Residential Space A creative outlet during residency, turned ongoing virtual soap box

Some thoughts after my least relaxing vacation to date – part II  0

Posted on April 5th, 2008. About Baby Dodds, Health Care, Ramblings.

I recently posted this entry describing the least relaxing vacation/week-and-a-half I have experienced – ever, perhaps. My original bulleted list of events looked like this:

  • Friday, March 21st – a trip to the emergency room with Little G after he manages to eat a clear plastic wrapper and chokes on it; got home at 11PM, packed until 1:30AM Saturday
  • Saturday, March 22nd – got up at 3:30AM to get ready and get all of our stuff to the airport for our 6AM flight; flew from Seattle to Chicago O’Hare with a layover, then from Chicago to Pittsburgh
  • Sunday, March 23rd – Gabriel met his great-grandparents for the first time! Happy Easter to us.
  • Monday, March 24th and Tuesday, March 25th – time with the family in Cranberry Twp, PA and Beaver Falls, PA
  • Wednesday, March 26th – flew from Pittsburgh to Dallas, layover, then Dallas to Austin for my cousin Kelli’s wedding
  • Thursday, March 27th – Gabriel met eight first-cousins-once-removed (all nine years old and younger) and many of my first cousins
  • Friday, March 28th – wedding preparation stuff, rehearsal dinner
  • Saturday, March 29th – wedding! It was beautiful.
  • Sunday, March 30th – flew from Austin to San Jose, CA, lay-over, then San Jose to Seattle, arriving into the Sea-Tac airport at 9PM, and getting home by 11PM
  • Monday, March 31st – Gabriel takes a long nap in the morning, eats lunch at 10AM, and at 11AM starts vomiting. He proceeds to either vomit or dry heave around 12 or 13 times between 11AM and 8PM, when it finally stopped. Thank you to our pediatrician, Dr. Spector, for seeing him yesterday afternoon, reassuring us that this was just “the crud” and not something more serious, and also a special thanks to PediaLyte.
  • Here is an addendum:

    Tuesday, April 1st – I was home from work with Gabriel, and he was looking much better. He was able to tolerate rice cereal, bananas, and larger amounts of PediaLyte.
    Wednesday April 2nd – I returned to work, but Evan woke up sick that morning with the flu. He was at home from work that day with – let’s say an array of symptoms very convincing for flu (I won’t go into details, since he should have at least some modicum of privacy!). When I got home from work in the early evening, Gabriel had just thrown up again, and his diet regressed back to PediaLyte sips.
    Thursday, April 3rd – I woke up at 3AM with nausea, night sweats, and chills. By 8AM the severe muscle aches had set in. Evan was feeling better, but not great – but he went to work while I stayed home, recovering.
    Friday, April 4th – I wasn’t well, but needed to go to work because my sick days are limited after being out on maternity leave last year. I spent the day mostly doing work at my desk, or if I had to interact with a patient, wearing a mask and gloves with lots of hand-washing. The nausea and muscle aches were better, but I was wiped out and had only had sips of Gatorade for 36 hours. I was also on call that night. However, it wasn’t the hospital that kept me up during the night, but Gabriel’s constant coughing over the baby monitor. I must have checked on him five or six times during the night, and rocked him back to sleep once. The nausea is gone, but all three of us are still quite congested with nasty coughs.

    Now, today is finally Saturday – a weekend day, where no one expects anything from any of us. I had hoped, a week ago, to have a play date between Gabriel and one of his baby friends, but this is the wrong weekend for that. I really hope we are all back to normal by Monday. What a crazy two weeks it has been.

    I apologize – I realize this is not interesting for anyone except for me, but having lived through it, I felt it was worth documenting. I really wonder what diseases I will end up catching from Gabriel – he’s not in daycare, but he will be around other children, and will start pre-school eventually. I have a friend whose son started daycare two months ago, and he’s already given her diarrhea twice and now a bad case of hand-foot-and-mouth disease (Coxsackie virus). Not too fun!

    Leave Doctors Alone  1

    Posted on March 21st, 2008. About Health Care, Ramblings.

