Shared Decisions

Many years ago I was shocked when some friends told me that when they lived in South America antibiotics could be purchased without a prescription. This seemed dangerous, and at some level, it left me feeling vulnerable. I worried that if this practice ever crept into North America, my status as a professional would be seriously devalued. The mere fact that only physicians could write prescriptions was one of those things that made me special ... certainly more special than lawyers. The power of the prescription pad was one that I felt must be guarded with the utmost diligence.

Things change. For a short while, I struggled with the notion that nurse practitioners could write prescriptions, but I have found that they are no more incautious in their prescribing practices than are physicians. After all, they are trained professionals. But allowing patients to decide when they should use a medication is a leap into another dimension.

But, again things change. When physicians finally realized that in many circumstances otitis media resolves without antibiotics, the door was opened into that uncomfortable dimension.

I can tell a parent, "We probably won’t need to use antibiotics for your child’s ear infection. Call me if she gets sicker." But that isn’t very customer friendly. The parent will need to call back and either make another appointment or wait for the chain of command in my office to spit out a prescription. The first option fails to acknowledge that most parents have jobs, and the second option ties up office overhead that won’t be reimbursed. And what about nights, weekends, holidays, and blizzards?

Another option is to provide the family with a few starter doses of medication to be used if the scenario changes. This is impractical for those of us who no longer accept samples from drug companies.

The solution that seems to work best for me is one I have learned to call a Shared Description Prescription (SDRx). I’m not sure where I first heard the term but I like its message and the way it rolls of the tongue.

I describe (and occasionally write down) the conditions under which I recommend using the medication. The written/printed scrip includes a "Do not fill after" date. I explain that because I can’t predict how things will change, I am asking the parents to be my eyes and ears because they know their child better than anyone else. And, I am sharing the treatment decision with them.

In the 10 years I have been writing SDRxs, most parents have been appropriately cautious in filling them. Those families who are unhappy about the wait-and-see strategy have stopped by the pharmacy on the way home. But they are the same families who would have to return the next day to badger one of my partners into writing a prescription if I hadn’t. Rarely, parents wait longer than I would have to treat, but the delays have not endangered the children.

I have been so pleased with SDRxs that I have expanded their use beyond otitis media. For example: Is the child with unilateral conjunctivitis and a hint of redness and swelling beneath his eye developing preseptal orbital cellulitis? If his parents have a track record as good observers, I will issue an SDRx for antibiotics and arrange for a follow-up call from our office. But I admit the latter doesn’t always happen.

My sense is that my patients are receiving fewer antibiotics. Our computer system only tracks prescriptions that are written, not whether they are filled. Somewhere a computer probably knows that by ever-so-slightly loosening my grip on my prescription pad, I am saving money and combating antibiotic overusage.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected]. This column, "Letters From Maine," appears regularly in Pediatric News, a publication of Elsevier.

Many years ago I was shocked when some friends told me that when they lived in South America antibiotics could be purchased without a prescription. This seemed dangerous, and at some level, it left me feeling vulnerable. I worried that if this practice ever crept into North America, my status as a professional would be seriously devalued. The mere fact that only physicians could write prescriptions was one of those things that made me special ... certainly more special than lawyers. The power of the prescription pad was one that I felt must be guarded with the utmost diligence.

Things change. For a short while, I struggled with the notion that nurse practitioners could write prescriptions, but I have found that they are no more incautious in their prescribing practices than are physicians. After all, they are trained professionals. But allowing patients to decide when they should use a medication is a leap into another dimension.

But, again things change. When physicians finally realized that in many circumstances otitis media resolves without antibiotics, the door was opened into that uncomfortable dimension.

I can tell a parent, "We probably won’t need to use antibiotics for your child’s ear infection. Call me if she gets sicker." But that isn’t very customer friendly. The parent will need to call back and either make another appointment or wait for the chain of command in my office to spit out a prescription. The first option fails to acknowledge that most parents have jobs, and the second option ties up office overhead that won’t be reimbursed. And what about nights, weekends, holidays, and blizzards?

Another option is to provide the family with a few starter doses of medication to be used if the scenario changes. This is impractical for those of us who no longer accept samples from drug companies.

