Hitting a Nerve

One of the nice things about solo office practice is occasionally being able to have one of my (or my staff members’) kids at the office. This isn’t, by any means, something I do often. But my wife’s job won’t allow her to have kids there, so when they’re too sick to go to school it comes down to one of us either staying home or me taking them to my office.

It actually works out pretty well. There’s an unused back office where they can set up shop, and the modern world is full of portable electronic gadgets to keep them busy. I can’t hear them from my office, and they can’t hear what’s said in my office.

What surprises me are the patients who find this upsetting. My kids know not to come out of there if I have a patient, and the only time a patient even knows a child is there is if they wander down the hall to use the bathroom or get something out of the refrigerator. And in my practice, I rarely see immune-suppressed patients.

In spite of this, I’ve had 5-10 patients in the last 10 years complain about it, always on the grounds that it "isn’t professional." Three patients have left the practice because of it. Not surprisingly, none of them had kids of their own.

I still don’t understand this. I have to see doctors myself, and the rare time I notice a child in the office I think nothing of it.

Granted, many of us don’t have the luxury of doing this. But when it’s possible, I have no issues with it at all. I’d rather have a doctor who is concerned enough to bring his kids to work rather than leave them at home alone.

One of the nice things about solo office practice is occasionally being able to have one of my (or my staff members’) kids at the office. This isn’t, by any means, something I do often. But my wife’s job won’t allow her to have kids there, so when they’re too sick to go to school it comes down to one of us either staying home or me taking them to my office.

It actually works out pretty well. There’s an unused back office where they can set up shop, and the modern world is full of portable electronic gadgets to keep them busy. I can’t hear them from my office, and they can’t hear what’s said in my office.

What surprises me are the patients who find this upsetting. My kids know not to come out of there if I have a patient, and the only time a patient even knows a child is there is if they wander down the hall to use the bathroom or get something out of the refrigerator. And in my practice, I rarely see immune-suppressed patients.

In spite of this, I’ve had 5-10 patients in the last 10 years complain about it, always on the grounds that it "isn’t professional." Three patients have left the practice because of it. Not surprisingly, none of them had kids of their own.

I still don’t understand this. I have to see doctors myself, and the rare time I notice a child in the office I think nothing of it.

Granted, many of us don’t have the luxury of doing this. But when it’s possible, I have no issues with it at all. I’d rather have a doctor who is concerned enough to bring his kids to work rather than leave them at home alone.

One of the nice things about solo office practice is occasionally being able to have one of my (or my staff members’) kids at the office. This isn’t, by any means, something I do often. But my wife’s job won’t allow her to have kids there, so when they’re too sick to go to school it comes down to one of us either staying home or me taking them to my office.

It actually works out pretty well. There’s an unused back office where they can set up shop, and the modern world is full of portable electronic gadgets to keep them busy. I can’t hear them from my office, and they can’t hear what’s said in my office.

What surprises me are the patients who find this upsetting. My kids know not to come out of there if I have a patient, and the only time a patient even knows a child is there is if they wander down the hall to use the bathroom or get something out of the refrigerator. And in my practice, I rarely see immune-suppressed patients.

In spite of this, I’ve had 5-10 patients in the last 10 years complain about it, always on the grounds that it "isn’t professional." Three patients have left the practice because of it. Not surprisingly, none of them had kids of their own.

I still don’t understand this. I have to see doctors myself, and the rare time I notice a child in the office I think nothing of it.

Granted, many of us don’t have the luxury of doing this. But when it’s possible, I have no issues with it at all. I’d rather have a doctor who is concerned enough to bring his kids to work rather than leave them at home alone.

How often do you take a sick day? For me, maybe 1-2 times a year.

I hate doing it because it’s a nightmare for my staff (to do the frantic rescheduling) and the patients. I have to work overtime down the road to get the rescheduled people seen in a timely fashion. Not only that, but from a solo practice financial point of view, if I’m not there, the revenue stream is shut off. So I’ll pretty much go to work unless I’m incapacitated.

Most patients are understanding when this happens, but a vocal minority become quite upset. They somehow expect us to be unaffected by the health concerns of nondoctors.

The nature of our work as healers doesn’t make us superhuman. We can have the same illnesses and injuries as our patients. Our kids bring home the same germs. We have to negotiate the same traffic hazards.

By the same token, it’s amazing how often I hear other doctors saying of their illness, "How could this happen to me? I’m a doctor!" There seems to be an unspoken belief that by caring for others we should be magically protected from those same diseases.

In spite of our knowledge, we’re still human. Most of us will take the cheeseburger over the tofu patty any day. And, as I noted in a previous column, the stress and hours of this job likely put us at higher risk of vascular disease than our own patients.

For better or worse, none of us are superhuman. And never will be.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. To respond to this column, e-mail him at [email protected].

How often do you take a sick day? For me, maybe 1-2 times a year.

I hate doing it because it’s a nightmare for my staff (to do the frantic rescheduling) and the patients. I have to work overtime down the road to get the rescheduled people seen in a timely fashion. Not only that, but from a solo practice financial point of view, if I’m not there, the revenue stream is shut off. So I’ll pretty much go to work unless I’m incapacitated.

Most patients are understanding when this happens, but a vocal minority become quite upset. They somehow expect us to be unaffected by the health concerns of nondoctors.

The nature of our work as healers doesn’t make us superhuman. We can have the same illnesses and injuries as our patients. Our kids bring home the same germs. We have to negotiate the same traffic hazards.

