DuWayne
    March 14, 2009

    bob -

    I don’t recall defending the pharmacist who refused to fill Red Deer’s prescription.

    And who exactly is saying you did?

    I did say that responsible commentary required more information…

    Why? Even if the commenter who told her story and started this was completely making it all up, every one of Pal’s points still stand.

    …and more recently, questioned the relevance of this case to disputes about so-called “conscience clauses”.

    And that point has been responded to by me and while I was typing my response, Pal. Points you don’t actually refute.

    The moral and legal dimensions of these issues are more nuanced than our friendly host, who is not, however, an idiot, merely ignorant.

    The legal dimensions will vary from state to state, unfortunately. But the moral issue is not the least bit nuanced here. If you take a state licensed job, you should do the damned job. If there are aspects of that job that disturb you, you shouldn’t go into that profession.

    If you believe that opiate based pain management is wrong, to the point you believe it is wrong for you to fill scripts for opioid pain killers, you should not become a pharmacist. If you believe that birth control pills are wrong to the extent that you can’t fill scripts for them, you shouldn’t be a pharmacist. If you think that psych meds do more harm than good, to the extent that you can’t fill scripts for those, you should not be a pharmacist. If you believe that antibiotics are far too dangerous, because using them creates super-bugs and don’t feel you can fill scripts for them, you shouldn’t be a pharmacist.

    There isn’t a single damned moral nuance, that makes it ok for the damned pharmacist not to fill a damned script, outside of very narrow damned parameters. Unless there is a contraindiction or a great deal of evidence that the patient in question is committing fraud, the pharmacist has no reason not to fill the damned scripts – period. No moral goddamned ambiguity there at all. If you can’t do the damned job, then that job isn’t for you.

  20. #20 The Blind Watchmaker
    March 14, 2009

    Pharmacists can and do overstep their bounds. Giving out medical advice is out of their bounds. In fact, how can anyone give proper advice to a patient (including doctors)if they essentially know nothing about the patient. The pharmacist is separated from patients by the counter.

    I would be very wary about taking advice from someone who has no problem selling isles of SCAM treatments like Ginkgo and Airborne.

    As the son of a pharmacist, I have a lot of respect for pharmacists. They have to undergo a lot of training. However, being trained in pharmacy does not mean they get to practice medicine. They don’t pay nearly enough malpractice insurance for that.

  21. #21 Joe
    March 14, 2009

    Whitecoat Tales | March 14, 2009 5:13 PM wrote “Thats not the general case here.”

    Try to follow along. I said the specific case, here, was wrong. ‘Kay?

  22. #22 PalMD
    March 14, 2009

    What he said.

  23. #23 Whitecoat Tales
    March 14, 2009

    Joe I’m not even argueing, I followed that you said in this specific case the pharmacist was wrong.

    I was pointing out that we were discussing conscience clauses, and the general case for conscience clauses does not include “The doctor did something medically wrong in prescribing this medicine”. The general case in conscience clauses is “While the doctor may be prescribing this medication appropriately, I feel it is immoral to prescribe it”

    My apologies if you took offense.

  24. #24 bob koepp
    March 14, 2009

    “The general case in conscience clauses is ‘While the doctor may be prescribing this medication appropriately, I feel it is immoral to prescribe [dispense] it.’”

    I doubt that you can find conscientious objectors in the healthcare world who would subscribe to this statement. In what sense would objectors see the prescription as appropriate? Presumably, they wouldn’t see it as morally appropriate. Nor are they likely to view it as medically appropriate, as indicated for the amelioration of some pathological condition. I would agree that when there’s a clear medical indication for the intervention, objectors are bumping up against professional obligations, and probably should find a different role to play where they won’t confront such dilemmas. But typically, conscientious objections have been raised in cases where the interventions in question are frequently elective, not medically indicated. That influences the way professional obligations figure in the cases.

    It’s precisely because in Ms Red Deer’s case the pharmacist could easily have dispelled any doubts about the medical appropriateness of the prescription, but apparently didn’t bother to do so, that the case seems so odd. And simply saying she should “find a different medication” isn’t expresing a moral objection to the drug. So what’s actually going on here?

  25. #25 Whitecoat Tales
    March 14, 2009

    Lets take a specific case so we can agree on some sort of definition of “medically appropriate”.

    Are oral contraceptives “medically appropriate”? In some cases they are indicated for the amelioration of some pathological condition. Note that I am NOT describing pregnancy as a pathologic condition, a number of gynecologic problems are treated with oral contraceptive pills. Additionally they can be prescribed as contraception.