The solution that seems to work best for me is one I have learned to call a Shared Description Prescription (SDRx). I’m not sure where I first heard the term but I like its message and the way it rolls of the tongue.

I describe (and occasionally write down) the conditions under which I recommend using the medication. The written/printed scrip includes a "Do not fill after" date. I explain that because I can’t predict how things will change, I am asking the parents to be my eyes and ears because they know their child better than anyone else. And, I am sharing the treatment decision with them.

In the 10 years I have been writing SDRxs, most parents have been appropriately cautious in filling them. Those families who are unhappy about the wait-and-see strategy have stopped by the pharmacy on the way home. But they are the same families who would have to return the next day to badger one of my partners into writing a prescription if I hadn’t. Rarely, parents wait longer than I would have to treat, but the delays have not endangered the children.

I have been so pleased with SDRxs that I have expanded their use beyond otitis media. For example: Is the child with unilateral conjunctivitis and a hint of redness and swelling beneath his eye developing preseptal orbital cellulitis? If his parents have a track record as good observers, I will issue an SDRx for antibiotics and arrange for a follow-up call from our office. But I admit the latter doesn’t always happen.

My sense is that my patients are receiving fewer antibiotics. Our computer system only tracks prescriptions that are written, not whether they are filled. Somewhere a computer probably knows that by ever-so-slightly loosening my grip on my prescription pad, I am saving money and combating antibiotic overusage.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected]. This column, "Letters From Maine," appears regularly in Pediatric News, a publication of Elsevier.

Many years ago I was shocked when some friends told me that when they lived in South America antibiotics could be purchased without a prescription. This seemed dangerous, and at some level, it left me feeling vulnerable. I worried that if this practice ever crept into North America, my status as a professional would be seriously devalued. The mere fact that only physicians could write prescriptions was one of those things that made me special ... certainly more special than lawyers. The power of the prescription pad was one that I felt must be guarded with the utmost diligence.

Things change. For a short while, I struggled with the notion that nurse practitioners could write prescriptions, but I have found that they are no more incautious in their prescribing practices than are physicians. After all, they are trained professionals. But allowing patients to decide when they should use a medication is a leap into another dimension.

But, again things change. When physicians finally realized that in many circumstances otitis media resolves without antibiotics, the door was opened into that uncomfortable dimension.

I can tell a parent, "We probably won’t need to use antibiotics for your child’s ear infection. Call me if she gets sicker." But that isn’t very customer friendly. The parent will need to call back and either make another appointment or wait for the chain of command in my office to spit out a prescription. The first option fails to acknowledge that most parents have jobs, and the second option ties up office overhead that won’t be reimbursed. And what about nights, weekends, holidays, and blizzards?

Another option is to provide the family with a few starter doses of medication to be used if the scenario changes. This is impractical for those of us who no longer accept samples from drug companies.

The solution that seems to work best for me is one I have learned to call a Shared Description Prescription (SDRx). I’m not sure where I first heard the term but I like its message and the way it rolls of the tongue.

I describe (and occasionally write down) the conditions under which I recommend using the medication. The written/printed scrip includes a "Do not fill after" date. I explain that because I can’t predict how things will change, I am asking the parents to be my eyes and ears because they know their child better than anyone else. And, I am sharing the treatment decision with them.

In the 10 years I have been writing SDRxs, most parents have been appropriately cautious in filling them. Those families who are unhappy about the wait-and-see strategy have stopped by the pharmacy on the way home. But they are the same families who would have to return the next day to badger one of my partners into writing a prescription if I hadn’t. Rarely, parents wait longer than I would have to treat, but the delays have not endangered the children.

I have been so pleased with SDRxs that I have expanded their use beyond otitis media. For example: Is the child with unilateral conjunctivitis and a hint of redness and swelling beneath his eye developing preseptal orbital cellulitis? If his parents have a track record as good observers, I will issue an SDRx for antibiotics and arrange for a follow-up call from our office. But I admit the latter doesn’t always happen.

My sense is that my patients are receiving fewer antibiotics. Our computer system only tracks prescriptions that are written, not whether they are filled. Somewhere a computer probably knows that by ever-so-slightly loosening my grip on my prescription pad, I am saving money and combating antibiotic overusage.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected]. This column, "Letters From Maine," appears regularly in Pediatric News, a publication of Elsevier.