By the same token, it’s amazing how often I hear other doctors saying of their illness, "How could this happen to me? I’m a doctor!" There seems to be an unspoken belief that by caring for others we should be magically protected from those same diseases.

In spite of our knowledge, we’re still human. Most of us will take the cheeseburger over the tofu patty any day. And, as I noted in a previous column, the stress and hours of this job likely put us at higher risk of vascular disease than our own patients.

For better or worse, none of us are superhuman. And never will be.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. To respond to this column, e-mail him at [email protected].

How often do you take a sick day? For me, maybe 1-2 times a year.

I hate doing it because it’s a nightmare for my staff (to do the frantic rescheduling) and the patients. I have to work overtime down the road to get the rescheduled people seen in a timely fashion. Not only that, but from a solo practice financial point of view, if I’m not there, the revenue stream is shut off. So I’ll pretty much go to work unless I’m incapacitated.

Most patients are understanding when this happens, but a vocal minority become quite upset. They somehow expect us to be unaffected by the health concerns of nondoctors.

The nature of our work as healers doesn’t make us superhuman. We can have the same illnesses and injuries as our patients. Our kids bring home the same germs. We have to negotiate the same traffic hazards.

By the same token, it’s amazing how often I hear other doctors saying of their illness, "How could this happen to me? I’m a doctor!" There seems to be an unspoken belief that by caring for others we should be magically protected from those same diseases.

In spite of our knowledge, we’re still human. Most of us will take the cheeseburger over the tofu patty any day. And, as I noted in a previous column, the stress and hours of this job likely put us at higher risk of vascular disease than our own patients.

For better or worse, none of us are superhuman. And never will be.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. To respond to this column, e-mail him at [email protected].

A recent issue of Practical Neurology had a brief article titled, "CT Scans for Dizziness May Not be Cost Effective" (January/February 2012, p. 6). The article described a study that found that less than 1% of CT scans of 1,681 emergency department patients presenting with "dizziness" showed a serious cause, leaving the scan’s cost effectiveness questionable.

(Although "dizziness" might not be very specific to you, it’s what the article said, and what patients say, and what gets listed on the admitting sheet.)

How many times have we seen studies like this? There are a lot of them. And how many times do they really change physician behavior? Any hands? Nope.

The issue here is not that doing a head CT in these cases is pointless. I think most neurologists and ED docs would agree the scan is pretty low yield in generic dizziness (assuming no other significant symptoms or exam findings).

The real issue here is the practice of defensive medicine in America. Just because the CT scan probably won’t show anything significant doesn’t change the fact that it could. It’s like a serious surgical complication: There may be only a 1% chance of something going wrong, but if it happens to you the incidence just went up to 100% for your case, and you may be in some deep trouble.

We all live in fear of being sued, and a routine CT scan is a simple, reasonably safe, and quick study. Unless there’s a legislative sea change that protects doctors who don’t order one (and we all know that isn’t going to happen), I don’t see their use for routine dizziness decreasing anytime soon.

Yes, this is the sort of behavior that drives costs up. It’s defensive medicine. And I don’t know any doctors who don’t do it. In the current climate, protecting ourselves always trumps saving money for an insurance company, because it won’t be the one on the hook if a disaster is missed.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

A recent issue of Practical Neurology had a brief article titled, "CT Scans for Dizziness May Not be Cost Effective" (January/February 2012, p. 6). The article described a study that found that less than 1% of CT scans of 1,681 emergency department patients presenting with "dizziness" showed a serious cause, leaving the scan’s cost effectiveness questionable.

(Although "dizziness" might not be very specific to you, it’s what the article said, and what patients say, and what gets listed on the admitting sheet.)

How many times have we seen studies like this? There are a lot of them. And how many times do they really change physician behavior? Any hands? Nope.

The issue here is not that doing a head CT in these cases is pointless. I think most neurologists and ED docs would agree the scan is pretty low yield in generic dizziness (assuming no other significant symptoms or exam findings).

The real issue here is the practice of defensive medicine in America. Just because the CT scan probably won’t show anything significant doesn’t change the fact that it could. It’s like a serious surgical complication: There may be only a 1% chance of something going wrong, but if it happens to you the incidence just went up to 100% for your case, and you may be in some deep trouble.

We all live in fear of being sued, and a routine CT scan is a simple, reasonably safe, and quick study. Unless there’s a legislative sea change that protects doctors who don’t order one (and we all know that isn’t going to happen), I don’t see their use for routine dizziness decreasing anytime soon.

Yes, this is the sort of behavior that drives costs up. It’s defensive medicine. And I don’t know any doctors who don’t do it. In the current climate, protecting ourselves always trumps saving money for an insurance company, because it won’t be the one on the hook if a disaster is missed.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

A recent issue of Practical Neurology had a brief article titled, "CT Scans for Dizziness May Not be Cost Effective" (January/February 2012, p. 6). The article described a study that found that less than 1% of CT scans of 1,681 emergency department patients presenting with "dizziness" showed a serious cause, leaving the scan’s cost effectiveness questionable.

(Although "dizziness" might not be very specific to you, it’s what the article said, and what patients say, and what gets listed on the admitting sheet.)

How many times have we seen studies like this? There are a lot of them. And how many times do they really change physician behavior? Any hands? Nope.

The issue here is not that doing a head CT in these cases is pointless. I think most neurologists and ED docs would agree the scan is pretty low yield in generic dizziness (assuming no other significant symptoms or exam findings).

