The term refill is understood by physicians and patients to mean the continuation of a certain medication. The problem is that it doesn’t mean a refill when it comes to the judicial system.

A recent med-mal case involved a patient who called the covering physician for a refill of a non-controlled pain medication for arm pain. The case ended up in court after the physician refilled the medicine and the patient died at home of an MI.

By the time the legal system and the surviving family were done with the physician the matter was no longer a refill issue but an allegedly negligent physician who failed to tease out the relevant history of this being a CABG patient with an ischemic arm pain.

Did the patient disclose it? Did the doctor screen for cardiac symptoms? Was the patient hiding his cardiac history in order to get the pain medication? Was the doctor lazy in documenting the facts?

A Refill is a New Prescription

What I learned from my Medical Professional Boundaries course is that I don’t have to prescribe a medication to enter a patient-doctor relationship.

A friend/family member can ask me a medical question and if I offer a medical opinion then I will have officially entered a patient-doctor relationship.

This is a very serious relationship to enter because unlike a marriage there is no divorce – you will own that patient forever.

Ordering a Medication

We are put into such refill request situations in an office setting, during a telemedicine consult, or when we cover phones for our group practice.

Whenever you order a medication you are 100% liable for everything related to that patient. They could have been on their furosemide for a decade but if you didn’t ask – and document – their last Cr and K and the patient falls over dead from a hypokalemic arrhythmia then it’s on you.

A Refill

You might be a neurologist who is seeing your MS patient and because the MS is their main medical problem and because this patient has mobility and financial constraints, they always come to you for their refills.

If you are trying to be nice and save the patient the headache of tracking down their doctor by refilling their NSAIDs and they get an AKI which requires dialysis then you are liable.

It doesn’t matter how long they were on the medication. It doesn’t even matter if you issued an OTC NSAID so that they could use their HSA. A refill is never a refill in the eyes of the legal system.

Refill Based on Chart Bx

So you’ve reviewed the chart, seen the notes from the patient’s PCP, and have decided that for whatever fucking reason this PCP want to continue to keep the patient on their metformin at a low dose even though they have a low GFR.

The patient loses their shit when you suggest to switch over to insulin instead of the metformin and they are strangely ‘allergic to glipizide due to ‘hypoglycemia’.

Next day the patient is in the ER for lactic acidosis. He took way more of the metformin than you prescribed but of course nobody will know that. He ended up in the ICU. He developed sepsis. Then DIC. Then he died.

A refill is not a refill – it’s a new script – and it doesn’t matter one iota what your colleague decided to do. You are 100% responsible for that infantilized patient once they set foot in your office.

Kindness & Consequences

As an avid reader of med-mal cases I have observed that frequently the physician attempts to minimize the burden on the patient.

She will try to manage a condition outpatient in order to prevent the patient from having to go to the ER.

Or the doctor agrees to refill the medication because the patient is about to leave for a trip out of the country and the patient cannot be without her medications.

A doctor will discharge the patient because the patient is insistent on going home even though he doesn’t look well post-op, promising that he will return in the morning for follow-up.

What We’re Taught

As clinicians we are taught empathy and kindness and being there for the patient when the legal system or their family support fails them. We bend over backwards for patients and get them plugged into services and make sure they get what they need.

What We Aren’t Taught

We are taught nothing about the risk of practicing medicine. We aren’t taught about consequences – not in residency, not as attendings, and not by our respective medical boards.

Confrontation

I don’t know what it’s like for you specialists but what it means for me to be a Family Medicine doctor – an Urgent Care doctor specifically – means that I need to deal with a lot of confrontation.

Saying no to refills, saying no to antibiotics, saying no to Rx’s without an exam, saying no to work notes, etc.

A decade into practicing medicine and I don’t know where the line is. I can’t overcome feeling bad for the patient but I cannot deal with another legal consequence of practicing medicine.

You’re Not Treating Just The Patient

The next time you are wearing your doctor’s hat and talking to a patient remember that you aren’t just treating the patient.

By entering the patient-doctor relationship you have automatically locked yourself into the following relationships as well:

• anyone survived by this person, in case they die
• their estate’s lawyer
• the District Attorney
• the medical board
• your medical group’s legal team
• a supposed medical expert
• the media
• a jury of your ‘peers’

You may have had a perfectly civil conversation with the patient who called you about SOB and chest pains and recommended that they go immediately to the ER. But you failed to document anything on that.

