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Author: rshunter2 Big red star, 1000 posts Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: of 892  
Subject: Poll: Patient Information Date: 10/25/2002 6:17 PM
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Full consult on all possible side effects in all patients & Dr insert
Discussion of patient - pertinent risks, Dr and Pt inserts
Discussion of patient - pertinent risks, offer FDA inserts
Discussion of patient - pertinent risks - FDA inserts if pt asks
Discussion of patient - pertinent risks

Click here to see results so far.

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Author: joseph714 Big gold star, 5000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 251 of 892
Subject: Re: Poll: Patient Information Date: 10/25/2002 6:37 PM
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RSH - i really can't imagine anyone would choose other than the full disclosure choice, so wonder about this as a poll...

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Author: danbobtx Big red star, 1000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 252 of 892
Subject: Re: Poll: Patient Information Date: 10/25/2002 7:12 PM
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Joseph,

The lists of possible side effects on most drugs is a bit too long. Most listed side effects will have a very low rate of occurence, or be of concern only in specific sub-groups. I would prefer that I be given clear information on LIKELY side effects, and a discussion if I fall into any minority risk groups (compromised immune, pregnant, young, Mylasian Yak Herders, etc). The information on other side effects should be available, but the patient should only be bothered with things of a reasonable concern.

Danbobtx



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Author: joseph714 Big gold star, 5000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 253 of 892
Subject: Re: Poll: Patient Information Date: 10/25/2002 7:40 PM
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danbobtx - yes isn't that the choice i spoke of - full disclosure?..Perhaps in my haste i mis-read this if you find your choice elsewhere...

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Author: danbobtx Big red star, 1000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 254 of 892
Subject: Re: Poll: Patient Information Date: 10/26/2002 12:27 PM
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I took full disclosure to mean all possible side effects: ie. may cause purple splotches if taken with Alcohol on Friday the 13 before Halloween... I've had some (a few) doctors/pharmacists who provided this level of detail, which is (IMHO) overkill. On the other hand, I've had others that didn't even mention possible (Common) interaction with regular OTC drugs.

Worst experiences have been with Dentists and Eye care practicioners...... Yes, I really did want to know what was in those eye drops, and what it might do

Best experiences have been with M.D.s with a long term relationship... Basic, likely facts, coupled with some knowledge of my medical history, and even works with me to find drugs I likely won't have a problem with. This is what I would like the standard to be, but the patient/provider (Doctor or Pharma) relationship seems to be the key.

Danbobtx

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Author: rshunter2 Big red star, 1000 posts Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 255 of 892
Subject: Re: Poll: Patient Information Date: 10/26/2002 4:16 PM
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RSH - i really can't imagine anyone would choose other than the full disclosure choice, so wonder about this as a poll...


Bear in mind that this is from the prescriber's point of view.

I'll discuss the reason for the poll in a bit; I suppose the thing about "correcting" product labelling started it off in my head.

RSH.

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Author: rshunter2 Big red star, 1000 posts Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 260 of 892
Subject: Re: Poll: Patient Information Date: 10/28/2002 10:32 PM
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Well, Dan and Joseph both have good points.

The recent posting about "correcting" labelling brought this to mind.

I had a relative, an LPN, who went around with a PDR, dug up all the drugs a person was taking, and terrorized them about the worst things that could possibly happen. And of course, since she is a nurse , more people listened to her than ought to have.

It wasn't even good, educated, or informed and balanced advice; and in any case she wasn't trained, qualified, or legally able to give it.

Growing up in a medical household, I think I saw all sides of it.

But my sympathies generally lie with the physician.

My stepfather dreaded news features, and then later on when drug companies were allowed to advertise, because, we heard at the dinner table, "WELL, you KNOW, the next month or so, EVERYBODY is going to want a presription for XYZ whether they need it or not, or whether it's safe for them or not." And boy was he right. He was, although not perfect, (nobody is) a stickler against prescribing anything he didn't feel a patient needed, and also, unlike many colleagues of his time, doing enough testing and studies to ensure the medication would be safe for the patient, AND, imagine this, extensively counselling them on how to take and use the medicine, what it was for, things to watch out for, and if or when they could stop taking it in an emergency.

