dodgy doctors

pharmacist

there seems to be a big increase in the number of dodgy gp's prescribing hugh amounts of benzo's and pain killers recently just to make an extra buck.
all the junkies know who they are too and seem to have no problem getting a script for whatever they want.
can never understand how some doctors can be so unscrupulous.
any other pharmacists notice an increase in this?

Dr Galen

any facts at all to back this sort of thing up? I don't have an issue with a discussion on prescribing habits, but baseless accusations aren't a good thing OP.

back it up or this thread will be going bye bye

Cheers

DrG

pharmacist

Dr Galen wrote: »

any facts at all to back this sort of thing up? I don't have an issue with a discussion on prescribing habits, but baseless accusations aren't a good thing OP.

back it up or this thread will be going bye bye

Cheers

DrG

i am a locum pharmacist and i see it every week in different areas.
i have had many a argument with these doctors but they don't seem to care.
i generally will refuse to dispense such scripts but the patient will just go to another pharmacy and eventually get it dispense somewhere.

drkpower

pharmacist wrote: »

i am a locum pharmacist and i see it every week in different areas.
i have had many a argument with these doctors but they don't seem to care.
i generally will refuse to dispense such scripts but the patient will just go to another pharmacy and eventually get it dispense somewhere.

I dont doubt that this is a problem (and is the subject of another thread here, i think).

Without wanting to go too OT, what is the legal/ethical basis for you refusing to dispense these scripts?

pharmacist

drkpower wrote: »

Without wanting to go too OT, what is the legal/ethical basis for you refusing to dispense these scripts?

i'll give you an example.
there was a woman who injured her back a year and a half ago.
initially her doctor prescribed her cyclomorph but wouldn't prescribe anymore after 3 months.
she wanted more so she went to a doctor who is well know for basically prescribing whatever benzo's pain killers, sleepers his patients ask for. (i sure her friends told her about him)

he had no problem continuing to prescribe the cyclomorph which she has been on for a year and a half now.
she admitted to me that she no longer has back pain but she needs the moprhine!
i rang the doctor and expalined that she told me she is no longer in pain and she is now addicted to the morphine.
he simply didn't care and has been prescribing her 20 amps of cyclimorph 10 a month.
This is just one of many examples.

drkpower

pharmacist wrote: »

This is just one of many examples.

I dont doubt it, but what is the legal/ethical basis for you refusing to dispense these scripts?

pharmacist

drkpower wrote: »

I dont doubt it, but what is the legal/ethical basis for you refusing to dispense these scripts?

the ethical basis is that the drug was being prescribed, my the patients own admission, because she was addicted to it and not for the drugs indicated use.

drkpower

pharmacist wrote: »

the ethical basis is that the drug was being prescribed, my the patients own admission, because she was addicted to it and not for the drugs indicated use.

So if the patient does not admit to an addiction, can you refuse to dispense (based on your own suspicion/clinical judgment that he is addicted)?

And does the doctor have to agree with your assessment or can you unilaterally make that decision?

angeldelight

It's definitely true that there are certain doctors known to drug addicts to be an easy touch - there a few doctors I'm aware of in the area I work in and almost as soon as I see their prescription I know what's going to be on it.

In most cases I would dispense but I have refused in the past. Not on a legal basis as in the prescription was correctly written but on an ethical one. Eg someone presents with a prescription on the 1st of the month for 30 Dalmane and 90 Anxicalm - then on the 13th they're back in again with a newly written script for another 30 Dalmane and 90 Anxicalm as they "lost them". Perhaps they received that supply from someone else then I'm there on the 22nd and they come in with another one written that day because their girlfriend "accidentally threw them out" - sorry but I am not dispensing another months supply within 3 weeks of the first one and they've had a second month supply in between! I know these are being sold on the street, and I'm not supporting that. I would contact the prescriber and suggest weekly dispensing but usually would be fobbed off and so I won't dispense it

Clearly this type of doctor is in the very small minority, thank God, I'm just agreeing with the OP that there are certain doctors that seem to be known by drug seekers and the doctors dont' seem to mind having that sort of reputation

pharmacist

drkpower wrote: »

So if the patient does not admit to an addiction, can you refuse to dispense (based on your own suspicion/clinical judgment that he is addicted)?