The real issue here is the practice of defensive medicine in America. Just because the CT scan probably won’t show anything significant doesn’t change the fact that it could. It’s like a serious surgical complication: There may be only a 1% chance of something going wrong, but if it happens to you the incidence just went up to 100% for your case, and you may be in some deep trouble.

We all live in fear of being sued, and a routine CT scan is a simple, reasonably safe, and quick study. Unless there’s a legislative sea change that protects doctors who don’t order one (and we all know that isn’t going to happen), I don’t see their use for routine dizziness decreasing anytime soon.

Yes, this is the sort of behavior that drives costs up. It’s defensive medicine. And I don’t know any doctors who don’t do it. In the current climate, protecting ourselves always trumps saving money for an insurance company, because it won’t be the one on the hook if a disaster is missed.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

In my last post, I wrote about trying to practice medicine solely by telephone. This week I’m going to the opposite extreme.

In a recent Sermo.com post, a doctor commented about how he NEVER deals with patients by phone under any circumstances. He uses his answering service as a go-between, with two options:

• Call back tomorrow.

• If this is an emergency, I will meet you right now at my office (if I can find a chaperone) or at the emergency department (if I can’t).

He was critical of doctors who do anything by phone, mainly on the grounds of potential legal liability and lack of reimbursement for such. On paper, this is a great, if not commendable, view. In reality, it won’t work for the vast majority of us.

I don’t like getting calls after hours, but they’re a fact of life in this business. Being in solo practice, I have the advantage of knowing my patients. My charts are only as far away as my MacBook (a relatively modern benefit).

Obviously, I’m not going to try to manage acute or serious things by phone, and have sent my share of patients to the ED. But I’d rather be called for a refill on an empty bottle of antiseizure medication by a patient than by an emergency physician seeing him for a missed-medication car wreck.

If one of my patients has a seizure (or other acute neurologic change) I’d rather know about it sooner than later. It’s easy to come to a decision and type up a quick note to document it. I’m not saying you should manage everything by phone, but refusing to manage anything by phone, especially in a patient who is well known to you, is just silly.

Yes, phone calls have legal liability, but so does everything else we do. Just like an office visit, you document it carefully. Even refusing to take phone calls and sending everyone to the ED has some degree of liability. It’s also going to cost you in the long run, from patients sick of being routed there for every call. They’ll leave your practice, and likely complain to your referring sources about you.

"We don't get paid to answer after-hours phone calls." So what? We also don’t get paid to write scripts for 90-day mail-in supplies, renew physical therapy, or order a follow-up MRI for a meningioma. Time is money, and dealing with phone calls can help. A simple question that could have been answered by phone will likely take up the same amount of schedule time as a more complex case that not only pays at a higher level, but needs to see you more.

Most doctors (I hope) have their own physicians. Have you ever called yours with a question after hours? If so, how would you have felt if they said "just go to the ED"?

No one likes getting calls after hours. But being able to tell what can (and can’t) be handled by phone is part of what we do. And part of providing good patient care.

In my last post, I wrote about trying to practice medicine solely by telephone. This week I’m going to the opposite extreme.

In a recent Sermo.com post, a doctor commented about how he NEVER deals with patients by phone under any circumstances. He uses his answering service as a go-between, with two options:

• Call back tomorrow.

• If this is an emergency, I will meet you right now at my office (if I can find a chaperone) or at the emergency department (if I can’t).

He was critical of doctors who do anything by phone, mainly on the grounds of potential legal liability and lack of reimbursement for such. On paper, this is a great, if not commendable, view. In reality, it won’t work for the vast majority of us.

I don’t like getting calls after hours, but they’re a fact of life in this business. Being in solo practice, I have the advantage of knowing my patients. My charts are only as far away as my MacBook (a relatively modern benefit).

Obviously, I’m not going to try to manage acute or serious things by phone, and have sent my share of patients to the ED. But I’d rather be called for a refill on an empty bottle of antiseizure medication by a patient than by an emergency physician seeing him for a missed-medication car wreck.

If one of my patients has a seizure (or other acute neurologic change) I’d rather know about it sooner than later. It’s easy to come to a decision and type up a quick note to document it. I’m not saying you should manage everything by phone, but refusing to manage anything by phone, especially in a patient who is well known to you, is just silly.

Yes, phone calls have legal liability, but so does everything else we do. Just like an office visit, you document it carefully. Even refusing to take phone calls and sending everyone to the ED has some degree of liability. It’s also going to cost you in the long run, from patients sick of being routed there for every call. They’ll leave your practice, and likely complain to your referring sources about you.

"We don't get paid to answer after-hours phone calls." So what? We also don’t get paid to write scripts for 90-day mail-in supplies, renew physical therapy, or order a follow-up MRI for a meningioma. Time is money, and dealing with phone calls can help. A simple question that could have been answered by phone will likely take up the same amount of schedule time as a more complex case that not only pays at a higher level, but needs to see you more.

Most doctors (I hope) have their own physicians. Have you ever called yours with a question after hours? If so, how would you have felt if they said "just go to the ED"?

No one likes getting calls after hours. But being able to tell what can (and can’t) be handled by phone is part of what we do. And part of providing good patient care.

In my last post, I wrote about trying to practice medicine solely by telephone. This week I’m going to the opposite extreme.

In a recent Sermo.com post, a doctor commented about how he NEVER deals with patients by phone under any circumstances. He uses his answering service as a go-between, with two options:

• Call back tomorrow.