The patient is found dead the next day by his family and autopsy reveals a PE. The family sues and they win – $1.5M worth. Nobody cares that you were slammed that day and short-staffed on call.

Acute Otitis Media on Telemedicine Consult

I got off the phone a few hours ago with the mother of a 5 year old who called in for her 5-yo’s follow-up after a diagnosis of an AOM. Mom spoke to another telemedicine doctor 2 days ago and because her 5-yo always gets AOM and had a high fever she requested antibiotics and the doctor acquiesced.

During my conversation with this not-so-bright parent I found out that the child was having fevers of 105.x, anuric, lethargic, and vomiting.

The child clearly has bacteremia/sepsis possibly from a PNA or UTI.

Pitfalls of Telemedicine

If you are going to be doing telemedicine then it’s important to understand and appreciate your limitations. A simple sentences such as “I cannot look inside your child’s ear and therefore I cannot make the diagnosis of an ear infection” will often go over well enough.

Yes, the mom will bitch at your and try to guilt you into giving the medicine. The question you have to ask yourself is whether mom will forgo the lawsuit if little Suzie dies of sepsis because she knew that she pressured you into giving her the medication. I suppose that’s possible though not likely.

Telemedicine Laws

Quite a few states are vehemently against telemedicine. There was a case of a physician who got taken to court for prescribing a medication to a patient who was traveling through a state where he wasn’t licensed. The patient was there for a short trip and it was abx for a UTI.

Some states will prosecute physician who do telemedicine in their states without ever having seen the patient in person before. Even my state’s medical board mentions in their telemedicine rules that a physical exam is required for a full diagnosis and assessment and that a treating physician will be held to that standard even if it’s done via telemedicine.

That’s the nature of our medical field. Feel free to disagree with telemedicine as a concept – I won’t fight ya’ on that. But patients are demanding this service and yet the medical boards are clearly vilifying telemedicine doctors.

Suggested Solution

Will my medical group retaliate against me if I start refusing all the seemingly benign refill requests? On first pass it would seem unlikely. But….

I am reminded of an immigrant physician we had at my old medical group who got fired because he refused to give abx for colds and didn’t refill any pain meds. It wasn’t directly because of that. It’s just that he had shitty patient satisfaction scores and a ton of patient complaints.

Maybe he didn’t refuse the meds tactfully but he was a good clinician and he was a diligent worker in the Urgent Care. But Kaiser Permanente used that as an excuse to get rid of him.

1. Financial Independence

There is so much leverage to be had when you aren’t dependent on the income from your employer. When you can sustain your lifestyle with your savings and investments alone then you have better bargaining power.

As physicians we are pulled into so many directions and have so many hands in our pockets with very little recourse. Financial independence is a tool – not meant to provide you luxury but instead security.

2. Income Redundancy

This is hard advice to follow but it’s better to not be employed by a single employer. If you are going to earn your income as a physician then it’s best to do it from different medical groups simultaneously.

When I was in Spain I got taken off of shifts by 2 employers simultaneously. Fortunately, I had a 3rd income source. Imagine the chances of that – 2 employers within a week of each other took me off of my shifts for unrelated reasons.

Your employer knows exactly how much they can push you around. When you earn income from other sources, when you are financially independent, and when you could give a fuck then they can’t lean you as hard.

I am talking about responsible clinicians here. None of should abuse the system, that’s not the point. Those of you who are hardworking and dedicated physicians know the kind of situation I’m talking about.

3. Independent Documentation

A PA buddy of mine won a wrongful termination lawsuit (settlement) against his employer because this guy kept meticulous records during his 8 years at that medical group.

They tried to bully him out and eventually let him go. By that time this guy had so much dirt on the medical director and the medical group practices that they settled on a very healthy amount – without him ever even having to disclose his recorded documents.

My advice to you is that if you have an odd patient interaction then create your own online document about that visit – this is admissible in court.

If you have a shitty interaction with your boss then write it down. Email it right away to a friend to timestamp the conversation. Maybe you’ll never use it or maybe it’ll save you from unfair practices.