    Okay, it’s been too long – it’s time for another post reminding everyone that, despite what the 24-hour news media and the Law & Order tv series would have you believe, doctors are good people who don’t deserve to be crucified when they cannot meet superhuman standards. Not to sound too much like Chris Crocker here (of “Leave Britney alone!” fame), but please – leave doctors alone.

    Case #1: John Ritter’s death – unfortunate and untimely, yes, but is the right response really to have gone after a radiologist and a cardiologist? Ritter’s widow, Amy Yasbeck, went after these two physicians and wanted $61 MILLION in damages. The jury disagreed and did not find the physicians negligent – but only after the hospital had settled with Yasbeck for over $10 million. Apparently, the story goes something like this: John Ritter had a random full-body scan several years ago (I’m so against randomly ordering tests screening for nothing in particular for no reason, unless a good randomized blinded controlled trial shows a meaningful benefit to patients – ie, the colonoscopy), and evidence of coronary disease showed up. The radiologist told Ritter to follow-up with a primary care physician for management, and he never did. Then, he presented to the ER the night he died with chest pain, and apparently was being managed the way one would manage a myocardial infarction rather than going immediately to surgery for an aortic dissection. Yasbeck’s attorney argued that Ritter would be standing here today, making us laugh, if the proper diagnosis had been made and he had gone to surgery. I find this slightly ridiculous – if it was a severe enough dissection to have killed him so quickly, there is not a guarantee he would have survived surgery. Maybe he would have. Who knows. I think it is unlikely the physicians were grossly negligent though – chest pain is a very common presenting ER complaint, and one does the best he or she can to properly diagnose and treat the cause. Sometimes we give antacids and if it goes away, we assume that it was severe reflux. We don’t sent every single patient with chest pain through a cardiac catheterization or inject IV contrast for a CT of the chest and abdomen to evaluate for an aortic dissection. In following this case, my response has been: thank goodness I’m not practicing in Southern California and having to regularly treat wealthy celebrities. I have always driven myself to provide the best patient care I am capable of providing, but the constant fear of being sued leads to excessive diagnostic testing. I am relieved that the jury believed that physicians are typically decent HUMANS (not superhumans) trying to do the right thing with the knowledge they have spent many years acquiring. 

    Case #2: Again, in Southern California, a transplant surgeon is ordered to trial for a patient’s death. He is accused of hastening the death of a patient in order to recover his organs for donation. The story on this case goes something like this: the patient was in a coma with a terminal disease and was going to die, but in order to be an organ donor, one must be declared brain dead. There are a large number of patients who will die a cardiac death prior to achieving brain death, and for a long time they have never been eligible for organ donation because they did not meet brain death criteria. Therefore, hospitals are starting to pursue options for “donation after cardiac death.” From what I know about this, it involves having the surgeon and operating staff ready in the operating room, and as soon as the patient has a cardiac death (cardiac arrest), the patient becomes an organ donor as soon as possible. One of the claims in this case is that the surgeon did not have experience with donation after cardiac death. My response is – most surgeons probably don’t. It’s new. It’s not traditional. That doesn’t make it wrong. Every transplant surgeon has to have his first time, and many times it will be unsupervised. This doctor has recovered hundreds of organs on patients who have not had cardiac death – is the anatomy suddenly going to change because the person has had a cardiac arrest? I would not think so. Is a 60 year old transplant surgeon who has been practicing independently for 20 years going to be told he or she has to go back through fellowship to learn to do this procedure under supervision before performing it independently? Likely not.

    Here is the second reason this case is ridiculous – the transplant surgeon has nothing to do with the care of the patient prior to the patient becoming an organ donor. There is no clear consensus on what actually happened. There is the argument that the patient received morphine and ativan prior to cardiac death. Most terminally ill patients who are expected to die soon receive these drugs – there are entire order sets called “Comfort Care Orders” that are completed when the decision is made by the patient’s family to be on “Comfort Care,” usually meaning the goal of care is comfort only – no heroic efforts to preserve life, only to preserve comfort. I don’t find the administration of morphine or ativan to a dying patient unusual at all, regardless of whether he was to become an organ donor. I also find it sad that, given the shortage of surgeons in this country, one of them is having to fight these charges in order to continue practicing medicine, to keep his medical license, and to stay out of jail.