    Who is the pharmacist to say that the former is an appropriate use and the latter is not? I sincerely doubt that pharmacists who object to OCP on moral grounds call physicians to check the prescribing indication when denying healthcare. I admit thats an assumption, rather than data, but if someone has data on the subject I’d love to see it.

  26. #26 DuWayne
    March 14, 2009

    Nor are they likely to view it as medically appropriate, as indicated for the amelioration of some pathological condition.

    Bullshit bob. I am absolutely certain, beyond a shadow of a doubt, that the “conscientious” objectors to filling birth control scripts generally don’t believe that the medication they are refusing to sell doesn’t work. And in the case of BC, all the damned pharmacist knows, is that the medication was prescribed by a doctor – they don’t necessarily know what for. And there are other uses for hormonal BC than just avoiding getting knocked up.

    But lets assume that this is never the case. Let’s assume that all the women going in for BC scripts are doing so to avoid getting pregnant. As long as that drug is prescribed by a doctor, the damned pharmacists feelings about BC are irrelevant. Again, if they don’t want to fill scripts for BC, the morning after pill or penis pills, they are not required to be fucking pharmacists. I don’t give a damn what the script is or the reason it’s prescribed. If the doctor prescribed it and the very narrow criteria of contraindiction or abuse doesn’t come into play, then a pharmacist has an ethical obligation to fill the damned script.

    This is not much different than someone claiming they should have a right to work in a convenience store that sells booze and not be required to ring up customers buying alcoholic beverages. Sorry asshole, it’s part of the job description.

    And simply saying she should “find a different medication” isn’t expresing a moral objection to the drug.

    You keep claiming that as though it’s actually true. First, he didn’t say you should find a different medication. He stated that she should find some alternative pain relief, which is not the same damned thing. And that pretty well clinches it as a moral objection. But even if he claimed she should find a different medication, it is still quite likely a moral objection.

    I explained the moral objection. To make it clearer, someone who doesn’t believe that antibiotics should be prescribed at all (and yes, such people exist) because using them is likely to create more super-bugs, is making a moral objection to the use of antibiotics. The fact that there may be some reality to the objection, doesn’t make it any less a fundamentally moral stance. We make firm moral stances every day that are firmly grounded in logic and reason, that doesn’t mean that those stances aren’t fundamentally grounded in our moral frames.

    Let me ask you bluntly. Do you think it would be reasonable for a pharmacist who firmly believes that the psych meds I’m taking are really bad for me, should be allowed to refuse to fill my scripts? Not because they’re contraindicted, this pharmacist truly believes that psychotropic drugs are actually one of the worse things you can give a person. Should that pharmacist be legally or ethically entitled not to give me my damned pills?

    It’s not even that uncommon a belief. There are a lot of people who really and truly believe that no one should take the drugs I am on. They believe that the drugs I am on are far worse than the neurological issues they are supposed to be treating. So if a pharmacist happens to be one of those people, should they be required to fill my script? If not, why not? Either way, do you understand that their objection is fundamentally a moral objection? If not, then what the hell is it exactly?

  27. #27 Whitecoat Tales
    March 14, 2009

    DuWayne and Bob,

    I agree with DuWayne, lets take a realistic case, a Scientologist pharmacist. They disagree with psych meds on principle, they would disagree that psych meds are inappropriate medical therapy. Should a Scientologist pharmacist not be required to prescribe antidepressants?

    No, a scientologist pharmacist who won’t prescribe antidepressants, should NOT be a pharmacist.

  28. #28 bob koepp
    March 14, 2009

    DuWayne – I don’t recall saying that anybody believed birth control is ineffective, or that it isn’t sometimes medically indicated. Who or what are you arguing against?

    OK, the pharmacist siad ‘she should find some alternative pain relief’. What’s missing here is any informtion about _why_ the pharmacist thinks this. Absent that bit of information I don’t think we can say that the pharmacist’s objection was based on moral considerations.

    As for your blunt hypothetical question, I’m afraid it’s incoherent. The pharmacist who sincerely believes the psych meds are bad for you would, presumably, also believe they are contraindicated. (BTW, simply because something is not indicated doesn’t mean it’s contraindicated).

  29. #29 bob koepp
    March 14, 2009

    Whitecoat Tales – Please note that a couple posts back, I said:

    “I would agree that when there’s a clear medical indication for the intervention, objectors are bumping up against professional obligations, and probably should find a different role to play where they won’t confront such dilemmas.”

    So I don’t hold the view that you apparently think I do.

  30. #30 Whitecoat Tales
    March 14, 2009

    Whats the definition of a clear medical indication?
    Most people would say OCP is clearly medically indicated for the prevention of pregnancy. It’s FDA approved to be used in that capacity. What is the inherant difference between a Scientologist who disagrees with prescribing antidepressants, and a Christian who disagrees with oral contraception?