• If this is an emergency, I will meet you right now at my office (if I can find a chaperone) or at the emergency department (if I can’t).

He was critical of doctors who do anything by phone, mainly on the grounds of potential legal liability and lack of reimbursement for such. On paper, this is a great, if not commendable, view. In reality, it won’t work for the vast majority of us.

I don’t like getting calls after hours, but they’re a fact of life in this business. Being in solo practice, I have the advantage of knowing my patients. My charts are only as far away as my MacBook (a relatively modern benefit).

Obviously, I’m not going to try to manage acute or serious things by phone, and have sent my share of patients to the ED. But I’d rather be called for a refill on an empty bottle of antiseizure medication by a patient than by an emergency physician seeing him for a missed-medication car wreck.

If one of my patients has a seizure (or other acute neurologic change) I’d rather know about it sooner than later. It’s easy to come to a decision and type up a quick note to document it. I’m not saying you should manage everything by phone, but refusing to manage anything by phone, especially in a patient who is well known to you, is just silly.

Yes, phone calls have legal liability, but so does everything else we do. Just like an office visit, you document it carefully. Even refusing to take phone calls and sending everyone to the ED has some degree of liability. It’s also going to cost you in the long run, from patients sick of being routed there for every call. They’ll leave your practice, and likely complain to your referring sources about you.

"We don't get paid to answer after-hours phone calls." So what? We also don’t get paid to write scripts for 90-day mail-in supplies, renew physical therapy, or order a follow-up MRI for a meningioma. Time is money, and dealing with phone calls can help. A simple question that could have been answered by phone will likely take up the same amount of schedule time as a more complex case that not only pays at a higher level, but needs to see you more.

Most doctors (I hope) have their own physicians. Have you ever called yours with a question after hours? If so, how would you have felt if they said "just go to the ED"?

No one likes getting calls after hours. But being able to tell what can (and can’t) be handled by phone is part of what we do. And part of providing good patient care.

How often do you get requests to do telemedicine? I get a few per month, all offering money (usually $20-$30 per call) for me to manage patients by phone. I’m not talking about Viagra or Vicodin mills, but places that cater to patients who either can’t or won’t see a doctor.

I always say no. In my mind, this is just another way to cheapen our profession, but I also have serious concerns about it.

Photo ©Alliance/Fotolia.com

There’s a lot to worry about when trying to treat patients without seeing them. Most migraines are migraines, but what if you can’t examine the patient? You might miss papilledema, or a reflex asymmetry, or other signs that something is amiss. The same could be said for routine lumbar pain or carpal tunnel syndrome.

I don’t mind handling the occasional phone call for an office patient I’m familiar with. And, of course, we all have to deal with cross-cover calls on nonpatients. But to try and do a full history and physical by phone? That doesn’t work for me.

I’m not deluding myself into believing that my refusal to participate will keep these things from happening. Hungry physicians willing to take the legal risks will be hired, and may end up costing me a few patients who would have otherwise come to my office. I’ve been told that I should participate in this sort of thing so at least I can shape the way it develops.

But my belief in my field makes me reluctant to compromise. I also have a family to provide for, and medicine is a risky enough undertaking as it is without adding more potential liability. And I just don’t believe you can provide a decent level of care solely by phone.

Knowingly doing an incomplete job is never a good idea, especially in medicine. And the people who use such services, as in everything else, get what they pay for.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

How often do you get requests to do telemedicine? I get a few per month, all offering money (usually $20-$30 per call) for me to manage patients by phone. I’m not talking about Viagra or Vicodin mills, but places that cater to patients who either can’t or won’t see a doctor.

I always say no. In my mind, this is just another way to cheapen our profession, but I also have serious concerns about it.

Photo ©Alliance/Fotolia.com

There’s a lot to worry about when trying to treat patients without seeing them. Most migraines are migraines, but what if you can’t examine the patient? You might miss papilledema, or a reflex asymmetry, or other signs that something is amiss. The same could be said for routine lumbar pain or carpal tunnel syndrome.

I don’t mind handling the occasional phone call for an office patient I’m familiar with. And, of course, we all have to deal with cross-cover calls on nonpatients. But to try and do a full history and physical by phone? That doesn’t work for me.

I’m not deluding myself into believing that my refusal to participate will keep these things from happening. Hungry physicians willing to take the legal risks will be hired, and may end up costing me a few patients who would have otherwise come to my office. I’ve been told that I should participate in this sort of thing so at least I can shape the way it develops.

But my belief in my field makes me reluctant to compromise. I also have a family to provide for, and medicine is a risky enough undertaking as it is without adding more potential liability. And I just don’t believe you can provide a decent level of care solely by phone.

Knowingly doing an incomplete job is never a good idea, especially in medicine. And the people who use such services, as in everything else, get what they pay for.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

How often do you get requests to do telemedicine? I get a few per month, all offering money (usually $20-$30 per call) for me to manage patients by phone. I’m not talking about Viagra or Vicodin mills, but places that cater to patients who either can’t or won’t see a doctor.

I always say no. In my mind, this is just another way to cheapen our profession, but I also have serious concerns about it.

Photo ©Alliance/Fotolia.com

There’s a lot to worry about when trying to treat patients without seeing them. Most migraines are migraines, but what if you can’t examine the patient? You might miss papilledema, or a reflex asymmetry, or other signs that something is amiss. The same could be said for routine lumbar pain or carpal tunnel syndrome.