    Let’s run through this one more time. In order to become a physician:

    1.  First there are four years of college – and not “hanging out at the bars on the weekends” years, but studying, preparing for the MCAT (Medical College Admissions Test) years.

    2. Then, there are four years of medical school, which are tough – my first year, after being in class all day during the first two years, I studied a MINIMUM of three hours a night after coming home from a full day. Exam periods were worse. I had friends who studied much more, if you can imagine. Then, at the end of the second year comes the USMLE Step 1 (U.S. Medical Licensing Exam), which is hard and expensive. But don’t worry – it’s not hard to pay for when you’re collecting tens-of-thousands-of-dollars of debt annually. The third and fourth year, you’re working like crazy in on-the-job training while caring for patients, and you’re doing this while continuing to accumulate debt because you’re not being paid. During the fourth year comes USMLE 2, which is hard and expensive, and the USMLE Clinical Skills exam, which is even more expensive. That’s okay – more loans to cover that.

    3. So then comes residency – where a doctor is finally paid what society thinks he is worth, ~$42,000/year for working 60 hours/week in a good week, and 80 hours/week in a bad one. Thirty hour-long shifts every fourth day are common. Don’t forget USMLE Step 3, which is long and expensive. For three to four years this goes on for most medical specialties, but for surgeons it can be much longer – this transplant surgeon endured a minimum of five years of surgery residency followed by two years of transplant fellowship, just to have the privilege of caring for patients independently.

    4. Finally, in your thirties, assuming you have gone straight through without stopping, you are ready to pay back loans and start earning a living, although surgeons then have to worry about high malpractice insurance premiums.

    I apologize if I’m sounding whiny (for the record, I’m not a surgeon, a cardiologist, or a radiologist), but I really wish people would give doctors a break sometimes. What they do is intense, and the wrong decision can come at the cost of a person’s life – believe me, doctors are aware of the trust their patients have given them, and it means a lot. They value this and often sacrifice self-care for patient care as a result. They don’t expect thank you notes in return, but I can imagine it is very demoralizing to be sued for malpractice over the results of a full-body scan on a seemingly healthy young patient (one study out of dozens that radiologist looked at that day, most likely), or to have felony charged pressed against a transplant surgeon for possibly hastening the death of a patient with whom the doctor had very little interaction, if any.

     What is more harmful than anything this doctor likely did is the negative press spotlight on organ donation – how many potential donors may decide not to be donors anymore because of what they perceive happened in this California hospital?

    Many call nights down, many to go…  0

    Posted on January 2nd, 2007. About Health Care.

    While many make resolutions for change at New Year’s, I decided to create a countdown list instead. Today, I count 48 remaining call nights before my residency is halfway completed on June 30, 2007. It breaks down like this:

    – University of Washington Medical Center: 10
    – V.A. Medical Center: 23
    – Harborview Medical Center: 15

    Another way of looking at it is this way:

    – Home Call Nights: 33
    – On Site Call Nights: 15

    So 48 more call nights. After tonight, it will be 47.

    Contemplating the notion of a “fat tax”  0

    Posted on November 3rd, 2006. About Health Care, Ramblings.

    The Becker-Posner Blog is again discussing a notion that, while not exactly politically correct, is an interesting topic for debate. Some of you may recall my intrigue in their musings last year regarding a nation in which organ donation was an opt-out rather than opt-in system. Now, they are theorizing about the consequences of a “fat tax.”

    Some of the “pros” for this fat tax, as mentioned both in their articles and in the section for reader comments, are:

    • Obesity leads to many of the United States’ most expensive health issues, such as hypertension, diabetes, hyperlipidemia, stroke, myocardial infarction, colon cancer, venous thrombosis, etc, and then these lead to other costly issues, such as peripheral neuropathy, gangrenous limbs, renal failure, colectomies, retinopathy, etc. Okay, so they didn’t list all of these as examples, but I am, and frankly I could name about sixty more, but another time perhaps…
    • Many of these people require impressive time and treatment in the inflated health care system, much of which is now supported by tax dollars (Medicaid and Medicare), and these taxes are paid by thin and obese people. Becker and Posner question – is it fair to make thin people pay for obese people when thin people are less likely to use the system for which they have paid? Hmmm…
    • A “fat tax” may serve as an initiative for people to diet and begin exercising. Better yet, the threat of such a tax, but suspension of it for those who are in the process of trying to lose weight (ie, those who can prove they have visited a gym at least two nights a week).
    • After all, many cities are beginning to impose fines on those who do not recycle in order to force a positive behavioral change for the good of greater society. Should this be so different?