And does the doctor have to agree with your assessment or can you unilaterally make that decision?

in 99% of cases you can ring the doctor and talk about your suspicions and most doctors are happy to discuss this.
these "dodgy" doctors, for want of a better term, don't give two sh*ts whether the patient is addicted or not, all they care is about making a buck and are more than happy to enhance their reputation amongst the addicts.

i'm not sure if i'm picking you up correctly from your line of questioning drkpower, are you suggesting that pharmacists should just dispense all prescriptions without question?

drkpower

pharmacist wrote: »

i'm not sure if i'm picking you up correctly from your line of questioning drkpower, are you suggesting that pharmacists should just dispense all prescriptions without question?

No, not at all. But I would be concerned if a pharmacist had carte blanche to decide to disregard what a doctor prescribes. So I am trying to explore what you, as a pharmacist, are entitled to do.

So, again, if the patient does not admit to an addiction, can you refuse to dispense (based on your own suspicion/clinical judgment that he is addicted)?

And does the doctor have to agree with your assessment or can you unilaterally make that decision?

pharmacist

drkpower wrote: »

So, again, if the patient does not admit to an addiction, can you refuse to dispense (based on your own suspicion/clinical judgment that he is addicted)?

And does the doctor have to agree with your assessment or can you unilaterally make that decision?

okay, sorry, i thought they were retorical questions!!
A pharmacist does not have to dispense any script they are uncomfortable with so yes they can refuse to dispense (based on your own suspicion/clinical judgment that he is addicted) and no the doctor does not have to agree with that decision.
in reality though as i said before 99% of doctors are happy to discuss and we would generally come to an agreement.
having said that there are also pharmacists out there who are happy to dispense these scripts without question so i'm sure if the person went to enough pharmacies they would eventually get it dispensed.

drkpower

pharmacist wrote: »

A pharmacist does not have to dispense any script they are uncomfortable with so yes they can refuse to dispense (based on your own suspicion/clinical judgment that he is addicted) and no the doctor does not have to agree with that decision..

Really? In any circumstances?
Does this just apply to suspicions of addiction or does it apply to any other decision to refuse?

And if you do refuse, do you have an obligation to inform the doctor?

Sorry for taking the thread OT, but genuinely interested in the extend of a pharmacists discretion to refuse treatment.

chanste

Hi, just thought I'd throw another angle in on this issue.

I was told last year by a GP that in many cases them and some of their colleagues feel intimitated to a point that they would prescribe pretty much anything a patient wanted. I don't think it was simply threats though, I think it was more that there was a fear that if a patient was agitated enough, and were requesting a doctor to prescribe something specific, the doc in question may fear for their own safety if they didn't comply with request (and this could also be in cases were patient genuinely meant no harm, but came across as potentially dangerous).

In such circumstances I'd be hard pressed to fault a doctor concerned about there safety, but I'm wondering is there a procedure that is supposed to be followed, or are there things in place to protect such doctors?

kdowling

drkpower wrote: »

Really? In any circumstances?
Does this just apply to suspicions of addiction or does it apply to any other decision to refuse?

And if you do refuse, do you have an obligation to inform the doctor?

you must remember that the role of the pharmacist is to ensure that medicines prescribed to patients are suitable.
i.e. that the dose is correct, the indications are correct etc, you seem to view the pharmacist as a shop keeper that hands out whats on the list with no thought of whats on it!!

also if a doctor prescribes an overdose that harms or god forbid kills a patient it is the pharmacist that would be responsible because it is the pharmacists job to ensure that the prescription is suitable so of course they can refuse to dispense.

but, yes, you would have an obligation to inform the doctor.

kdowling

chanste wrote: »