I don’t mind handling the occasional phone call for an office patient I’m familiar with. And, of course, we all have to deal with cross-cover calls on nonpatients. But to try and do a full history and physical by phone? That doesn’t work for me.

I’m not deluding myself into believing that my refusal to participate will keep these things from happening. Hungry physicians willing to take the legal risks will be hired, and may end up costing me a few patients who would have otherwise come to my office. I’ve been told that I should participate in this sort of thing so at least I can shape the way it develops.

But my belief in my field makes me reluctant to compromise. I also have a family to provide for, and medicine is a risky enough undertaking as it is without adding more potential liability. And I just don’t believe you can provide a decent level of care solely by phone.

Knowingly doing an incomplete job is never a good idea, especially in medicine. And the people who use such services, as in everything else, get what they pay for.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

Unless you’ve been living under a rock, you likely saw the New England Journal of Medicine paper last fall on the SAMMPRIS trial in which aggressive medical treatment beat intracranial stenting for patients with intracranial artery stenosis (N. Engl. J. Med. 2011;365:993-1003).

I’ve sent my share of patients for stenting. I’m sure you have, too. Sometimes, it’s even been against my better judgment. Patients (and doctors) often are infatuated with high-tech procedures, so when they come to me demanding a referral for such, it’s hard to refuse. Doing so runs the risk of losing a referral source.

Neurology, by nature, is a very tech-dependent field. We live by MRI, EEG, EMG/NCV [electromyography and nerve conduction velocity], and a bunch of other alphabet soups. Human nature leads us to believe that more expensive/invasive/high-tech treatments are better, compared with "take an aspirin and call me in the morning."

I have the highest respect for my colleagues in neurosurgery and interventional radiology. They often do incredible things.

However, technology isn’t always the best answer, even though it’s certainly the flashiest. Since 2004 the Wingspan intracranial stent has been available in the United States for humanitarian cases (people who had failed all other reasonable treatments). But in March 2012, an FDA advisory panel seriously questioned the device after the SAMMPRIS study was stopped prematurely. The fancy stent had a 14.7% incidence of death and early recurrent stroke (within 30 days of use), compared with 5.8% with boring old pills.

Cardiac disease treatments often lead to cerebrovascular treatments because of the similarities between the two systems. But that isn’t always the case. The combination of clopidogrel (Plavix) plus aspirin is routinely used in cardiology and, for many years, in neurology. But, as time has gone by, we’ve found this practice has no benefit, and greater risks, in stroke prevention. So it’s falling by the wayside.

Perhaps the best lesson to learn from this applies to all areas of life: bigger, newer, and more expensive doesn’t always mean better and can sometimes mean quite the opposite.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

Unless you’ve been living under a rock, you likely saw the New England Journal of Medicine paper last fall on the SAMMPRIS trial in which aggressive medical treatment beat intracranial stenting for patients with intracranial artery stenosis (N. Engl. J. Med. 2011;365:993-1003).

I’ve sent my share of patients for stenting. I’m sure you have, too. Sometimes, it’s even been against my better judgment. Patients (and doctors) often are infatuated with high-tech procedures, so when they come to me demanding a referral for such, it’s hard to refuse. Doing so runs the risk of losing a referral source.

Neurology, by nature, is a very tech-dependent field. We live by MRI, EEG, EMG/NCV [electromyography and nerve conduction velocity], and a bunch of other alphabet soups. Human nature leads us to believe that more expensive/invasive/high-tech treatments are better, compared with "take an aspirin and call me in the morning."

I have the highest respect for my colleagues in neurosurgery and interventional radiology. They often do incredible things.

However, technology isn’t always the best answer, even though it’s certainly the flashiest. Since 2004 the Wingspan intracranial stent has been available in the United States for humanitarian cases (people who had failed all other reasonable treatments). But in March 2012, an FDA advisory panel seriously questioned the device after the SAMMPRIS study was stopped prematurely. The fancy stent had a 14.7% incidence of death and early recurrent stroke (within 30 days of use), compared with 5.8% with boring old pills.

Cardiac disease treatments often lead to cerebrovascular treatments because of the similarities between the two systems. But that isn’t always the case. The combination of clopidogrel (Plavix) plus aspirin is routinely used in cardiology and, for many years, in neurology. But, as time has gone by, we’ve found this practice has no benefit, and greater risks, in stroke prevention. So it’s falling by the wayside.

Perhaps the best lesson to learn from this applies to all areas of life: bigger, newer, and more expensive doesn’t always mean better and can sometimes mean quite the opposite.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

Unless you’ve been living under a rock, you likely saw the New England Journal of Medicine paper last fall on the SAMMPRIS trial in which aggressive medical treatment beat intracranial stenting for patients with intracranial artery stenosis (N. Engl. J. Med. 2011;365:993-1003).

I’ve sent my share of patients for stenting. I’m sure you have, too. Sometimes, it’s even been against my better judgment. Patients (and doctors) often are infatuated with high-tech procedures, so when they come to me demanding a referral for such, it’s hard to refuse. Doing so runs the risk of losing a referral source.

Neurology, by nature, is a very tech-dependent field. We live by MRI, EEG, EMG/NCV [electromyography and nerve conduction velocity], and a bunch of other alphabet soups. Human nature leads us to believe that more expensive/invasive/high-tech treatments are better, compared with "take an aspirin and call me in the morning."

I have the highest respect for my colleagues in neurosurgery and interventional radiology. They often do incredible things.