  31. #31 DuWayne
    March 14, 2009

    Bob, you’re either really fucking stupid or being willfully obtuse. I tend to give people the benefit of the doubt on intelligence, so I am going to assume the latter. In case I am wrong however…

    I don’t recall saying that anybody believed birth control is ineffective, or that it isn’t sometimes medically indicated. Who or what are you arguing against?

    I’m arguing against this:

    Nor are [conscientious objectors] likely to view it as medically appropriate, as indicated for the amelioration of some pathological condition.

    Which would imply that said objector, does not believe that birth control, if that is what they are objecting to, is medically appropriate.

    The pharmacist who sincerely believes the psych meds are bad for you would, presumably, also believe they are contraindicated. (BTW, simply because something is not indicated doesn’t mean it’s contraindicated).

    Guess what bob, I’m well aware what contraindicted means. It means that something else the patient is taking would likely cause a serious reaction if interacted with the drug in question. Or that the patient is likely to have a bad reaction to the drug, because of a separate condition.

    As far as the pharmacist believing that the meds I am on are going to make my condition worse, it’s irrelevant. They are not allowed to make that determination, the FDA does that.

    So answer the question bob. Is it ok for the pharmacist who feels that way to refuse to fill my damned scripts? If not, why not?

    What’s missing here is any informtion about _why_ the pharmacist thinks this.

    We have the pharmacist’s refusal to fill the damned script, or to follow professionally prescribed procedures. The exact thinking involved is irrelevant. When a person chooses to impose their views on someone else, stepping entirely outside the bounds of their professional purview, they are making a moralistic decision to do so. Ultimately, even following procedure, a lot of pharmacists who give people shit over pain meds, are probably doing so for moral reasons. But when there is a willful abandonment of proper procedure and rationality, such as there is in the described situation, then the motivation left is moral in nature.

  32. #33 DLC
    March 15, 2009

    Hm. Gotta agree with PalMD on this. The pharmacist should have given the opioid. It’s not up to the pharmacist to decide that Jane Doe or Joe Smith “Doesn’t Need” morphine.
    If Jane or Joe’s doctor legitimately prescribed morphine then that’s what they should get. Full Stop.

  33. #34 bob koepp
    March 15, 2009

    Whitecoat Tales – You say, “Most people would say OCP is clearly medically indicated for the prevention of pregnancy.” Are you assuming that the prevention of pregnancy is itself medically indicated? Usually it’s not.

    DuWayne – Get a grip, and learn some basic logic.

  34. #35 Whitecoat Tales
    March 15, 2009

    Bob – I asked you for a definition of “medically indicated” a few posts back because I felt “amelioration of some pathological condition” is a crap definition that doesn’t fit a large portion of medications we consider standard of care.
    For example, all primary preventative care does not ameliorate a pathological condition (secondary preventative care I don’t think you’d argue about). Many would say prevention of an unwanted pregnancy is primary preventative care. Infact a quick google of the term reveals few definitions, and at least 3 books on bioethics.

  35. #36 bob koepp
    March 15, 2009

    Whitecoat Tales – I was being less than precise in speaking simply of “amelioration” of pathological conditions. Prevention of such conditions is clearly medically indicated. But pregnancy, even if unwanted, is usually not a pathological condition — not in the medical sense of ‘pathology’. So when pregnancy is not itself medically contraindicated, its prevention is not medically indicated, but strictly elective. And typically, there is not a professionally grounded obligation to provide such elective services.

  36. #37 PalMD
    March 15, 2009

    the whole “medically indicated” trope is so idiotic that my head just asploded.

    it is entirely meaningless in the context of modern medicine. “medically indicated” is whatever the standard of care and the md and her patient say it is. I mean, with bob’s inane defn, you could say that a tylenol isn’t medically indicated unless someone’s pain level is above “6″ or some such nonsense.

    Really, anyone who practices medicine would find the entire concept quixotic.

  37. #38 PalMD
    March 15, 2009

    …and, bob, there most clearly IS a professional obligation to provide such services. Truly your ignorance is unbounded.

  38. #39 DuWayne
    March 15, 2009

    bob -

    The irony of your statement about me and logic is simply staggering.

    And I may just get a grip when you can explain logically, how some jackass in a pharmacy has a right to decide they aren’t going to fill a legitimately prescribed script from the patients doctor. Because while you keep making an awful lot of claims here, you provide no reasoning to support those claims.

