Monday, October 01, 2007

The Med List

There has been a tremendous amount of (frequently justified) criticism of physicians over the years for poor handwriting. Thankfully for you, I am typing this, rather than writing it out longhand, as I must admit that my own handwriting tends to get a trifle difficult to interpret as the day wears on. Prescriptions in particular seem to be a target of late, with many calling for wider use of computer generated faxes to pharmacies rather than hand written prescriptions. That's all well and good for the docs who never leave their offices and can do so, but at least half of the prescriptions I write are handed to patients in the hospital, ED, or outpatient surgery center. When I know I am having a particularly bad "hand" day, I try to print the whole thing. In 13+ years, I have been called only a handful of times by a pharmacist for clarification, but never for inability to read my writing. (hand firmly patting back)

There is, however, another side to this coin. As much as I don't mind letting people have fun at physicians' expense, I'd like to play devil's advocate and put you into my shoes for a few minutes. An important part of the information sheet that every patient fills out in my office includes a list of medications he or she is currently taking. Here's a peek at what I commonly encounter (yes, these have actually appeared in one chart or another):

Water Pill ?
Blood Pursure (sic) 60
Doxobonosin (sic) once
Breathing medicine when I need it
Aspurn (sic) every day
Diabetes ?
? ?

This is frequently preceded by a list of allergies that rivals the length of the Oxford English Dictionary, complete with a description of all the supposed allergic reactions to said medications scrawled along the edges of the paper --- "made me throw up;" "headache;" "dizzy;" "palpitations;" "didn't feel right" --- none of which can be reasonably described as a true allergy, but which will nonetheless get duly recorded as sacrosanct for all eternity in the patient's medical record.

OK. Based on what is listed, we can reasonably assume a few things. First of all, this patient has hypertension, possibly an element of congestive heart failure (although that is far from certain), COPD or asthma, and diabetes. In other words, the bases are loaded and the tying run is at bat. And I am the pitcher, who needs to throw strikes in the form of questions to keep this patient from hitting a grand slam --- which could be a potential fatal perioperative event.

So, what is one to do? A few options:

[1] Call the patient's primary care physician. This assumes that the patient actually has one, and that he or she sees them on a regular basis; not the case all too often. This also assumes that we can reach the PCP's office and get a real, live person on the phone who can send us some information. That would be, of course, the same information we requested 10 days ago when the patient made this appointment. But, as we all know, getting the phone answered between the hours of 11AM and 2PM is damn near impossible, and after 4PM maybe out of the question.

[2] Call the patient's pharmacy. Er, which one? The one around the corner from their home, the one in the hospital, the one across the street from the hospital and the local VA pharmacy are all potential suspects, and frequently patients utilize more than one.

[3] Ask what each pill is for. Unfortunately, this request can be met with nothing more than a recitation of "I take a little blue one in the morning, a white one and a purple one at noon, and then three more at night." Nice, but not helpful.

[3] Ask the patient to actually bring in their medications at the time of their next visit, which in my case is generally a preoperative visit. Be specific. Actually state "BRING IN THE BOTTLES" so that you will know what they are supposed to be taking. This is different than what many actually are taking. You will find that many of the bottles date back to the Carter administration, but the patient may state that they still take one of those little pills every once in a while.

[4] If you have opted for approach number three, there is one more important thing to do: pray. Pray that the patient is not on Coumadin, in which case you will need to cancel the planned operation and deal with anticoagulation issues. Pray that if he is prescribed Coumadin, he is actually taking it --- it's not handed out willy nilly. Pray that most of the bottles have the same physician's name on them, because polypharmacy is a can of worms that can take months to sort out.

While electronic medical record systems may help with this situation, they will never be a panacea. Different systems will not interface well at first, and everybody --- doctors' offices, clinics, hospitals, and every pharmacy --- will need to be able to access the same data set. Finally, as I've alluded to, not every patient is follows their prescriptions like a Marine following orders.

If you have gotten to the end of this without falling asleep, you may be wondering about the terribly sloppy physician handwriting samples above. The first came from the hand of a certain psychiatrist of some notoriety, and the second was written by the father of modern medicine. I suspect that were they around today, some clipboard-carrying JCAHO nurse would demand that they have their hospital privileges suspended for poor handwriting.