No More Prescriptions

Is it time to stop writing prescriptions? Is it worth the headache? Say it with me: “Doctors should no longer write prescriptions. Let someone else deal with it.” Think for a second what practicing medicine would be like if prescribing was no longer our responsibility. At first it sounds like a relief! What is the worst part of our day and most common trigger of burnout? What takes up most of our time and creates the most animosity between us and patients?

Prescribing anything nowadays is a misery, summarily because nobody trusts us anymore. Patients already come to our clinics covered in coconut oil and apple cider vinegar with contempt for whatever science comes from applying the mechanisms of action of a therapy to counter the building blocks that make a disease…they have all the knowledge they need from their neighbors, social media, and their hairdressers. Plus, they eventually just believe what the pharmacists tell them, and blame us for their high expenses and for “pushing too many drugs.”

Fellow physicians also believe—and judge despite not addressing their own biases—that anyone with ties to pharma cannot prescribe objectively, even going so far as to voluntarily expose the reporting to the government in the name of transparency, trusting the government over fellow physicians. Congratulations, everyone! Do these doctors believe generic companies will step up to support medical education and patient advocacy, and help to keep the dues for meetings and societies at reasonable levels? Maybe the anti-industry doctors should have a separate category and fee for meetings and memberships that relieve them of the dirty money that industry contributes…$2,500 for AAD dues might be an eye opener.

One of my most recent online reviews came from a cash-paying patient with a cluster of plantar warts. Already having “tried everything,” the patient wanted the warts gone the same day. I offered to freeze them, which the patient refused. Then I suggested we try to medically shrink them with tazarotene and set up a day to surgically remove what we could, allowing the patient to plan ahead for some downtime post-treatment. Instead, the patient cancelled the follow-up appointment and posted online about how I tried to treat the warts with an acne drug saying that I should go back to school since I don't know how to treat a simple wart. Very classy, and yet a shining example of how too little knowledge is pathetic. In a new non-prescribing universe, the medical modality would have been someone else's problem, and I would have frozen the hell out of those warts.

Then there are the pharmacies and the pharmacy benefit managers (PBMs) who now can determine a patient's need for a therapy from behind a desk. For many, this is the answer to controlling costs, access to opioids, and so many of the violations physicians make as prescribers.¹

I heard a great story the other day. Isotretinoin was denied for an acne patient because, from the notes alone, a PBM determined that the acne was not severe enough to warrant treatment. After more wasted time, the patient sent photos to the insurance company (not the dermatologist) to back up the case, and the prescription was finally approved. There you go…the telemedicine prescriber in this episode was not the physician. So why even see us? Just send the photos straight to the PBM and roll the dice with which therapy arrives.

And of course there are costs and impact to “the system.” Proposed mergers like CVS and Aetna are hardly meant to help patients, but there will be more like these until corporate profits are maximized. A recent article² evaluated how the transfer of the burden of costs can end up causing higher deductibles and premiums while payoffs to those in the supply chain continue to soar unnoticed.

Prescribing is meant to be the finishing touch to the patient care transaction, it is the art that harmonizes with the science and connects the dots of why patients come to us. We have to trust our sources, our training, and our guts. We can listen to all the noise, and note that “prescribing choices between generic and branded medications are not without consequence, and these decisions require careful consideration as these may potentially lead to patient confusion, medication errors and adverse events.”³ Now more than ever, we are facing obstacles for patient care success while still ending up with the liability, the virtual and personal vitriol, and the extra time and headaches to simply make our patients better.

So what are you going to do with the next prescription you write? Are you going to fight for it to be covered? Explain to the patient the rationale for therapy? Or simply let it be just a suggestion? There's nothing wrong with asking to see the liability insurance plan for the PBM when they're responsible for outcomes or for circling every bad alternative drug and writing “off-label” or “not medically indicated,” especially in a female of child bearing potential. These points often work, and it catches them off guard because the bullies on the playground don't expect us to fight back.

Let's hope we still have these choices in a few years, because the vultures are at the door just waiting for their chance, and where that leaves us as clinicians will be a new future for sure. But in the meantime, find your own way to fight back, and share the pearls with your colleagues, because we all deserve to win at least one round.

—Neal Bhatia, Chief Medical Editor

1. forbes.com/sites/robertglatter/2012/05/11/should-pharmacists-prescribe-prescription-medications/#11390d5fcca6

2. bloomberg.com/news/features/2018-04-06/when-these-new-pharma-bros-show-up-drug-prices-tend-to-go-monumentally-higher

3. Grant M, Chapman M. (Intern Med J. 2015;45(7):774-6)