I was told last year by a GP that in many cases them and some of their colleagues feel intimitated to a point that they would prescribe pretty much anything a patient wanted. I don't think it was simply threats though, I think it was more that there was a fear that if a patient was agitated enough, and were requesting a doctor to prescribe something specific, the doc in question may fear for their own safety if they didn't comply with request (and this could also be in cases were patient genuinely meant no harm, but came across as potentially dangerous).

i would imagine that it would be very rare that a doctor would prescribe due to fears for his/her safety.
whats more common is being pressured into prescribing antibiotics even when they are not needed which is one of the reasons we are becoming resistant to antibiotics.
when a patient has just paid €60 or €70 for a consultation and are asking for an antibiotic it must be hard to say no, go to the pharmacy and just take paracetamol even though thats what they should say.

drkpower

kdowling wrote: »

you must remember that the role of the pharmacist is to ensure that medicines prescribed to patients are suitable.
i.e. that the dose is correct, the indications are correct etc, you seem to view the pharmacist as a shop keeper that hands out whats on the list with no thought of whats on it!! .

No, I certainly dont view a pharmacist as merely a shopkeeper, but nor is it a pharmacist's role to decide if a drug is suitable, in the sense of whether it is medically indicated and appropriate. That is the doctor's role. Now clearly, there is a degree of overlap and that is what i am seeking to explore; where the line is drawn and most particularly, in what circumstances can a pharmacist essentially over-rule a doctor.

kdowling wrote: »

also if a doctor prescribes an overdose that harms or god forbid kills a patient it is the pharmacist that would be responsible because it is the pharmacists job to ensure that the prescription is suitable so of course they can refuse to dispense. .

Both would probably be responsible. It would take an error of gargantuan proportions (by the pharmacist) to fully absolve the doctor.

AmcD

pharmacist wrote: »

there seems to be a big increase in the number of dodgy gp's prescribing hugh amounts of benzo's and pain killers recently just to make an extra buck.
all the junkies know who they are too and seem to have no problem getting a script for whatever they want.
can never understand how some doctors can be so unscrupulous.
any other pharmacists notice an increase in this?

I don't see how dodgy GPs are making an extra buck by prescribing benzos and painkillers. In the areas that I have worked so far, nearly 99% of benzo addicts would have medical cards, therefore the GP makes no extra money by writing a script.

Also I think it is unlikely that there is an increase in "dodgy" GPs. Surely it is just the same lazy minority doling out the scripts. It takes far more effort to address a benzo addiction and try to reduce the dose. Perhaps you might have addicts taking advantage of locums, but the majority of locums will have been vocationally trained and hopefully would be a little more conscientious.

Strategies I have for coping with benzo-seeking behaviour include:
Weekly scripts- as you have mentioned.
Clearly stating that I won't be reissuing scripts- before the sob story takes off (usually robbed handbag/left on train/"pharmacist left me short!"
Ring the pharmacist with the patient present to confirm what has been dispensed and when.

angeldelight

I wouldn't necessarily say the pharmacist is over-ruling the doctor, its not as though we would confiscate or shred the prescription. The patient is free to attend another pharmacy. However if we genuinely feel that what is written on a prescription is not safe/ appropriate/ in the best interest of the patient how could we dispense it? We wouldn't be discharging our professional duty if we had such misgivings and proceeded to dispense the item.

pharmacist

drkpower wrote: »

where the line is drawn and most particularly, in what circumstances can a pharmacist essentially over-rule a doctor.

i'm not sure where the line is myself and i would be interested to hear the opinion of other pharmacists.

my opinion is that in the above situations a pharmacist is not over ruling a doctor because if a pharmacist decides not to dispense a prescription it doesn't mean that the patient does not get that medication. They will most likely get the medication from a different pharmacy.

where you get into a grey area is when a doctor prescribes a medication off-licence or a dose that is higher than for example the max dose according to the BNF. in these situations the doctor is accepting responsibility for prescibing outside of the licence but if something goes wrong the pharmacist is also responsible so he/she has a right to question it. its not just a case of the pharmacist sticking his/her nose in, they are potential open to litigation if something goes wrong also.

drkpower

pharmacist wrote: »

i'm not sure where the line is myself and i would be interested to hear the opinion of other pharmacists.

my opinion is that in the above situations a pharmacist is not over ruling a doctor because if a pharmacist decides not to dispense a prescription it doesn't mean that the patient does not get that medication. They will most likely get the medication from a different pharmacy. .