  39. #40 Whitecoat Tales
    March 15, 2009

    Bob – Thats a crock of shit, lots of medicine is “elective” yet still considered standard of care. Infact, C-sections, do not ameliorate a pathological condition in many instances. Alot of the time doctors induce them for no pathological reason at all. Should an anesthesiologist be allowed to say “Nope, not gonna give her pain meds, its not a medically indicated procedure to me?” I can tell you what would happen to such an anesthesiologist at my hospital, they’d be out on their ass.

    PalMD – clearly you’ve learned something I haven’t, I need to learn when to stop feeding the trolls.

  40. #41 bob koepp
    March 15, 2009

    There’s nothing at all idiosyncratic about the way I’m using the term ‘medically indicated’ to contrast with ‘elective,’ and it’s not equivalent to ‘standard of care,’, though it’s included in that category.

    And Pal, you say here and now that ” there most clearly IS a professional obligation to provide such [elective] services,” though elsewhere you have said that “Doctors are not ethically obliged to perform elective/cosmetic procedures, in most cases.” Seems you’ve got a problem with consistency.

  41. #42 PalMD
    March 15, 2009

    Bob, an individual doctor can decide who to treat and who not to treat, but with certain limitations and consequences. An ER doc who is on a shift and refuses to treat a gunshot victim because of the circumstances, their own squeamishness, or whatever can indeed refuse to do so—and be summarily fired. A doctor who joins an OB practice that explicitly performs elective abortions can refuse whatever he wishes—and be summarily fired.

    A doctor who refuses to treat pain adequately because they feel it shows stronger moral fibre to suck it up can do so, but can be sued for failing to fulfill his duty to treat a patient properly and with respect.

    Doctors cannot be coerced into doing anything, including being a doctor.

  42. #43 bob koepp
    March 15, 2009

    Pal – I don’t disagree with the statments you make in your 9:58 post. But none of them is incompatible with providing scope for conscientious objections in healthcare, if that notion is properly understood. Just because some provider calls “Conscience!” doesn’t mean his or her “appeal” actually will be acknowledged as a bona fide case of conscientious objection. There are a lot of cases, like the refusal to provide IVF to a lesbian, where the “appeals” are shot down, and appropriately so, because they didn’t meet the requirements for conscientious objections to be respected. Rather than simply deny that there can be legitimate conscientious objections, we need to clarify what distinguishes the legitimate and the illegitimate cases.

  43. #44 ema
    March 15, 2009

    bob koepp,

    Are you sure you want to play the “medically indicated” shell game at a medblog? Because if you do, I’m game:

    But pregnancy, even if unwanted, is usually not a pathological condition — not in the medical sense of ‘pathology’.

    Define pathological condition…in the medical sense of ‘pathology’. [Hint: This is a trick question when dealing with pregnancy.]

    State the morbidity and mortality of pregnancy.

    Support your claim that the contraceptive and noncontraceptive benefits of OCPs are not medically indicated.

    [W]hen [X] is not itself medically contraindicated, its prevention is not medically indicated….

    It would be most helpful to practicing physicians everywhere if you could explain how a pharmacist makes a proper medical determination by simply looking at a stranger. [Mind you, the medical profession has been working on this trick for a long time, but no luck so far.]

  44. #45 PalMD
    March 15, 2009

    ema, please explain to me why the hell it’s take this long for me to hear of you…jeez, why do i always get left out

  45. #46 ema
    March 15, 2009

    PalMD,

    Heh, usually I lurk but a righteous “advocating for my patients” rant was just too hard to resist.

  46. #47 PalMD
    March 15, 2009

    I don’t think i’ve ever seen such a good pic of a cervix on line…almost like im there myself…

  47. #48 bob koepp
    March 15, 2009

    ema – By ‘pathological condition’ I mean (roughly) a condition where a natural functional capacity is compromised. I could give you a long and detailed account of how the notion of ‘natural functional capacity’ is understood in light of the theory of natural selection, but I’ll pass on that for now.

    I won’t go look up the actual numbers for morbidity and mortality of pregnanc. I know that it’s a very risky business with serious long term sequalae. So pregnancy is certainly classified as a risk factor. But a risk factor is not the same thing as a medical pathology. And sometimes the risks associated with pregnancy are sufficiently severe that pregnancy itself is contraindicated. When that’s the case, contraceptives are unproblematically medically indicated. I’ve never suggested otherwise. But normal pregnancies, despite the significant risks, are viewed as part of normal functioning, and so not pathological.

    I’ve never claimed that pharmacists are qualified to make medical determinations by looking at a person. The fact that some pharmacists have done so while claiming the protection of conscientious objection doesn’t mean they were right to do so. But that doesn’t mean a pharmacist couldn’t, in a responsible and respectful way, learn whether a prescription was written for a medical indication.