    However, there are cons:

    • If an obese person is not losing weight and is hypertensive, and is being taxed and feels ostracized by the health care system and thus does not seek treatment, he or she is more likely to have a stroke – a much more costly outcome than monthly antihypertensive medications. When debilitated, on whom does the burden for his or her care now fall?
    • I know when I’m cooking nutritious ingredients for meals (lean chicken breasts, fresh produce, etc) my grocery bill is higher than when I buy cheap snacks (chips, cookies, etc). If we tax overweight people, will that give them an extra reason to continue buying junk food?
    • Some will argue that it’s judgmental and critical to impose such a tax – but as is the nature of the Becker-Posner Blog, they evaluate every issue from a purely economic perspective, devoid of morality and ethics. It is an exercise in reason, much as the book Freakonomics is.

    As I type this post, the thought occurs to me that perhaps fatty foods can be taxed heavily – vice taxes, if you will, much like the ones on cigarettes and alcohol. If we taxed potato chips and soft drinks (but not on diet drinks – Diet Coke with Lime and Crystal Light remain tax-free) – wow, that could pay for another two whole weeks in Iraq!

    My Beef with Express Scripts – Part 3  7

    Posted on August 2nd, 2006. About Health Care, Ramblings.

    You may recall my tirade against Express Scripts, the online pharmacy that my primary health insurance company requires I use for maintenance medications in order to receive my negotiated rate. For those of you whose memories fail you, please take a second to peruse my soap box moment regarding this company. Last week, two separate people in the blogosphere used Residential Space as a means for venting their own frustrations towards Express Scripts. It appears that they have pissed off more than just yours truly.

    Recently I refilled my birth control pills, and enjoyed a strange pleasure in paying money for them at my local Walgreen’s. I suppose the day may arrive where I could require medications for hypertension, diabetes, and hyperlipidemia, and it may become too expensive to purchase them. Of course, what would be more expensive would be fees for a nursing home following a stroke because Express Scripts failed to send my medications to me on time. Yet, another reason not to have a chronic illness.

    W Opens Mouth and Inserts Foot  1

    Posted on June 18th, 2006. About Health Care, News and Politics.

    Some of you may have heard about the president’s recent gaffe when, at a press conference, he began haranguing L.A. Times reporter Peter Wallsten for asking a question while wearing sunglasses. The exchange went like this (referenced from MSNBC and The Daily Show):

    Bush: Are you going to ask that question with shades on?

    Wallsten: I can take them off.

    Bush: I’m interested in the shade look. Seriously.

    Wallsten: All right, I’ll keep it, then.

    Bush: For the viewers, (he looks at the cameras here) there’s no sun. (laughter in the press corps)

    Wallsten: I guess it depends on your perspective.

    Bush: (after giving a snorting sort of laugh) Touché.

    Peter Wallsten has a degenerative retinal condition known as Stargardt’s Disease that has not only rendered him legally blind, but is thought to progress more slowly with consistent protection from UV light.

    Apparently the president was in a joking sort of mood, and I believe he was unaware of Wallsten’s condition. He stuck his foot in his mouth, something we have all done. I do think this situation is reflective of a flaw in the president’s personality on which many have commented since he took office in 2000. Bush always seems to think he knows how things are and implies that others are inferior in some respect. He really behaves quite condescendingly towards others. “We have a really big border with Mexico” and “You can’t read a newspaper if you can’t read” come to mind here.

    National Healthcare System – The Way To Go  3

    Posted on May 4th, 2006. About Health Care, Money, News and Politics.