That presumes that the pharmacist is obliged to inform the doctor that he did not dispense - but i presume that that is a minimum requirement. Perhaps (and this is probably, imo) a pharmacist has an over-riding ability to not serve anyone (except in emergencies), in which case they can refuse for any reason whatsoever (barring discriminatory reasons).

pharmacist wrote: »

where you get into a grey area is when a doctor prescribes a medication off-licence or a dose that is higher than for example the max dose according to the BNF. in these situations the doctor is accepting responsibility for prescibing outside of the licence but if something goes wrong the pharmacist is also responsible so he/she has a right to question it. its not just a case of the pharmacist sticking his/her nose in, they are potential open to litigation if something goes wrong also.

Well i think the pharmacist always has a right (and an obligation, in some cases) to question. But if the pharmacist questions a script (ie. i think this guy isaddicted to benzos) and the doctor re-affirms his initial view (ie. no, he's grand, give him 60 valium), what is the pharmacist's entitlements and obligations?

pharmacist

AmcD wrote: »

I don't see how dodgy GPs are making an extra buck by prescribing benzos and painkillers. In the areas that I have worked so far, nearly 99% of benzo addicts would have medical cards, therefore the GP makes no extra money by writing a script.

i agree most are on medical cards. i heard stories of this years ago and thought they were highly exagerated but i have seen it myself a good few times now and definately noticed it a lot more recently. they are prescribed on private scripts so obviously there are more numerous than the 1% you are suggesting!!

angeldelight

I would imagine that quite often the person might have a medical card and be on the panel of one doctor but are happy to attend a different benzo happy doctor and pay privately. Twice in the last few months just I have encountered the above - I do have to admit the look on their face when they see me and recognise me as the pharmacist working in their "normal" pharmacy last week where they got their medical card script filled, and in one case their methadone script filled, can be quite amusing

pharmacist

drkpower wrote: »

. But if the pharmacist questions a script (ie. i think this guy isaddicted to benzos) and the doctor re-affirms his initial view (ie. no, he's grand, give him 60 valium), what is the pharmacist's entitlements and obligations?

in this situation i would (and i assume the vast majority of pharmacists) agree with the gp and dispense the script. after all its the gp who has had the consultation with the patient and would know the patients history so he would be in a far better position to make that call.

it is only an issue if the doctor is prescribing an potential overdose or for me it becomes an issue in principal it is one of the afformentioned (and in the vast minority) doctors who simply don't care if the patient is addicted and is continuing to over prescribe to make an extra buck.

drkpower

pharmacist wrote: »

in this situation i would (and i assume the vast majority of pharmacists) agree with the gp and dispense the script. after all its the gp who has had the consultation with the patient and would know the patients history so he would be in a far better position to make that call.

it is only an issue if the doctor is prescribing an potential overdose or for me it becomes an issue in principal it is one of the afformentioned (and in the vast minority) doctors who simply don't care if the patient is addicted and is continuing to over prescribe to make an extra buck.

I tend to agree with your view. And no doubt, if there is a potential prescription error/interaction issue, the pharmacist is obliged to refuse to dispense, even if a stupid GP insists he is right!

But the interesting one is where a pharmacist is convinced that a patient is addicted to benzos, and the GP vehemently disagrees, what can the pharmacist do?

AmcD

pharmacist wrote: »

i agree most are on medical cards. i heard stories of this years ago and thought they were highly exagerated but i have seen it myself a good few times now and definately noticed it a lot more recently. they are prescribed on private scripts so obviously there are more numerous than the 1% you are suggesting!!