  48. #49 ildi
    March 15, 2009

    DuWayne: “To make it clearer, someone who doesn’t believe that antibiotics should be prescribed at all (and yes, such people exist) because using them is likely to create more super-bugs, is making a moral objection to the use of antibiotics. The fact that there may be some reality to the objection, doesn’t make it any less a fundamentally moral stance. We make firm moral stances every day that are firmly grounded in logic and reason, that doesn’t mean that those stances aren’t fundamentally grounded in our moral frames.”

    Beautifully put. Using an example of a moral position based on reason rather than religion makes the argument more nuanced and more powerful for me.

    bob the troll: Your high school debating techniques have no power here!

  49. #50 DuWayne
    March 15, 2009

    And I note that bob still has yet to actually explain what makes it ok for pharmacists to refuse to fill a script. And now he seems to be arguing with actual doctors over the definition of medical terms.

    ildi -

    Thank you, but I have to take exception to the high school debating techniques bit. I was once an assistant debate coach (mostly judging) and worked with a lot of kids who are actually pretty damned good. Far higher caliber than bob.

  50. #51 ema
    March 15, 2009

    bob koepp,

    Your definition of a pathological condition…in the medical sense of ‘pathology is a condition where a natural functional capacity is compromised. Fine.

    Not only is implantation indistinguishable from a neoplastic process (with all the anatomical/functional compromise that entails), but everything from lung function to intestinal transit time is compromised by pregnancy.

    Also, the only “normal” pregnancy is one that’s delivered, with satisfactory Apgars.

    Just because women are willing to become pregnant and tolerate the impact of a pregnancy on their system[s] and pregnancies are viewed as part of normal functioning (?) that in no way changes the fact that a pregnant state is a compromised one when compared to a nonpregnant one.

    It’s not up to a physician (or pharmacist, for that matter) to elect when a patient is to become pregnant. That medical decision is up to the patient.

    But that doesn’t mean a pharmacist couldn’t, in a responsible and respectful way, learn whether a prescription was written for a medical indication.

    Yes, because when you’re a female patient of repro age, having to share your medical history and the details of your gyn exam with a polite stranger in a public place in the hope that said stranger’s personal beliefs will allow him/her to deem you worthy of access to proper medical treatment should be a requirement for having a script filled.

    Of course, to be fair to responsible and respectful pharmacists, there’s always the possibility that they’ll forgo the public patient interrogation in favor of just cracking open a PDR and looking under FDA-approved (muahahaha) indications for OCP use like, you know, contraception.

  51. #52 PalMD
    March 15, 2009

    I think one of the basic problems here is that bob wants to redefine the role of the pharmacist, and create a sort of clinician. The problem here is that the patient has not consented to this relationship, the pharmacist isn’t trained for it, and THE WHOLE LINE OF REASONING (sic) IS BULLSHIT.

  52. #53 Marilyn Mann
    March 15, 2009

    In order to find a good internist I had to go to one who doesn’t take insurance. In addition, his fees are pretty high, although he spends a lot of time with each patient. I have Blue Cross, so they cover some portion of it. I had a question recently and he actually researched it in the medical literature and sent emails to a number of local specialists asking their views on the issue. He also gave me his email address and cell phone number, and he doesn’t talk to drug reps.
    You get what you pay for, I guess.

  53. #54 DuWayne
    March 15, 2009

    Just so we can see exactly what sorts of legislation are or have been bandied about by various states, regarding bob’s precious damned “conscience” clauses – here is a listing of them. While many of them do specify reproductive health issues (not to say that I approve of a damned one of them), many of them are blanket clauses that would meanany damned thing the pharmacist or other health care professionals disagree with. This would include every damned hypothetical I listed, including my own damned meds.

    I honestly don’t know which got me more riled up, bob’s inane bullshit or what I found while looking into this. But this is absolute insanity. Chalk up yet another thing for me to get irritable and write about. Just as I was intending on writing about my recent visit to the therapist, then my doctor (back to back, which was rough). It is shaping to be a rather different post than initially intended, which should have just been about my new meds – day two. Still up in the air, but not looking grand – brain not entirely functional.

  54. #55 KristinMH
    March 15, 2009

    Actually, DuWayne, you seem to have kept your temper better than I would when dealing with an asswipe like bob. Bob, the next time you feel the need to tell someone with a psychiatric condition to “get a grip”, do yourself and everyone else a favour – go fuck yourself.

  55. #56 khan
    March 15, 2009

    To go off on a tangent:

    I was born in 1950. Back in the ’80s a lot of gynecologists decided they would not prescribe BCP to women over 30.

    I don’t know what their reasons were.