My former internist did much the same thing, but skipped most of it for obvious reasons in my case and just cut to the chase if it were really important, like, "Now that you're taking 600 mg of Inderal a day, you DO know you cannot suddenly stop it or miss a day's dose, right?". That was just like an obligatory reminder, he knew I taught pharmacology. But it was nice, and appropriate.

The purpose of the poll, sadly unresponded to as it was, was to divine a sense of when enough is enough, or too much, or not enough.

"Here, I'm writing you an Rx, take one of these at breakfast time every morning and come see me in two weeks.", isn't good enough (hell, I'd pitch a fit if a doctor ever tried to pull that with me, after correcting his mistakes in the Rx, first, and then most likely tearing it up and walking out of the office.)

Between capitation and other cost-control measures due to HMO's, insurance, Medicare / Medicaid, DVA, TriCare, I think the old fashioned doctor is being pushed out of the way he/she used to practice. Time limits on patient visits and consults, a limited formulary/compendium from which you are allowed to prescribe, DRG's, ICD's, all seem to be colliding (seem to be, who am I kidding? are colliding) in a way that is ending up with poorer quality health care, increased adverse drug reactions, misdiagnoses and consequent inappropriate treatment and iatrogenic consequences, and more lawsuits and adverse media for the med/pharma/biotech industry.

The sort of things the old country doctor who did house calls generally would not contribute to. He / she knew their patients without needing a chart, and what their real and imagined woes were.

So, a particular drug. Let's pick Ritalin. It has 8 million warnings and side effects and is Schedule II. A week's worth was prescribed for my grandmother after her husband died, because she was suicidally depressed. It worked miraculously.

The prescriber told my grandmother, "I know how badly you're feeling right now, and your husband was a good man; I can't do anything to replace him, but you ought to remember the many years you had together and the wonderful children you raised.

Now, I'm a little worried about you dealing with all this, so I'm going to prescribe something to perk you up a little, because I can see you are so down in the dumps, and we can't have that right now, can we?

It's only for a little while, you'll be on your feet in no time, though I know it's hard for you to feel that right just now.

And if you have any problems, you just call me anytime, here or at home."


Especially then, she didn't need "if you have hypertension, this can be addictive, blah blah blah". One or two weeks, hell, either amphetamine or methylphenidate would have been perfectly safe for her. My grandma the dope fiend.

The LPN from Hell would have cheerfully scared her off her week or two of pills, to a great detriment. Thank God she didn't get her claws into her before she was better. Alternatives at the time, there weren't any that would be effectual in a timely manner; tricyclics and MAOI's would have been disasters, apart from their onset of action.

So my grandmother lived so she could die of cancer. Okay, maybe not the best story, or maybe so.

She'd been on Aldomet forever and did well on it (for hypertension) and HCTZ and took K-Lyte (don't know if it is still made), an oral tasty potassium supplement that was like a fruit-flavored Alka-Seltzer tablet you put in a glass of cold water. But the key is, a soluble K dosage form that is taken orally after it's dissolved.

Enter new know-it-all doctor.

Even though slow release K tablet formulations were pulled off the market at least once previously, correlated with GI bleeding, GI Ca, that's what she gets.

And gets bowel Ca from a specific focal lesion that closely correlates with all the reasons the FDA yanked this stuff the first time.

Concentrated potassium ions aren't good for you in the space the size of a pea, anywhere in the GI tract.

So, she died, eventually. After metastases to everywhere.
And I had to manage her pain care.

The consult amounted to "Irma, take these instead; they are released more gradually and I think they will be better for you."

So, what is the balance between, "There's a hundred reasons you might be hurt taking this pill" and "Here's your prescription. Any problems, have your coroner call me."?

Scaring off patients from treatment they need and is generally accepted as safe and appropriate, is bad.

Having patients blindly accept medications and treatment without a thorough risk assessment, is bad.

But, where do you draw the line? In the old, take all the time you want, non-HMO days, the physicians made that call, and more often than not did it right.

All patients are entitled to counseling and informed consent, but how much is too much and how little is too little?