    I attended a conference this morning during which one of my colleagues, a graduating third year internal medicine resident, gave an excellent presentation on the pros and cons of a national healthcare system. Prior to graduating from medical school, I was quite hesitant about this idea. After a year of practicing medicine as a physician, I am in favor of it, because I honestly believe it would provide better care to more people at a lower overall cost.

    Let’s be honest – healthcare inflation is drastically out of control in this country. It’s only getting worse – it will not get better. I think that is worth re-stating for emphasis – IT WILL NOT GET BETTER. Healthcare is >12% of our GDP and is rising. More than 40 million Americans are uninsured, and this does not include those on Medicaid and Medicare – also funded by tax dollars. In short, I do not think our current system is sustainable.

    I was against this notion for a long time because I possessed several fears: A) Huge waiting lists would arise and it would take months to have a simple procedure done. B) Research and development would be stifled because drug company profits would fall and thus there would be less incentive to fund research. C) Physicians would be paid little for the amount of training they have undergone. D) The quality of care would be compromised.

    I will address these points individually, as I believe many people share these concerns:

    • Waiting Lists – I, as an individual with excellent private health insurance, had to wait over two months for an esophagogastroduodenoscopy (EGD). I have had patients this year who have had CT scans in the ER demonstrating masses in their colons, and if they are not admitted to the hospital, then the soonest they can be worked in for a colonoscopy is three months. The truth is, we have horribly long waits today, and if anything a national system will be more uniformly funded in such way that some of these waits can be reduced.
    • Research and Development Dropoff – A national plan would likely involve bargaining with drug companies to label certain drugs in specified classes as “formularies,” that is, first-choice selections that can be obtained at lower cost. I am all for R&D, but much of the funding, even in private companies, comes from the federal government already. The National Institutes of Health (NIH) gives huge grants to the pharmaceutical industry for scientific investigations. In addition, 85% of new drugs are what we call “me toos,” drugs that are not new or innovative, but just different forms of what already exists and offers no added benefit to what is currently available. If anything, I believe that this new system would encourage true R&D – why develop yet another statin when three others, the three that are supported with clinical trials, have been shown to be more effective? They would be motivated to then focus their efforts on creative new approaches to, say, amyotrophic lateral sclerosis (ALS), a disease where no good treatments currently exist.
    • Physician Compensation – There are many models that exist for a national system, including one that supports single-party payer reimbursement. Under similar systems physicians are well-compensated without the hassle of having to jump through twenty different hoops with hundreds of insurance companies (and each company selects their own hoops) to try to get a procedure covered that may end up being denied – and if denied, the financial burden falls on the patient, or if the patient will not pay, the healthcare provider. On the other hand, under our current system, we see many patients without insurance who will never be able to pay the bill. The hospital, or the physician’s office, eats the cost. We are required to treat “emergencies” whether the patient has funding or not – and while this may seem okay to some, why should the hospital, a business, have to eat the cost? Under a national system, the hospital and physician are reimbursed for every patient, patient’s don’t have to worry about hospital bills, and the system comes into better balance.
    • Quality of Care Compromise – It is now difficult for me to imagine the quality of healthcare being compromised. For some of my patients, when they realize that their funding is about to run out, or if they worry that they can’t pay their bill, they leave the hospital prematurely before their treatment has been completed. Because physicians spend so much time on paperwork, there is less time to provide patient care – eliminate the papers, and suddenly we have more time to spend with each patient, or we have time to see more patients to reduce the waiting periods for appointments.

    Perhaps the biggest reason I am in favor of this system is because it would bring preventive healthcare to the forefront of medicine and reduce the cost of catastrophic medical complications. For example, in Quebec a $2 copay was added for each prescription picked up at the pharmacy and a small copay (don’t know the amount, but it was similarly small – less than $5 per visit) was added to each visit. The number of ER visits shot up dramatically and the number of dollars spent on inpatient hospital admissions skyrocketed. Now, a system is in place with no copays for anything, and their healthcare spending overall is back down significantly. I have seen several studies outlining this and it really does appear to be effective.