  56. #57 Juniper Shoemaker
    March 16, 2009

    Bob, the next time you feel the need to tell someone with a psychiatric condition to “get a grip”, do yourself and everyone else a favour – go fuck yourself.

    I second this. Wholeheartedly.

  57. #58 PalMD
    March 16, 2009

    khan, there is an increased risk of blood clots in women on ocps over 30, esp if they smoke. However, i don’t know of a lot of docs who have a “rule” for over 30. I do know of docs who won’t prescribe to smokers or to older smokers.

  58. #59 DPSisler
    March 16, 2009

    I agree with PalMD’s assertion. I expect, and then would demand, that my GP go medieval on this pharmacist’s ass! Luckily, I have a most excellent GP and a regular pharmacist who does not play that game. I take a high dosage of schedule II narcotics that has a high street value. The first time the pharmacist looked at it, he questioned the level and why my doctor would request such a dosage. Once I provided him the reason, his reaction was, “Oh, yes. That makes sense. I will order it for you.” I had issues with a pharmacy closer to my house, but the issue was that they would not order such a high dosage. I went to another pharmacist – and yes, I have a man crush on him ;) Never underestimate the value of a good GP and pharmacist. From a patient’s perspective, you are spot on PalMD!!!

  59. #60 bob koepp
    March 16, 2009

    ema – I can easily accommodate the each of the points you make about the biology of pregnancy under the heading of ‘risk factors’. So I assume you didn’t take into consideration how the distinction between pathology and risk affects our classification of conditions like pregnancy. But more to the point, if, as you seem to be claiming, pregnancy is always, or virtually always, a pathological condition, why don’t we find it listed as such in any of the standard nosologies? Further, if pregnancy is a pathology, why aren’t physicians routinely prescribing termination? Are they remiss? If so, why aren’t they being routinely sanctioned by medical boards? I think you haven’t thought through the issues very carefully.

    Finally, you say, “It’s not up to a physician (or pharmacist, for that matter) to elect when a patient is to become pregnant. That medical decision is up to the patient.” If you think something I’ve said implies that I want to put restrictions on reproductive freedom, you are very, very wrong. Actually, I’m a long-time supporter of the right of women to choose whether or not be become pregnant and whether or not to terminate a pregnancy. But I don’t burden this choice with the implied constraints in calling it a ‘medical decision.’

  60. #61 khan
    March 16, 2009

    I never smoked. And the same thing happened to several coworkers with different doctors. Maybe it was an Ohio thing.

  61. #62 Isis the Scientist
    March 16, 2009

    You’ve got a scrappy bunch here, Pal.

  62. #63 DuWayne
    March 17, 2009

    But I don’t burden this choice with the implied constraints in calling it a ‘medical decision.’

    Because you’re a narrow minded fucking moron.

    Having multiple inputs into a decision, does not negate any of the input. The decision to reproduce or not has a great many factors involved. The fact that one of the factors happens to be the medical aspects of the decision, doesn’t narrow anything. It’s just one of many factors involved in the choice.

    We’re still waiting however, on the reasoning that explains how this even matters. Elective or not, what makes it ok for a pharmacist to decide they won’t dispense the drug prescribed by a fucking doctor?

  63. #64 Joe
    March 17, 2009

    “Elective or not, what makes it ok for a pharmacist to decide they won’t dispense the drug prescribed by a fucking doctor?”

    Posted by: DuWayne | March 17, 2009 1:29 PM

    Try to follow this: in the case here, the pharmacist screwed-up. ‘Kay?

    In the general case, an RPh can refuse to fill a prescription that is technically in error. ‘Kay?

    That can be a drug that is prescribed at a toxically high dose, a drug that is contraindicated by allergy, a medication that is more likely to kill than cure. The latter is illustrated by the legal action taken against an RPh who dispensed IV H2O2 when it is not a recognized therapy and it is recognized as lethal (and the victim died).

    Consider the case (about 20 years ago) in which overdoses of anti-cancer drugs were prescribed at a hospital in Boston. I was surprised that the nurses who administered the drugs were also considered at fault for not recognizing that the doses were unusually high, an RPh should have caught it (and refused it).

    DuWayne, you are right that “conscience” is no reason to deny a prescription; but there are legitimate reasons for an RPh to deny a prescription. Try to make that distinction- I don’t know how else to clarify it for you.

  64. #65 bob koepp
    March 17, 2009

    DuWayne – Notice that I say I don’t burden a woman’s choice with _constraints_ that are implied by framing it as a medical decision. That means the choice doesn’t have to meet any criteria for being medically appropriate. In other words, there are other reasons besides medical concerns which can justify a woman’s choice. If that makes me narrow minded or a fucking moron in your eyes, then perhaps you need glasses.