That was the purpose of the poll.

RSH.

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Author: urche Three stars, 500 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 262 of 892
Subject: Re: Poll: Patient Information Date: 10/30/2002 11:15 AM
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RSH--- this was a brilliant post (#260) that deserves wider readership. Taking your permission for granted, I am going to try to forward this to someone at the Fool discussion boards in hopes that it might get picked as a post of the day.
You expressed very well the predicament I have found myself in more and more often over the 20 years I have been in medical practice.
Here was my favorite line:
So, what is the balance between, "There's a hundred reasons you might be hurt taking this pill" and "Here's your prescription. Any problems, have your coroner call me."?

Therein lies the art of medicine. Unfortunately, therein also lies the likelihood of doing the wrong thing no matter how you prescribe.

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Author: rshunter2 Big red star, 1000 posts Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 263 of 892
Subject: Re: Poll: Patient Information Date: 10/31/2002 3:20 PM
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RSH--- this was a brilliant post (#260) that deserves wider readership. Taking your permission for granted, I am going to try to forward this to someone at the Fool discussion boards in hopes that it might get picked as a post of the day.
You expressed very well the predicament I have found myself in more and more often over the 20 years I have been in medical practice.


Dr. Jerry, I cannot remember the last time I have been so flattered by a compliment, on TMF or anywhere. I hope they do post it, if only because it was heartfelt and based on my own knowlege and personal experiences.

I saved my grandfather from almost certain death from his first home IPPB treatment, when I noticed he was reacting poorly, complaining of tachycardia; I stopped the treatment, and found that the dosage of Isuprel (isoproterenol) was a quadruple overdose. I was 12.

There are all kinds of doctors out there, as you well know. There are doctors who have a collegial approach, and doctors who sit on a high, unapproachable throne.

Advising a patient is always walking on a wire, especially with the elderly, or those with mental defecits, or a tendency toward hypochondria, or just plain not very bright. The prescriber has to balance all that out, and give counselling that is appropriate, without scaring the patient to death, and making sure they understand as best they can what they are taking, why, and what it does.

But even that rule needs to be broken sometimes, if a patient desparately needs a drug, say for severe depression, and they're the type that "won't take pills like that".

And then there are the drugs that you absolutely, positively MUST put the fear of God into the patient, such as Flagyl and NO ALCOHOL, or MAOI's and {huge list of things you mustn't eat, drink, or take} or protease inhibitors and grapefruit juice.

Anyone able to make all their patients finish their 7,10,14 whatever day course of oral antibiotics should be automatically eligible for the Nobel Prize for Medicine. (My pet peeve, even my own mother the RN; "Mom, " take this medicine until finished ", is there another language you'd prefer they print the label in?" That mean's when the bottle's empty, not when you feel like not taking it anymore."

Nurses are THE worst patients in the world, Physicians are second worst.

RSH.

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Author: ladyandy Three stars, 500 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 269 of 892
Subject: Re: Poll: Patient Information Date: 11/5/2002 7:03 PM
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Anyone able to make all their patients finish their 7,10,14 whatever day course of oral antibiotics should be automatically eligible for the Nobel Prize for Medicine. (My pet peeve, even my own mother the RN; "Mom, " take this medicine until finished ", is there another language you'd prefer they print the label in?" That mean's when the bottle's empty, not when you feel like not taking it anymore."

Nurses are THE worst patients in the world, Physicians are second worst.


Just today I was at the pharmacy picking up a prescription. There was a gentleman there picking up a new prescription for amoxicillin who asked for the pharmacist to come to the desk to explain how to take the medication.

There was one of those harried pharmacists who finally came over to help him and said just that you take it every xx hours as needed. He had to force her to give him a little more information, like could he take it with food or what other instructions there were. She just said take it with plenty of water. There was not even a mention of finishing the entire prescription, and the pharmacist acted like she was being asked something unreasonable, like any idiot should know how to take this stuff.

I was irritated with her even though I wasn't the one being treated poorly. It would have taken even less time for her to do her job and explain thoroughly than the "pulling teeth" grudging response she finally gave.

