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Three weeks for an antihistamine... - Nobody wears a white coat any more... — LiveJournal
...a tribute to becoming a doctor.
Three weeks for an antihistamine...
I have a patient. She is eleven, she is athletic, she has allergies and asthma and she needs an antihistamine. She has been on Allegra-D in the past; her symptoms resolved. Allegra has a generic. I prescribed Allegra. Medicaid informed me that I needed a prior authorization. I called them on a Saturday. "Oh," says the cheerful and friendly voice on the phone, "we covered her Allegra-D in the past, we should cover it again. I'll have the PA people look into it on Monday." Several days passed, and on Thursday I called again. They didn't know what I was talking about. I sent a PA form. They were very polite and refused. Medicaid informed me that she needed to be on Claritin, or that they needed documentation that she had tried over-the-counter medications in the past. I called her mother and verified that yea, indeed, Allegra was the end of a long chain of attempts. I sent that documentation - this had all been prior to my care. They waited a day before telling me that that was very nice, she needed to be on a formulary drug first, and would I please select from the following list of medications, including Zyrtec syrup, Atrovent nasal spray, Rhinocort Aqua, and several others. I wrote for Zyrtec chewables - after all she is eleven. I got a polite letter back saying that I must give her Zyrtec syrup instead.
What could I do? I wrote for the Zyrtec syrup and called her house and let her stepfather know that we were going to have to try Zyrtec. The poor man, he has no clue; his wife has been dealing with this with me.
What I don't understand, O Best Beloved, is why I can't prescribe the medication that's previously worked for this little girl's symptoms. I hate having to bow to the whim of people who think they know best. I am happy to change medications when my self-pay patient calls and tells me that she cannot afford her 1-gram prophylactic dose of Azithromycin ($30+); I will write her 7 days of doxycycline instead ($15) and not complain - I should have thought of that to begin with. I am not so happy to delay and delay as I am informed that no, I have to give oral Flagyl instead of vaginal gels (treat the infection where it bloody well is, is my thinking); I have to prescribe this antihistamine and not the other; I have to start at ground zero every time.
Now the converse: I am aware that formularies are the result of negotiations between drug companies and insurance companies; they allow cost savings to a degree not otherwise possible. I am not necessarily arguing against formularies - as long as they have a basis in evidence medicine (not all drugs in a class are always alike, after all) there is a place and a time for them. I am arguing that when I prescribe a medication and I want that specific medication for a specific reason, it is frustrating in the extreme to be told that my reason isn't good enough. It is even more frustrating to be arguing this with their specialists who know only what they are told.

It has been a bad day for prior authorizations.

It has been a good day for patients, if one does not mind doing vaginal exams all day. Six patients here of ten scheduled today : one pleasant gentleman who works for the food bank and tells me his blood sugars are out of whack thanks to eating fast food at the Hurricane Katrina relief site over the last few months, one woman with a painful right hand (no clue, folks, and a brand new mouthful of words to look up too - complex regional pain syndrome - which might be what she's got), my lady whose hair is falling out (still falling out, let's try Rogaine), and three pelvics - one follow up on chlamydia, one STD exposure (and boy, is she never going back to that boyfriend again), and one abdominal pain with pelvic tenderness. I spent half the morning looking in the microscope searching for bugs. I found a few.
I am still slow. I wish my six-year-old new patient had showed; she is cute and cuddly and I would like to see her again. But all of that is overshadowed by the fact that vacation begins now, and I am free of responsibilities until next Thursday morning.
That feels good.

Tomorrow, mom and Grandpa will be coming for dinner. Any suggestions? I have a meal planned; I'm looking for garnishes.

now feeling:: happy happy

11 whispers echo . o O ( ... ) O o . whisper a word
missysedai From: missysedai Date: November 10th, 2005 10:16 pm (UTC) (etched in stone)
Geez, it sounds like what my doc went through when trying to get my blood pressure straightened around. The insurance company drove us BOTH mad!

What are you cooking?
ayradyss From: ayradyss Date: November 11th, 2005 12:01 am (UTC) (etched in stone)
You would ask :)
Chicken parmesan and risotto, but I can't decide on a vegetable to go with them.
missysedai From: missysedai Date: November 11th, 2005 01:53 am (UTC) (etched in stone)
Sauteed fresh green beans with pesto. Works beautifully with anything Italian. Alternatively, steamed fresh broccoli with a Parmigianno cheese sauce. Might be a bit much with the chicken parmesan, but it's such a decadent little surprise, I doubt anyone would complain.
pwwka From: pwwka Date: November 11th, 2005 02:46 am (UTC) (etched in stone)
If the risotto is served on a round plate, peas look amazing when ringed around the edge. Especially if you're using saffron in the risotto.
ayradyss From: ayradyss Date: November 11th, 2005 03:51 am (UTC) (etched in stone)
You can make risotto without saffron?
pwwka From: pwwka Date: November 11th, 2005 03:54 am (UTC) (etched in stone)
In a sick parallel universe, yes. It ends up looking like a glob of mucus, but it's still edible. Not that I would know... ::blinks innocently::
albionschild From: albionschild Date: November 11th, 2005 04:02 am (UTC) (etched in stone)
But of course! If you use pumpkin, you need not concern yourself with saffron. Salmon risotto, too, so long as it has the right wine, doesn't need the delectable spice. Since, however, you are making risotto paired with Chicken Parmesan, your choice of a saffron-touched risotto is most certainly best.
trinapink From: trinapink Date: November 10th, 2005 10:45 pm (UTC) (etched in stone)
It makes me a little crazy when my treatment is prescribed by some shirt in an office somewhere, comparing numbers and charts. He can treat me after HE finishes medical school.

I can only imagine how frustrating it must be for you, who have finished med school.
pwwka From: pwwka Date: November 11th, 2005 02:44 am (UTC) (etched in stone)
There are five or six different colors of bell pepper-- they always look pretty when sliced and artfully arranged. Easy, too. :)
deadrose From: deadrose Date: November 11th, 2005 04:38 am (UTC) (etched in stone)
I'm going through this right now - I'm experiencing vaginal mucosa problems related to menopause. My GYN wants (like you) to treat the problem locally, with small doses of Estrace cream. Unfortunately, the only cream the insurance company will allow is Premarin, which I'd really wanted to avoid.
fyrfitrmedic From: fyrfitrmedic Date: November 11th, 2005 11:35 pm (UTC) (etched in stone)
Managed-care issues make me nuts sometimes.
11 whispers echo . o O ( ... ) O o . whisper a word