    There are multiple propositions on how to fund such a system. For starters, the taxes we pay for Medicare would go to the new system. It has also been estimated that the amount of tax required would be anywhere from 8 to 17%. It sounds expensive, and it is, but consider that employers providing health coverage (even with copays) pay anywhere from 7 to 25% of each employee’s annual salary to provide this benefit. Employers could still bear this cost, or else be able to increase salaries such that the federal tax could be removed from the employee’s paycheck.

    Consider this – uncontrolled diabetes over years often leads to kidney failure, blindness, non-healing skin wounds that lead to amputations, and premature nursing home placement. If I have a patient with early diabetes and without insurance, she can either A) go to her physician for her checkups every two to three months and obtain her oral medication or her insulin free of charge, or B) she can act noncompliantly with her recommended care because she has no money and no insurance – and then, 15 years later, we have a woman in florid kidney failure, on dialysis three days a week (hugely expensive), going blind, in a nursing home at the age of 60, and draining the system of thousands of dollars a month. It sounds dramatic, but I cannot count the number of cases I have seen almost exactly like this one. I know people often think of a nationalized system as a “liberal” idea, but I insist that it is a fiscally conservative notion, and one that must be considered before being cast aside. Over a ten year period, it is estimated by healthcare economists that a nationalized single-party pay system would save over a trillion dollars – yes, that actually says trillion. A thousand billion. That’s $100 billion dollars a year.

    If you have read this far, I applaud your attention span. If you would like to learn more about a national single-party pay healthcare system, one website many of us like is that of the Physicians For a National Health Plan. I am also including a link to the Physicians’ Proposal for such a plan that was published in the Journal of the American Medical Association in 2003. There are many excellent resources listed in the bibliography for more information. I welcome comments on this issue, as always, and hope to hear what you have to say.

    What I have learned from the Harborview ER  1

    Posted on March 28th, 2006. About Health Care, Ramblings.

    The city of Seattle is in shock over what is now being called “The Capitol Hill Massacre.” In a city where acceptance and tolerance are a given, Capitol Hill is the neighborhood reflective of Seattle’s welcoming attitudes. Rainbow flags fly from many businesses, people talk openly on the streets while waiting for buses, and the area’s high street features everything from Indian cuisine to handmade fabrics. It is generally considered one of the more desirable places to live. The thought of seven people dying violent, tragic deaths in a home there recently is a bit surprising, to say the least.

    Just prior to the shootings, I finished my overnight shift in the Harborview Medical Center emergency department. When I returned later in the evening for another shift, the residents and attendings who had been on during the day looked emotionally and physically drained. The surgery residents seemed unable to comprehend that they were resuscitating these trauma victims featured in the national news media. As has been reported publicly, another victim died after reaching Harborview, and two others made it to the intensive care unit. During the night, I saw a stabbing victim, several young people in a horrible motor vehicle collision (one died), multiple injuries from fist fights, “car vs tree,” “pipe vs head,” cardiac arrest, and of course countless overdoses and intoxications brought in by the police. Everyone left feeling depressed and tired.

    This past month has been a frustrating one. I have “treated” some of the same intoxicated individuals on five or six different occasions within a four week period. I have been sworn at, had to order restraints on meth overdoses for taking swings at paramedics, and seen people who come to the ER at 4AM for indigestion they have had for the past two weeks.

    Over the past two nights, though, things have come together for me. I have really learned to care for these patients. For example, intoxicated patients get an IV and a good dose of thiamine (a vitamin those with chronic alcoholism are often lacking from malnutrition). Then, they get IV fluids as they sleep for a few hours. Eventually, from all of the fluid, they have to go to the bathroom. When I see a patient walking to the restroom, I know he/she is stable enough to walk safely out of the hospital. When they go back to sleep, A) I take his/her blanket away. He/she gets crabby, but some can still sleep. If this is the case, then, B) elevate the head of the bed to a 90 degree angle and withdraw the pillow. This may help someone wake up, or make him/her even crabbier. C) Speak in a kind, but firm tone about how it is going to be a lovely day in Seattle and you would hate for them to miss out on it by lying on a gurney in the ER. If all of this has still been ineffective, D) swing his/her legs over the side of the bed and get him/her on his/her feet. No one who has walked to the bathroom will fall from this; everyone wakes up. Ninety percent of these patients (once awake) are very pleasant, thank me for the care they have gotten, and leave willingly.

