The life of a PCP: pet peeves department

The primary care providers (PCPs) I work with all love what we do. Partnering with patients to improve their lives is challenging but rewarding work, and I almost never hear regrets about going into primary care. But we do complain. And one of the things we like to complain about is that we often feel abused by our better paid limited-specialty colleagues. It doesn’t happen often, but when it happens, the bad feelings may linger for a long time.

 

The details vary from one episode to another, but the crux is taken advantage of. An example from a month ago (that;s how long it took for the irritation to settle enough to write about it) is typical.

Allyson R. called the office and asked to speak to my nurse. She was a few days out from her bariatric surgery procedure and needed help with her medications. Specifically, she needed to know which of her 9 medications she could crush and whether any of them came as liquids. We knew she had had the surgery because we had received the discharge summary, which my nurse and I reviewed. It said, specifically, that her discharge medications had been reviewed and that ‘they had been changed to crushable or liquid as appropriate.’ The discharge summary listed as discharge meds only her pain medication and her thyroid medication and not the other seven medications listed in her admission note. There was nothing in the discharge not about intentionally discontinuing her other medications (two for her lipids, one for depression, one for diabetes, one for arthritis, and two for blood pressure).

My nurse and I went through the list, identifying which could be crushed, which had small sized pills, and which came as liquids. This took some time and effort, looking up what formulations are available, and calling a pharmacist about one of the medications. Two required prior authorizations (PAs) and then extra phone calls to the pharmacy to get emergency short term prescriptions to cover her pending the PA process. Late on a Friday afternoon amidst the end-of-week rush.

When my nurse called Allyson to let her know that the prescriptions had been changed and to review the list, she asked her why she called us rather than the bariatric surgery office.

“Oh, I called them. Several times. For two days they didn’t call me back. When they finally called me, they told me the doctor had left for the day and to call my PCP.”

From my perspective, this is a predictable task and should be addressed prior to the hospitalization for surgery. The patient should be told in advance what medication changes are anticipated and prescriptions (and PAs) done ahead of time. This would allow the patient to ask questions and perhaps even fill the prescription in advance rather than on the way home from the hospital. It would also mean that a copy of the medication changes could be sent to the PCP. And it would mean that the PCP is not being asked to do some of the scut work made necessary by the surgery.

When I whined about this over lunch with two of my partners, they both rolled their eyes. One said that’s why, whenever a patient of hers is scheduled for a bariatric procedure, she tells them to make an appointment 2-3 weeks before the scheduled surgery so they can review the medication list, make changes, answer questions, do research if necessary, accomplish the insurance tasks - and not have to do this at 4:00 on a Friday afternoon on the phone and without reimbursement.

 



 

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