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Why I Ignore Pharmacy Requests for Refills

Recently, a patient got upset and quit my practice because I didn't respond to their pharmacy request for a refill of their medication. At appointments with patients, I think I make myself clear when follow-up is necessary and when refills will be approved, but apparently I need to be more clear.

There are dangers associated with doctors responding to requests for refills from pharmacies. For example: the only death I have seen from a statin medication is the result of two different doctors approving refills for two different statin meds from two different pharmacies.

Context. The patient was a traveling businessman. Overweight, with high blood pressure, and with an appetite for alcohol. A very busy executive businessman. The kind of guy that would show up for appointments in a three-piece suit and with a briefcase. Always on jets and flying all over the country.

Patients on meds like statins and blood pressure medications should get blood work and follow-up annually. But this patient would always cancel appointments, or simply not show up, and he'd call or his wife would call and inform staff that he was running out of his meds and needed refills. Often about the same time, we'd receive a fax from the patient's pharmacy requesting to refill the patient's meds.

It seemed easy enough. Print the pharmacy request for a refill. Sign, date, and refax. Done.

But unforeseen dangers lurked just below the surface.

Unbenownst to me, the cardiologist the patient saw a couple years ago for a stress test was refilling a different statin medication to a mail-in pharmacy. As with us, the patient was skipping appointments and skipping lab draws because he was always out of town, and the cardiologist was receiving refill requests from his second pharmacy.

So the patient was taking two statin drugs, from two different pharmacies, prescribed by two different doctors.

The motto that dictates what doctors do should be, "First, do no harm." Even if the patient wants us to do things that could be harmful, we need to be careful. Doing what's best for the patient is more important than doing what the patient wants. It is foolish to prescribe meds that might hurt the patient without documenting its benefit, any side effects, and monitoring for side effects and labwork.

This kind of mistake is MUCH more common if I respond to a request from a pharmacy for a refill.

Fortunately for me, after a couple years of this habitual cancelling of appointments and requests from pharmacies for refills, I finally refused to refill the patient medications any more unless he came in for follow-up. So he got another family doctor to refill the med I refused to fill, and this is when the patient died from liver failure as a consequence of taking two high dose statin drugs.

Another example: the pharmacy asks for a refill of a medication I've discontinued, or a dose I've discontinued. If I refill it when asked, without confirming with the patient that it's working, without side effects, and confirming the dose, that's my fault. This kind of medical error is unacceptable.

So I wisely choose to ignore all pharmacy requests for refills because I choose to work with patients. I give you enough medication until an update is necessary, or labwork is necessary. If something comes up and you forget to make the appointment or cannot make the appointment, I'll give a month or two of medication, but it's malpractice and, in fact, lazy doctoring to respond to pharmacy requests for refills without first discussing with the patient.

Sad, but a completely unnecessary death that resulted in part from doctors being lazy, and being more concerned about hurting a patient's feelings that they were about the patient's well-being.

Questions need to be asked and answers documented before refills are to be given. Is the problem justifying the medication, such as blood pressure, controlled? Are there any side effects? When was the last time blood work was drawn and was it normal? Do I have an up-to-date med list for all meds from all doctors? These are the kinds of questions doctors should ask, documenting answers on the chart. It is unwise and dangerous to permit pharmacies to refill meds without asking such questions and documenting answers.

So if you're about to run out of your meds and the pharmacy tells you, "Don't worry, we'll fax the doctor with a request for a refill!", rest confident that I'm a good doctor and will therefore IGNORE such foolish requests and expect you to make an appointment. Even if it's just a phone appointment.

By the way, established patients should make phone appointments not by clicking the link at the top of the home page for a "Free 15 minute consultation with Dr. Johnston", but rather, click "Established Patients" and make an appointment. You can comment in the comment section that it's a phone appointment.

The reason is, the free consultation appointments are for non-patients who are interested in becoming patients. And if you have friends or family you'd like to refer to me for medical care, encourage them to schedule a free consultation with me on my website I may be hiking a mountain trail when I do these appointments. It's not an active patient, so I don't need the chart.

But for established patients, I need to have your chart open before me and I need to take notes. So it's important for established patients to make appointments through the "Established Patients" link on the website.

James P. Johnston, D.O.

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