  65. #66 DuWayne
    March 17, 2009

    No bob, what makes you a narrow minded fucking moron, is the fact that you see viewing it as a medical choice as somehow constraining. For fucks sakes, it doesn’t have to be one thing or the other. It can be a medical choice, a lifestyle choice and a eugenics choice, all at the same fucking time.

    Joe -

    Did you note what exactly I was responding to? Have you noted the several comments where I have stated when it is appropriate for a pharmacist to not fill a script? Do you really need to be a condescending asshole?

    Sorry I didn’t clarify with every damned post that there are legit reasons for pharmacists to not fill a script, but I rather assumed that folks who have been following this thread would recall that I have made that point.

  66. #67 bob koepp
    March 17, 2009

    DuWayne -
    Medical choices _are_ constrained. They are subject to standards that are different from non-medical choices. That’s what it means to be constrained. How you get from there to the notion that I’ve implied that a choice has to be “one thing or the other” is beyond basic logic, with which I’ve suggested you might acquaint yourself.

    Now I’m tired of dealing with you as if you might be a reasonable, even if incivil, person. Your medical problems, whatever they might be, are not an excuse your persistent misrepresentation of others’ views, and your insults. You, sir, are an ass.

  67. #68 DuWayne
    March 17, 2009

    Please bob, don’t worry about my neurological issues. I am in fact, an asshole. That doesn’t make me wrong or mean I am misrepresenting shit.

    Medical choices _are_ constrained.

    Bob, this is nothing more than word salad. Absolutely meaningless bullshit.

    They are subject to standards that are different from non-medical choices.

    Like what?

    The fact of the matter is bob, that reproductive decisions are ultimately medical decisions. Whatever else may contribute to the decisions made, reproductive choices have a profound medical impact, even if the choice is to abstain from sex to avoid getting pregnant.

    And the decision to take birth control pills is unquestionably a medical decision.

    How you get from there to the notion that I’ve implied that a choice has to be “one thing or the other” is beyond basic logic, with which I’ve suggested you might acquaint yourself.

    Read what you fucking wrote moron. And while you’re at it, you might acquaint yourself with basic logic.

    You, sir, are an ass.

    And you’re a fucking moron who can’t even explain why it is reasonable for a state licensed pharmacist to refuse to fill a script written by a doctor, that falls within ascribed health and safety constraints (since you’re so fond of that word). You support conscience clauses, but refuse to address why they should exist. You claim that they should only apply to non-pathological conditions – unfortunately, a great many of your fellow CC supporters disagree – see the link I posted upthread. When questioned specifically about psych-meds, you claimed that if the pharmacist believes they are bad for neuro-issues, then said pharmacist believes they are contraindicted – implying that it would be ok for them not to fill the script.

    And you wonder why people think you’re a neanderthal fucking moron? Nobody put a gun to anyone’s head here, and forced them to go to school, get a license and become a fucking pharmacist. Becoming a pharmacist, when you know what sorts of duties are required and then deciding that you don’t wish to fulfill those duties, is like going to work in a convenience store and deciding you don’t want to ring up customers buying alcohol.

  68. #69 Whitecoat Tales
    March 17, 2009

    Bob –
    Your arguments have not improved. Claiming that medical decisions are somehow constrained is infact bull.
    Pharmacists can legitimately question decisions for the reasons talked about early in this thread (reasons that Joe somehow couldn’t remember DuWayne specifically covered… reading comprehension much Joe?)
    However outside those narrowly defined regions, a pharmacist does NOT gerenally know why a med like say, an OCP is prescribed.
    It is not appropriate for a pharmacist to delay EVERY OCP prescription so that they can check with the prescribing physician if the medical indication fits with their moral code. If you can’t prescribe the drug in a timely manner, get a new job.

  69. #70 PalMD
    March 17, 2009

    In fact, that has me thinking…

    OCPs, Plan B, and related meds may deserve special protection. Since there are folks like bob out there who would disproportionately deny the reproductive rights of women, there should be a different level of scrutiny for these rxs—perhaps one where anyone denying the rx must have the most compelling imaginable reason, or face charges of discrimination.

  70. #71 Joe
    March 17, 2009

    “If you can’t prescribe [sic] the drug in a timely manner, get a new job.” Posted by: Whitecoat Tales | March 17, 2009 9:39 PM

    Writing comprehension much?

    ‘Tis true that someone who writes as much as DW cannot expect me to dwell on every word. Perhaps you can cite (for me) those posts where he admitted that an RPh can refuse to fill an Rx.