However, technology isn’t always the best answer, even though it’s certainly the flashiest. Since 2004 the Wingspan intracranial stent has been available in the United States for humanitarian cases (people who had failed all other reasonable treatments). But in March 2012, an FDA advisory panel seriously questioned the device after the SAMMPRIS study was stopped prematurely. The fancy stent had a 14.7% incidence of death and early recurrent stroke (within 30 days of use), compared with 5.8% with boring old pills.

Cardiac disease treatments often lead to cerebrovascular treatments because of the similarities between the two systems. But that isn’t always the case. The combination of clopidogrel (Plavix) plus aspirin is routinely used in cardiology and, for many years, in neurology. But, as time has gone by, we’ve found this practice has no benefit, and greater risks, in stroke prevention. So it’s falling by the wayside.

Perhaps the best lesson to learn from this applies to all areas of life: bigger, newer, and more expensive doesn’t always mean better and can sometimes mean quite the opposite.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

I’m in solo practice (yes, one of those doctors). We’re a dying breed, which is sad because I genuinely like it. It’s certainly not for everyone, but it suits me perfectly.

It’s not easy. In my first 6 months of doing this, I pretty much picked up an MBA just by experience. I’d never had to deal with payroll, withholding taxes, forms, licensing, and a million other things, and had to learn them on the fly.

But looking back, I’m glad I did it. Like many other doctors, I joined a large group right out of residency. They seemed to offer security, and it was easier than trying to hang up my own shingle. But after a few years of office politics, dealing with business people, and being forced to review graphs labeled "physician revenue per square foot of office space," I couldn’t take it anymore.

So here I am. This will be my 12th year flying solo, and I regret none of it. Nobody argues with me about my choice of computer systems, what I wear, vacation scheduling, taking call, or whether we need to hire different staff or open satellite offices (I still don’t understand why some doctors do the latter).

I could probably make more money by joining a group, but money isn’t the biggest thing to me. My life is a lot simpler here. I can control how many patients I see, how many hours I work, and what cases I take; this gives me time to see my kids.

Unfortunately, the pressures of repaying loans ASAP drive most people to join whatever group offers them the most money. As a result, most of today’s solo doctors are on their second (or third or ...) practice incarnation. They’ve gained enough experience to realize that big groups aren’t always what they’re made out to be. In solo practice, you’re at least working with someone you’ve lived with for your entire life, and you have a good idea of their strengths and weaknesses.

I have no more idea of what the future holds than you do. Every few years, there’s a prediction that solo doctors are on our way out. And maybe some day they’ll be right, and I’ll be forced to join a group again.

That will be too bad because medicine started out as a solo job, going back to the tribal medicine man, or healer. And, after all these years, I wouldn’t have it any other way.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

I’m in solo practice (yes, one of those doctors). We’re a dying breed, which is sad because I genuinely like it. It’s certainly not for everyone, but it suits me perfectly.

It’s not easy. In my first 6 months of doing this, I pretty much picked up an MBA just by experience. I’d never had to deal with payroll, withholding taxes, forms, licensing, and a million other things, and had to learn them on the fly.

But looking back, I’m glad I did it. Like many other doctors, I joined a large group right out of residency. They seemed to offer security, and it was easier than trying to hang up my own shingle. But after a few years of office politics, dealing with business people, and being forced to review graphs labeled "physician revenue per square foot of office space," I couldn’t take it anymore.

So here I am. This will be my 12th year flying solo, and I regret none of it. Nobody argues with me about my choice of computer systems, what I wear, vacation scheduling, taking call, or whether we need to hire different staff or open satellite offices (I still don’t understand why some doctors do the latter).

I could probably make more money by joining a group, but money isn’t the biggest thing to me. My life is a lot simpler here. I can control how many patients I see, how many hours I work, and what cases I take; this gives me time to see my kids.

Unfortunately, the pressures of repaying loans ASAP drive most people to join whatever group offers them the most money. As a result, most of today’s solo doctors are on their second (or third or ...) practice incarnation. They’ve gained enough experience to realize that big groups aren’t always what they’re made out to be. In solo practice, you’re at least working with someone you’ve lived with for your entire life, and you have a good idea of their strengths and weaknesses.

I have no more idea of what the future holds than you do. Every few years, there’s a prediction that solo doctors are on our way out. And maybe some day they’ll be right, and I’ll be forced to join a group again.

That will be too bad because medicine started out as a solo job, going back to the tribal medicine man, or healer. And, after all these years, I wouldn’t have it any other way.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

I’m in solo practice (yes, one of those doctors). We’re a dying breed, which is sad because I genuinely like it. It’s certainly not for everyone, but it suits me perfectly.

It’s not easy. In my first 6 months of doing this, I pretty much picked up an MBA just by experience. I’d never had to deal with payroll, withholding taxes, forms, licensing, and a million other things, and had to learn them on the fly.

But looking back, I’m glad I did it. Like many other doctors, I joined a large group right out of residency. They seemed to offer security, and it was easier than trying to hang up my own shingle. But after a few years of office politics, dealing with business people, and being forced to review graphs labeled "physician revenue per square foot of office space," I couldn’t take it anymore.

So here I am. This will be my 12th year flying solo, and I regret none of it. Nobody argues with me about my choice of computer systems, what I wear, vacation scheduling, taking call, or whether we need to hire different staff or open satellite offices (I still don’t understand why some doctors do the latter).

I could probably make more money by joining a group, but money isn’t the biggest thing to me. My life is a lot simpler here. I can control how many patients I see, how many hours I work, and what cases I take; this gives me time to see my kids.