Yes, there is lots of room for improvement when it comes to the antibiotics.

Best regards,
Ladyandy

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Author: rshunter2 Big red star, 1000 posts Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 270 of 892
Subject: Re: Poll: Patient Information Date: 11/5/2002 8:57 PM
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Just today I was at the pharmacy picking up a prescription. There was a gentleman there picking up a new prescription for amoxicillin who asked for the pharmacist to come to the desk to explain how to take the medication.

There was one of those harried pharmacists who finally came over to help him and said just that you take it every xx hours as needed. He had to force her to give him a little more information, like could he take it with food or what other instructions there were. She just said take it with plenty of water. There was not even a mention of finishing the entire prescription, and the pharmacist acted like she was being asked something unreasonable, like any idiot should know how to take this stuff.

I was irritated with her even though I wasn't the one being treated poorly. It would have taken even less time for her to do her job and explain thoroughly than the "pulling teeth" grudging response she finally gave.

Yes, there is lots of room for improvement when it comes to the antibiotics.

Best regards,
Ladyandy


Ma'am, have I told you lately I'd love to give you a big kiss or at last, buy you a cup of coffee?

There is no excuse, on ethical if not even legal bounds, for providing patient counseling in the pharmacy setting. Many states have laws on the books in this regard but there is no Federal mandate as yet.

And if a patient ASKS?? Then it turns into potentially ugly legal recourse if any adverse reaction should occur, which can end up even backfiring on everyone involved in the chain of care, back to the pharmaceutical company.

For example, Amox prescribed to a Pt with an active mononucleosis infection often gives them a frightening purple rash and skin discoloration. I've seen it, it is not pretty.

All the new modern pharmacy systems such as the major chains use use rudimentary database methods to find dangerous drug interactions. It's a step. I guess. But I think it also provides a false sense of security.

Unless HIPPA / HCFA and other patient privacy rules are violated as Bush seems to want to do, Pharmacy and Pharmacist A won't know what their B counterpart are up to. Polypharmacy remains a risk, a terrible one, for the infirm and elderly, and in fact the general public.

On the other hand, I don't want Big Brother consolidating all my medical and drug records, no matter how good the intentions might be, because information systems security, particularly in medical and forensic systems, can be broken, for the right price, to the wrong people.

What to do?

Let's take your Amox Pt. as an example:

Prescriber should have briefed him on the purpose of the medicine, ensured he had no contraindicating conditions, maybe even done a culture? That's old fashioned these days it seems, but my stepfather routinely did in-office susceptibility cultures from nasal and throat swabs, sputum, and, er well other things. And of course either administered stat in the office, or prescribed; if he had the least suspicion of anything unusual, a susceptibility plate was run, and blood drawn and sent out. They used to be easy and cheap to do, a monkey could do them.

And certainly the prescriber should have instructed the Pt on how to take the medicine and side effects and what to do.

RN's out of this one.

Pharmacist, first, should have ensured proper labelling including the "FINISH THIS WHOLE BOTTLE OR WE SEND THE ANTIBIOTIC NAZI's OUT TO GET YOU" label. Labelling should also have included proper administration, take with food, on an empty stomach, yadda yadda.

More importantly, the Pharmacist should first have asked "Do you have any allergies? Especially to molds or to penicillin or to other antibiotics? Have you ever taken this medicine before, that you can recall, Mr. Jones?"

That could have caught a mistake that would have cost that patient his life; acute anaphylaxis is not a nice way to go.

And, lots of people cannot or will not read; if they cannot read or speak English, they are in even more trouble.

Labelling and printouts and computer systems will never replace family practitioners, nurses, and pharmacists who actually know patients as people, instead of by file or prescription number.

RSH.

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Author: rshunter2 Big red star, 1000 posts Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 271 of 892
Subject: Re: Poll: Patient Information Date: 11/5/2002 9:03 PM
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Er, correction:

This should have read:


There is no excuse, on ethical if not even legal bounds, for NOT providing patient counseling in the pharmacy setting. Many states have laws on the books in this regard but there is no Federal mandate as yet.



*blush*

RSH.

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