  71. #72 DuWayne
    March 18, 2009

    There isn’t a single damned moral nuance, that makes it ok for the damned pharmacist not to fill a damned script, outside of very narrow damned parameters. Unless there is a contraindiction or a great deal of evidence that the patient in question is committing fraud, the pharmacist has no reason not to fill the damned scripts – period.
    March 14 5:44

    And it’s implicit in several of my other comments, that I accept the professional obligations of pharmacists to refuse to fill scripts under those circumstances.

    Don’t care if you want to dwell on my every word or not. But pay enough attention to glean my position and not be a condescending prig who doesn’t know what he’s talking about. Makes you look silly.

  72. #73 bob koepp
    March 18, 2009

    PalMD – I see that you are emulating DuWayne in misrepresenting my views. You say I would “disproportionately deny the reproductive rights of women,” when you know perfectly well from previous discussions that I would give women greater access to reproductive control than you want them to have. You know that I’ve been advocating for Plan B to be available over the counter, so that it would be available in other venues than pharmacies — just like condoms are now. You also know that I think the data on safety support making most OCPs similarly available. Please explain to us how that amounts to denying the reproductive rights of women. Of course, both you and I know that you can’t provide any such explanation.

    You also still haven’t cleared up that little inconsistency regarding the matter of whether or not there is a professional obligation to provide elective services. Or is it just physicians, but not pharmacists or other healthcare professionals, who have rights of conscience?

  73. #74 DuWayne
    March 18, 2009

    I see that you are emulating DuWayne in misrepresenting my views.

    Bob, you are misrepresenting your own damned views. It is not the fault of any of us that you can’t express yourself clearly. And it’s not like you’re dealing with people who aren’t intelligent enough to comprehend the words you write.

    And you are still refusing to explain what makes it reasonable for a pharmacist to determine that the pills they want to refuse to fill are pathologically necessary or not. You can’t seem to explain why it’s ok for a pharmacist to refuse to fill scripts that were duly prescribed by a physician.

    All in all a huge fail bob.

  74. #75 PalMD
    March 18, 2009

    As i explain in my next post, it’s not that we are too dense to understand bob, it’s that bob is too dense to understand what he himself is saying.

  75. #76 j davis
    May 20, 2009

    Pain contracts? Drug Testing? Pharmacists refusing to fill prescriptions? Sounds like we are approaching a police state of medicine thanks to the idiots at the DEA! I have seen close friends and relatives suffer unnecessarily because doctors live in fear of DEA thugs. The pharmacist who refused to dispense the morphine should lose his or her license! Doctors should be free to treat patients as they see fit without the interference of rogue government agencies.

  76. #77 MJK06
    June 14, 2009

    unfortunately i was taking 32 paramol (UK branded codeine OTC drug) a day for over a year as it made me ‘happy’..also gave me headache so I took cheap stuff for those too. I did it also cos i didnt feel hungry and i lost over 25kg. It also helped me sleep at night which i had always had problems with. I had to trail around different pharmacies for my addiction and even got banned from two places for buying too many. Then i got them off the internet…3 packs a time. They made me more energetic and as i said happy, but they also messed up my body big time. I now have to visit the hospital a few times a years as my intestines are inflamed and bleeding and my stomach never feels right. I havent told them what i did for me to be like this as i am ashamed…they presume its colitis and give me pills for that. I wish i never did all that shit. I cost me a lot of money for what? A messed up body, pain, constipation, and i actually do feel better without. I still get tempted to get that high sometimes but prevent myself…i hope i can carry on with the willpower…

  77. #78 nyc1961
    September 14, 2009

    You mention taking “32 a day”, and it’s your bragging that is exactly what gets the USPS, DEA and US Customs to cooperate a little closer.It also people like you who have forced those Chemist to post, “we can no longer ship these products to the USA”;Point made
    It’s the 18 grams of Acetaminophen you take each day that is making you sick and wrecking your liver. Also it’s also people like you who have the FDA suggesting that opiates in Schedule III, that is Codein and Hydrocodone mixed with Acetaminophen, as being banned. What happens when they remove the acetaminophen? It places Hydrocodone and Codeine into Schedule II; read on
    By the way how does the DEA flag Doctors? Well all Schediule II medications a Pharmacy orders requires they fill out a from called DEA-222 which the DEA place into a database; Read on
    What happens when the DEA sees a lot of DEA-222 forms coming in from a particular group of Drug Stores? They go into those Pharmacies and gather up all the prescriptions written for that Schedule II medication; read on
    That is exactly what triggers an investigation into the Doctor or Doctor’s who they sbelieve are overprescribing that opiate. Next they contact the state and together the ivestigation of those Doctor’s begin.
    Finally, with Doctor’s scared those in pain who cannot find a Doctor to help them turn to other ways of dealing with their pain. Do you get it; you know the cycle?

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