    This is not the medicine that I learned as a medical student, but knowing people’s behaviors and understanding how to negotiate realistically was a crucial part of surviving this past month. Knowing how homeless shelters and detox programs operate was also very important. I also got to run my first ACLS (Advanced Care Life Support) code and experienced what it is like to give orders to a room full of providers during a cardiac arrest. I placed numerous central IVs into jugular and femoral veins, performed lumbar punctures for spinal fluid sampling, and learned how to throw a quick IV into superficial neck veins. Looking back, while the experience was stressful and exhausting, I feel like twice the physician I was a month ago.

    What can I say? There is bad stuff out there. But I finish my ER experience hoping I am better able to deal with it.

    My beef with Express Scripts – Part 2  8

    Posted on March 22nd, 2006. About Health Care, Ramblings.

    My handful of readers may recall my recent post in which I expressed my frustration over being unable to obtain my birth control pills through my insurance company’s preferred mail-order pharmacy, Express Scripts. To summarize, I sent them a prescription from my doctor for ortho tricyclen, they chose to fill it with a generic (tri previfem), they are now out of tri previfem, and were stating that they could not fill it now with ortho tricyclen, the original medication indicated in the prescription. The *only solution*, they claimed, was for my doctor to write another prescription, and I could mail it to them. They insisted that once a prescription has been filled, even with a generic of a different name, only that generic can be dispensed.

    Okay, so I went to my neighborhood Walgreen’s today, and they confirmed that tri previfem was unavailable. Fine – I will accept that this generic is unavailable for the time being. BUT the first question the pharmacist had for me was – would it be okay to provide me another generic or ortho tricyclen? Ummm, YES, I told her. She warned me that my insurance may not cover it, to which I replied that I didn’t care at this point. So I questioned her – Are you SURE you can fill a prescription with a different generic once it has already been filled with a generic of a different name? Of course, she answered, we do it all of the time. Otherwise when generics are discontinued patients would have to return to their doctors for prescriptions too frequently. EXACTLY. Thank you. I feel vindicated – somebody gets why this was bothering me. Do you ever have those moments when something seems perfectly reasonable or unreasonable to you, but those around you are not bothered by it? And you think – is there something wrong with my brain? Why am I not getting this? Now I feel justified – there is something wrong with the representative and “supervisor” at Express Scripts.

    Who knows – perhaps I will go to retrieve my prescription tomorrow and the pharmacist will say – Sorry, I’m a new graduate fresh out of pharmacy school and I didn’t know that I wasn’t supposed to be filling prescriptions this way. Oops. But I will assume for the time being that she knows what she is talking about moreso than a customer sales representative without any medical training.

    My beef with Andrx Pharmaceuticals, Express-Scripts, and “The System”  3

    Posted on March 17th, 2006. About Health Care, Ramblings.

    Wow, I am fuming mad about another experience. I can only imagine how James would react to something like this were he in my shoes. This is a big one.

    So it’s one of those things about being female – taking a little pill each night that A) prevents babies before one is ready for them, B) regulates the cycle thus preventing anemia, and C) keeps the hormones in balance to prevent acne and other un-pleasantries.

    Here’s a little background on this situation to better explain why I am so freakin’ mad. Since I began working in June 2005, my new insurance company, Uniform Medical, will only partially reimburse for prescription drugs that are filled through their preferred online/mail-order pharmacy, Express Scripts. In June, I had a great amount of difficulty getting my prescription transferred from my previous insurance company’s mail-order pharmacy to Express Scripts, and then rather than sending me a letter or calling and refusing to fill the order, Express Scripts just didn’t fill it. When I contacted the company, wanting to know where my pills were, they gave me this, “Oh yeah, the nurse practitioner never wrote a DEA number and we can’t fill it without one.” First of all, that is BOLOGNA/BOLONEY – DEA numbers come into play with controlled substances. I never write my DEA number on prescriptions for my patients because I don’t want the wrong person getting ahold of it and forging scripts for their street associates with it – and it has not been a problem. My hospital’s pharmacy encourages residents not to put our DEA numbers on there in order to protect them – if they need it, they call me and I provide it to the pharmacist over the phone. Second of all, Express Scripts never attempted to contact the nurse practitioner who wrote the prescription (whose number was on the script) to ask for the DEA number, and third, they never attempted to let me know that it was not being filled.