Maybe I should work in better areas.
I cannot believe that these guys would pay for private scripts. Is it worth their while?

pharmacist

AmcD wrote: »

Maybe I should work in better areas.
I cannot believe that these guys would pay for private scripts. Is it worth their while?

i suppose it depends on how addicted they are or how much they are selling them for.

on a seperate note a girl came in yesterday looking to buy ensure which was 3 euro something and said they are getting them on the medical card and selling them for €1 on the street.

another patient was getting montly medication which was coming to €120 and then getting a ridiculous amount of gluten free stuff which was all free as a result. i mean she was getting 20 loafs of bread 10 porridges, 20 rolls, 10 packs of pasta etc. couldn't believe the DPS was covering all of it.
anyways i was in the local market the next week and who was sitting on one of the stalls selling gluten free products? you should have seen the look on her face!

AmcD

pharmacist wrote: »

on a seperate note a girl came in yesterday looking to buy ensure which was 3 euro something and said they are getting them on the medical card and selling them for €1 on the street.

another patient was getting montly medication which was coming to €120 and then getting a ridiculous amount of gluten free stuff which was all free as a result. i mean she was getting 20 loafs of bread 10 porridges, 20 rolls, 10 packs of pasta etc. couldn't believe the DPS was covering all of it.
anyways i was in the local market the next week and who was sitting on one of the stalls selling gluten free products? you should have seen the look on her face!

Ensures are on my hitlist too. The last young gentleman to request these turned out to weigh sixteen stone and was certainly not wasting away.

But gluten-free products, that is a new one to me.

pharmacist

drkpower wrote: »

But the interesting one is where a pharmacist is convinced that a patient is addicted to benzos, and the GP vehemently disagrees, what can the pharmacist do?

as i said before i think in this situation the pharmacist will agree with the gp as he would be in a better situation to make that call.

drkpower

pharmacist wrote: »

as i said before i think in this situation the pharmacist will agree with the gp as he would be in a better situation to make that call.

i think in most cases, that is fair comment. But I suppose you could conceive of a situation where the pharmacist might be in a better position to judge, for instance, where a locum GP is involved. I wonder then, what could the pharmacist do in the case of a disagreement between the pharmacist and the locum GP>

chompchomp

Pharmacists do a very important job and viewing their decisions as 'overruling the doctor' is a load of cod. The same goes for radiographers, physios and other allied health professionals. They are experts in their field and should not be viewed as merely servants of the doctors wishes. thankfully those days are long gone.

Sardonicat

AmcD wrote: »

Ensures are on my hitlist too. The last young gentleman to request these turned out to weigh sixteen stone and was certainly not wasting away.

But gluten-free products, that is a new one to me.

Sorry to drag the thread off-topic, but why is there such a niche in the black market for Ensure? Would there be that many people on it to make it a nice little sideline for someone?

drkpower

chompchomp wrote: »

Pharmacists do a very important job and viewing their decisions as 'overruling the doctor' is a load of cod. The same goes for radiographers, physios and other allied health professionals. They are experts in their field and should not be viewed as merely servants of the doctors wishes. thankfully those days are long gone.

Where do i state or suggest that a pharmacist is a servant to the doctor?

I think you might be getting into an argument with noone!

SomeDose

My understanding of the situation is that, legally, there is no obligation for a pharmacist to dispense a medicine if they aren't satisfied it would be in the patient's best interests to do so. A prescription is an instruction and authority against which a medicine may be supplied, and I'm not aware of any legislation which compels a pharmacist to dispense irrespective of their professional concerns. Professionally and ethically, the pharmacist must ensure they are at all times acting in the patient's best interests and in the above example I think there would be clear justification for refusal to dispense. I cannot imagine any legal or professional action being taken against the pharmacist in this case.