Unfortunately, the pressures of repaying loans ASAP drive most people to join whatever group offers them the most money. As a result, most of today’s solo doctors are on their second (or third or ...) practice incarnation. They’ve gained enough experience to realize that big groups aren’t always what they’re made out to be. In solo practice, you’re at least working with someone you’ve lived with for your entire life, and you have a good idea of their strengths and weaknesses.

I have no more idea of what the future holds than you do. Every few years, there’s a prediction that solo doctors are on our way out. And maybe some day they’ll be right, and I’ll be forced to join a group again.

That will be too bad because medicine started out as a solo job, going back to the tribal medicine man, or healer. And, after all these years, I wouldn’t have it any other way.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

Recently, there was a post on Sermo.com, the online physician community, concerning a doctor taken to small claims court. A patient decided to seek a second opinion in another city and was trying to recoup travel expenses by suing him for plane fare.

That hit home. A few years ago, I ordered an MR angiogram to see if a patient had an aneurysm. His insurance covered the test, but he still had to pay about $500 as part of his deductible. He threatened to sue me for the entire amount unless I agreed to pay half.

I refused, and he tried very hard to make life miserable for me. He threatened several times to file a malpractice suit, telling me that he’d make sure my rates rose more than the $250 needed to placate him. I even reported it as a possible risk to my carrier, and they told me issues of this sort were quite common (to my surprise). I was told that they generally don’t go anywhere and are often used as a way of giving doctors ulcers.

I stood my ground, and after a few weeks he gave up and stopped calling. The experience left me quite shaken, which I suppose is what he wanted. I don’t routinely discuss tests and other costs with a patient unless asked. The variability in insurance plans makes it impossible for me to know how much of a study will come out of a patient’s pocket.

This doesn’t mean people haven’t tried. Patients do occasionally ask me to pick up part of a test’s cost, or to cover cab fare because I referred them to a tertiary care center downtown, or to pay other miscellaneous charges. I always refuse.

Obviously, there are significant differences between the two cases. My patient was following treatment recommendations, whereas the other patient sought a second opinion. But the point is similar: Should we be held liable for a patient’s ancillary expenses?

My answer is no, and I suspect I’d be hard pressed to find a doctor who disagrees. I certainly don’t expect my own internist to cover my deductible for routine tests, or to pay for time I take off work to go to his office or the cost of gas to drive there.

At the end of the day, we are only advisers. No one can force a patient to have a test or procedure, or take a medication, regardless of whether or not it’s within their financial means.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

Recently, there was a post on Sermo.com, the online physician community, concerning a doctor taken to small claims court. A patient decided to seek a second opinion in another city and was trying to recoup travel expenses by suing him for plane fare.

That hit home. A few years ago, I ordered an MR angiogram to see if a patient had an aneurysm. His insurance covered the test, but he still had to pay about $500 as part of his deductible. He threatened to sue me for the entire amount unless I agreed to pay half.

I refused, and he tried very hard to make life miserable for me. He threatened several times to file a malpractice suit, telling me that he’d make sure my rates rose more than the $250 needed to placate him. I even reported it as a possible risk to my carrier, and they told me issues of this sort were quite common (to my surprise). I was told that they generally don’t go anywhere and are often used as a way of giving doctors ulcers.

I stood my ground, and after a few weeks he gave up and stopped calling. The experience left me quite shaken, which I suppose is what he wanted. I don’t routinely discuss tests and other costs with a patient unless asked. The variability in insurance plans makes it impossible for me to know how much of a study will come out of a patient’s pocket.

This doesn’t mean people haven’t tried. Patients do occasionally ask me to pick up part of a test’s cost, or to cover cab fare because I referred them to a tertiary care center downtown, or to pay other miscellaneous charges. I always refuse.

Obviously, there are significant differences between the two cases. My patient was following treatment recommendations, whereas the other patient sought a second opinion. But the point is similar: Should we be held liable for a patient’s ancillary expenses?

My answer is no, and I suspect I’d be hard pressed to find a doctor who disagrees. I certainly don’t expect my own internist to cover my deductible for routine tests, or to pay for time I take off work to go to his office or the cost of gas to drive there.

At the end of the day, we are only advisers. No one can force a patient to have a test or procedure, or take a medication, regardless of whether or not it’s within their financial means.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

Recently, there was a post on Sermo.com, the online physician community, concerning a doctor taken to small claims court. A patient decided to seek a second opinion in another city and was trying to recoup travel expenses by suing him for plane fare.

That hit home. A few years ago, I ordered an MR angiogram to see if a patient had an aneurysm. His insurance covered the test, but he still had to pay about $500 as part of his deductible. He threatened to sue me for the entire amount unless I agreed to pay half.

I refused, and he tried very hard to make life miserable for me. He threatened several times to file a malpractice suit, telling me that he’d make sure my rates rose more than the $250 needed to placate him. I even reported it as a possible risk to my carrier, and they told me issues of this sort were quite common (to my surprise). I was told that they generally don’t go anywhere and are often used as a way of giving doctors ulcers.

I stood my ground, and after a few weeks he gave up and stopped calling. The experience left me quite shaken, which I suppose is what he wanted. I don’t routinely discuss tests and other costs with a patient unless asked. The variability in insurance plans makes it impossible for me to know how much of a study will come out of a patient’s pocket.