    Anyway, eventually (let’s call her my “primary care provider”) wrote me a prescription for a year’s supply of birth control pills – Ortho Tricyclen, a popular brand, now available in several generic forms. Physicians can either sign on the line that says “Substitution Permitted” or on the line that says “Fill as Written.” My primary care provider signed on the “Substitution Permitted” line, as I almost always do as well, so that the pharmacy and patient have flexibility should the trade brand cost too much or if the trade brand is unavailable. I sent the script to Express Scripts and received the medication within about two weeks. Instead of sending Ortho Tricyclen (the trade brand), they sent Tri-Previfem, a generic form manufactured by Andrx Pharmaceuticals. Fine. Problem solved. FYI – these pharmacies often send patients a three months’ supply of meds, and expect one to request a refill a few weeks before running out.

    Today, I thought – well, I have two weeks left before my pills are gone. Time to reorder. I attempted to reorder on the Express Scripts website, but when I typed in the Rx number, nothing was coming up. So I called the toll-free number, spoke with a phone representative, and she explained that Tri-Previfem was on back order, and that it would be the end of April (at the earliest) that Andrx Pharmaceuticals would be able to provide Express Scripts with an adequate supply of this medication. Fine. So I explained that I would accept any other generic form that could be substituted for Ortho Tricyclen. I’m sorry, said the helpful representative, but your doctor will have to write another prescription and I will have to mail or fax it to Express Scripts. What?! I told her that my doctor had already written a prescription for Ortho Tricyclen, and that it was Express Scripts who filled it with this now-unavailable generic. They told me that (apparently this is a problem with “The System”) once a prescription is filled with ANY MED – be it the trade drug or a generic form – the prescription is only good for that single medication, and nothing else can be substituted later. So even though my prescription was written for Ortho Tricyclen, and Express Scripts and Uniform Medical decided to fill it for Tri-Previfem instead, now the prescription is only good for Tri-Previfem and there is no way to fill it for what the doctor actually prescribed in the first place. I asked the supervisor with whom I eventually spoke why Express Scripts filled my Ortho Tricyclen prescription with a generic form that they could not guarantee I would be able to receive on refill three months later, to which he replied, “Well, you could have a local retail pharmacy call us, and we will be happy to give them the prescription information over the phone.” My response was incredulous: “But you just said the problem was that the drug company cannot provide the medication because the drug is on back-order. That means no one should have it. And if my local pharmacy does have it, not only will I have to pay full price for it because my insurance company demands that I go through you guys, but it also means that the drug is available and that you should have it.”

    I swear, this is a totally broken system. What if this was a drug to keep my blood pressure from getting outrageously high, or a blood-thinning medication to keep that second pulmonary embolism from occurring? I hate being forced to use a preferred mail-order pharmacy that provides crappy service, but not easily being able to go elsewhere if I am dissatisfied. I suppose I could always pay full-price at the local pharmacy, but as we all know – medications are expensive, and this is not always feasible. I am so angry that I want to yell at someone, but I don’t know who should face my wrath. The Express Scripts guy eventually agreed to give me a credit on my account with them for the difference between what I will end up paying at the retail pharmacy and what I would have paid with them, so I guess that is a small victory. I think I will next call Andrx Pharmaceuticals to jump on them for over-committing their drug (if this actually turns out to be the case). Then, I am going to figure out why in the hell a prescription cannot be filled for its originally prescribed drug after it has been filled with a generic. That is just plain dumb. If I find this is a federal law, then I might have to go on a Shawshank Redemption letter-writing campaign – you know, where Andy DuFresne wrote a letter a week asking for funds for the prison library until the powers-that-be got sick of him and gave him what he wanted. And if that doesn’t work, well – I’ll probably be a mother by that time.


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