A pharmacy owner with a GMS contract does of course have a legal obligation to dispense GMS scripts, however this does not supercede their professional and ethical duty to refuse inappropriate prescriptions on an individual basis.

drkpower wrote: »

No, I certainly dont view a pharmacist as merely a shopkeeper, but nor is it a pharmacist's role to decide if a drug is suitable, in the sense of whether it is medically indicated and appropriate. That is the doctor's role. Now clearly, there is a degree of overlap and that is what i am seeking to explore....

Incorrect to state that it is solely the doctor's role, certainly in present times, and yes there is a degree of overlap. It is a pharmacist's professional duty to satisfy themselves prior to dispensing, as far as possible, that the drug indication and dosage prescribed are appropriate for the patient. In primary care, this is curtailed to a certain extent due to lack of patient history etc and therefore there is a significant element of justifiably trusting the GP's judgement, but the duty remains nonetheless.

drkpower

SomeDose wrote: »

My understanding of the situation is that, legally, there is no obligation for a pharmacist to dispense a medicine if they aren't satisfied it would be in the patient's best interests to do so. A prescription is an instruction and authority against which a medicine may be supplied, and I'm not aware of any legislation which compels a pharmacist to dispense irrespective of their professional concerns. Professionally and ethically, the pharmacist must ensure they are at all times acting in the patient's best interests and in the above example I think there would be clear justification for refusal to dispense. I cannot imagine any legal or professional action being taken against the pharmacist in this case.

A pharmacy owner with a GMS contract does of course have a legal obligation to dispense GMS scripts, however this does not supercede their professional and ethical duty to refuse inappropriate prescriptions on an individual basis.

I tend to agree with most of that, but certain aspects of it appear to be incorrect.

On what basis can a pharmacist decide that a prescription is inappropriate/not in the patient's best interests? Can they stray into areas which might be considered clinical decisions?

To take an example, if a doctor believes that antibiotics are indicated to treat a certain infection and the pharmacist disagrees, can they refuse to dispense?

Traumadoc

Sure when the OCP was introduced some pharmacists refused to provide ( as did some GPs).

ttmd

drkpower wrote: »

I tend to agree with most of that, but certain aspects of it appear to be incorrect.

On what basis can a pharmacist decide that a prescription is inappropriate/not in the patient's best interests? Can they stray into areas which might be considered clinical decisions?

To take an example, if a doctor believes that antibiotics are indicated to treat a certain infection and the pharmacist disagrees, can they refuse to dispense?

I think it would be the appropriate test to question whether the item being prescribed has the potential to cause harm. In the case of the antibiotic this is unlikely.

opinion guy

Traumadoc wrote: »

Sure when the OCP was introduced some pharmacists refused to provide ( as did some GPs).

Some still do

drkpower

Traumadoc wrote: »

Sure when the OCP was introduced some pharmacists refused to provide ( as did some GPs).

That is on the basis of a conscientious objection, which has been a fairly established basis to refuse to treat for a long time.

That is not really the issue here.

drkpower

ttmd wrote: »

I think it would be the appropriate test to question whether the item being prescribed has the potential to cause harm. In the case of the antibiotic this is unlikely.

That sounds like a reasonable way forward. But I wonder if it covers every eventuality. For instance, prescribing benzo/other addictive medication can absolutely cause harm. Are we suggesting that a pharmacist has an absolute right to refuse to dispense if they disagree with the doctor's assessment that the medication is indicated and appropriate (assuming it is the right dose etc..)

SomeDose

drkpower wrote: »

On what basis can a pharmacist decide that a prescription is inappropriate/not in the patient's best interests? Can they stray into areas which might be considered clinical decisions?

To take an example, if a doctor believes that antibiotics are indicated to treat a certain infection and the pharmacist disagrees, can they refuse to dispense?

I've highlighted the words above because the question of "on what basis can they..." suggests there is some legal or professional framework which dictates whether or not they must dispense a medicine . There isn't. If they decide not to dispense it, they must be able to show that they were acting in the patient's best interests and that by not dispensing, they did not compromise the patient's care or wellbeing. That's as prescriptive as it gets I'm afraid. How the pharmacist arrives at that decision, and how they may justify it should it result in a legal or professional inquiry, is done purely on an individual basis and couldn't possibly be answered here.

Your example of antibiotics is probably not the easiest to illustrate the point. If the doctor has made the diagnosis, I have no reason to dispute it. For the purposes of this discussion, I would trust the docs judgement in deciding an antibiotic is indicated (ignoring the clichéd cold/URTI scenario). I will however look at the choice of antibiotic and whether or not it's suitable, using all information available to me. If it's not suitable, I'll suggest an alternative and I'd like to think most reasonable docs would agree to change it. Like I said previously, pharmacists in primary care frequently do not know the exact diagnosis or patient history so the point is moot in many cases anyway.

drkpower wrote: »

Are we suggesting that a pharmacist has an absolute right to refuse to dispense if they disagree with the doctor's assessment that the medication is indicated and appropriate (assuming it is the right dose etc..)

See my point in the first paragraph, there are no absolutes in these cases. Can only be decided on a case by case basis. Yes, the do have a "right to refuse", but must be able to justify it as explained before.
Here's a better example: Patient presents with script for methadone, but is clearly intoxicated or narcotised. I'm going to refuse to dispense it ten times out of ten, whether the doc agrees with me or not. Now that probably could be described as a clinical decision on my part, and I would be 100% confident that my decision was both legally and professionally sound.

drkpower

SomeDose wrote: »

suggests there is some legal or professional framework which dictates whether or not they must dispense a medicine . There isn't. ..

Are you sure about that? Is there no guidelines form professional or industry bodies that cover this particular issue? It seems like an incredible omission for the pharmacist's professional body not to put in placse some guidelines on something so fundamental as the refusal to treat.

SomeDose wrote: »

Your example of antibiotics is probably not the easiest to illustrate the point. If the doctor has made the diagnosis, I have no reason to dispute it. For the purposes of this discussion, I would trust the docs judgement in deciding an antibiotic is indicated (ignoring the clichéd cold/URTI scenario). I will however look at the choice of antibiotic and whether or not it's suitable, using all information available to me. If it's not suitable, I'll suggest an alternative and I'd like to think most reasonable docs would agree to change it. Like I said previously, pharmacists in primary care frequently do not know the exact diagnosis or patient history so the point is moot in many cases anyway..

Sure, but the issue I am trying to get at does not even arise where a pharmacist raises a question and the doctor agrees. It only arises where the pharmacist raises a query and the doctor disagrees witth their query. There are 3 posibilities:
1. The pharmacist retains absolute discretion to refuse to dispense (except perhaps in emergencies)
2. The pharmacist must dispense in accordance with the doctor's prescription
3. There are certain situations where the pharmacist can refuse, others where they cannot. I am trying to ascertain where the line is. If (3) is the correct answer, i would be quite surprised if it was entirely up to the pharmacist's discretion and there was no professional guidance available.

SomeDose wrote: »

See my point in the first paragraph, there are no absolutes in these cases. Can only be decided on a case by case basis. Yes, the do have a "right to refuse", but must be able to justify it as explained before.
Here's a better example: Patient presents with script for methadone, but is clearly intoxicated or narcotised. I'm going to refuse to dispense it ten times out of ten, whether the doc agrees with me or not. Now that probably could be described as a clinical decision on my part, and I would be 100% confident that my decision was both legally and professionally sound.

That is a good example and I couldnt argue with the logic, and would agree with the conclusion. But in clear cut examples, there is a clear cut answer; what i am trying to discern is what are the rules/guidance when it comes to more grey areas, of which there are surely many.

angeldelight

drkpower wrote: »

Are you sure about that? Is there no guidelines form professional or industry bodies that cover this particular issue?

There are no such guidelines

3. There are certain situations where the pharmacist can refuse, others where they cannot. I am trying to ascertain where the line is. If (3) is the correct answer, i would be quite surprised if it was entirely up to the pharmacist's discretion and there was no professional guidance available.

It is 100% up to the pharmacist in question to decide whether they are going to dispense something or not. How it was drummed into us in college, and also when I was doing my pre-reg year is - whatever decision you make, you must be able to stand up in a court of law or at a disciplinary hearing and be able to justify your actions. As long as the patient's wellbeing has been central to your decision-making process and you can outline the steps that brought you to your decision, making use of as much information as is available to you at that time, you have discharged your professional responsibility.

pharmacist

anyone have examples of situations in which they refused to dispense?

for me, one of the aforementioned doctors wrote a script for xanax that was more than the 3g a day maximium dose so i refused to dispense it.

i rang the doctor and he said he was happy to go ahead with the origional dose which i objected to and told him i wan't going to dispense it.

now, 99% of doctors i'm sure would adjust the dose but this doctor new that the only reason the patient was going to him was because she knew no other doctor would write her a prescription for such a dose.

opinion guy

drkpower wrote: »

That sounds like a reasonable way forward. But I wonder if it covers every eventuality. For instance, prescribing benzo/other addictive medication can absolutely cause harm. Are we suggesting that a pharmacist has an absolute right to refuse to dispense if they disagree with the doctor's assessment that the medication is indicated and appropriate (assuming it is the right dose etc..)

My thinking would be that pharmacists do have the right to refuse to fill a script but I would imagine then if something happened the patient as a result the pharmacist would be held to account, no ?

kdowling

opinion guy wrote: »

My thinking would be that pharmacists do have the right to refuse to fill a script but I would imagine then if something happened the patient as a result the pharmacist would be held to account, no ?

not really, because as long as the pharmacist informes the doctor that he is not prepared to dispense the medication it is then up to the doctor to check if the patient is able to get the medication dispensed in any other pharmacy. if not he would then have to reconsider what he has prescribed.

opinion guy

kdowling wrote: »

not really, because as long as the pharmacist informes the doctor that he is not prepared to dispense the medication it is then up to the doctor to check if the patient is able to get the medication dispensed in any other pharmacy. if not he would then have to reconsider what he has prescribed.

How do you reckon ?
If the pharmacist says I think he shouldn't get this for x,y,z reasons and doc says no well he should for a,b,c and I'm not changing it how is it the doctors responsibility if the pharmacist continues to refuse to dispense it ?

kdowling

opinion guy wrote: »

How do you reckon ?
If the pharmacist says I think he shouldn't get this for x,y,z reasons and doc says no well he should for a,b,c and I'm not changing it how is it the doctors responsibility if the pharmacist continues to refuse to dispense it ?

because the doctor has been made aware that the pharmacist is not going to dispense the medication and has a duty of care to the patient to see that if nobody will dispense the medication that they prescribe an alternative.

opinion guy

kdowling wrote: »

because the doctor has been made aware that the pharmacist is not going to dispense the medication and has a duty of care to the patient to see that if nobody will dispense the medication that they prescribe an alternative.

So if the patient has their DPS with that pharmacist and has financial hardship what do you expect the doctor to do when the patient cannot afford to go elsewhere?
Surely if the pharmacists is refusing to fill the script the responsibility falls on him to either redirect the patient or deal with the consequences ? The doctor has done his part

sam34

kdowling wrote: »

not really, because as long as the pharmacist informes the doctor that he is not prepared to dispense the medication it is then up to the doctor to check if the patient is able to get the medication dispensed in any other pharmacy. if not he would then have to reconsider what he has prescribed.

fantastic, the old " dr informed, therefore it's no longer my responsibility" trick of many allied health professionals :rolleyes:

kdowling

opinion guy wrote: »

So if the patient has their DPS with that pharmacist and has financial hardship what do you expect the doctor to do when the patient cannot afford to go elsewhere?

first of all this is a purely hypothetical situation, unlikely to arise, as in 99.9% of cases the doctor and the pharmacist would come to an aggreement.

if the patient had to go elsewhere they would be able to claim the money back on the DPS scheme so that would not be an issue.

are you suggesting that a pharmacist should dispense a prescription regardless of whether they believe it may be harmful to the patient or not?