This doesn’t mean people haven’t tried. Patients do occasionally ask me to pick up part of a test’s cost, or to cover cab fare because I referred them to a tertiary care center downtown, or to pay other miscellaneous charges. I always refuse.

Obviously, there are significant differences between the two cases. My patient was following treatment recommendations, whereas the other patient sought a second opinion. But the point is similar: Should we be held liable for a patient’s ancillary expenses?

My answer is no, and I suspect I’d be hard pressed to find a doctor who disagrees. I certainly don’t expect my own internist to cover my deductible for routine tests, or to pay for time I take off work to go to his office or the cost of gas to drive there.

At the end of the day, we are only advisers. No one can force a patient to have a test or procedure, or take a medication, regardless of whether or not it’s within their financial means.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

Anybody ever give a patient a specific drug just because he asked for it? I do it all the time.

Granted, this doesn’t extend to situations where a drug is unnecessary or contraindicated, but – for example – if a migraine patient comes in and wants to try another preventive or triptan, what do you do? As with any other drug, I discuss it with the patient, and if she still wants it, and it’s not unreasonable, I’ll do it.

© Daniel Stein/istockphoto.com

Some out there will say that this makes me a pushover for direct-to-consumer advertising, since that’s where most patients hear about these things. (For the rest, the information usually comes from a friend or their own research.)

But realistically, resistance is futile. If you deny patients a reasonable request because it was their idea instead of yours, they’ll likely move on to another doctor, complain to their internist or friends about you, or both.

The argument of "your insurance doesn’t cover this" won’t hold water at first. Samples or your handwritten script are free. All it takes for them to realize they’d rather stay with their old medicine is the pharmacist’s telling them how much it will cost. So, in the end, economics will be the decider.

Generics work the same way. In most cases – the exception being epilepsy drugs – I won’t fight for brand names. Some patients think I can write magic notes to get them brand-name drugs at generic prices. It’s easier than arguing, so I write them. The cost will always make them change their mind.

After years of experience, I find that it’s a lot easier to let the patients’ pocketbooks make them realize this than to waste time trying to convince them myself.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

Anybody ever give a patient a specific drug just because he asked for it? I do it all the time.

Granted, this doesn’t extend to situations where a drug is unnecessary or contraindicated, but – for example – if a migraine patient comes in and wants to try another preventive or triptan, what do you do? As with any other drug, I discuss it with the patient, and if she still wants it, and it’s not unreasonable, I’ll do it.

© Daniel Stein/istockphoto.com

Some out there will say that this makes me a pushover for direct-to-consumer advertising, since that’s where most patients hear about these things. (For the rest, the information usually comes from a friend or their own research.)

But realistically, resistance is futile. If you deny patients a reasonable request because it was their idea instead of yours, they’ll likely move on to another doctor, complain to their internist or friends about you, or both.

The argument of "your insurance doesn’t cover this" won’t hold water at first. Samples or your handwritten script are free. All it takes for them to realize they’d rather stay with their old medicine is the pharmacist’s telling them how much it will cost. So, in the end, economics will be the decider.

Generics work the same way. In most cases – the exception being epilepsy drugs – I won’t fight for brand names. Some patients think I can write magic notes to get them brand-name drugs at generic prices. It’s easier than arguing, so I write them. The cost will always make them change their mind.

After years of experience, I find that it’s a lot easier to let the patients’ pocketbooks make them realize this than to waste time trying to convince them myself.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

Anybody ever give a patient a specific drug just because he asked for it? I do it all the time.

Granted, this doesn’t extend to situations where a drug is unnecessary or contraindicated, but – for example – if a migraine patient comes in and wants to try another preventive or triptan, what do you do? As with any other drug, I discuss it with the patient, and if she still wants it, and it’s not unreasonable, I’ll do it.

© Daniel Stein/istockphoto.com

Some out there will say that this makes me a pushover for direct-to-consumer advertising, since that’s where most patients hear about these things. (For the rest, the information usually comes from a friend or their own research.)

But realistically, resistance is futile. If you deny patients a reasonable request because it was their idea instead of yours, they’ll likely move on to another doctor, complain to their internist or friends about you, or both.

The argument of "your insurance doesn’t cover this" won’t hold water at first. Samples or your handwritten script are free. All it takes for them to realize they’d rather stay with their old medicine is the pharmacist’s telling them how much it will cost. So, in the end, economics will be the decider.

Generics work the same way. In most cases – the exception being epilepsy drugs – I won’t fight for brand names. Some patients think I can write magic notes to get them brand-name drugs at generic prices. It’s easier than arguing, so I write them. The cost will always make them change their mind.

After years of experience, I find that it’s a lot easier to let the patients’ pocketbooks make them realize this than to waste time trying to convince them myself.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

How many of you out there use e-prescribing to get the Medicare bonus? Raise your hands. And how many of you with your hands up really find it’s easier than regular prescribing? I thought so.

I use it, too, although I am far from enamored with it. But, like most of you, I take Medicare, and don’t want to lose the bonus (or eventually be penalized). How do I hate thee? Let me count the ways.

My biggest gripe is controlled substances, an area where technology has clearly outstripped regulation. I can understand wanting to control some drugs, such as those on schedule II or maybe even schedule III, but my e-prescribing system won’t let me refill even minor things, like pregabalin (Lyrica) or zolpidem (Ambien). Here in Arizona, it also won’t let me fill carisoprodol (Soma) or Fioricet (acetaminophen, butalbital, and caffeine).

©Brian Jackson/iStockphoto.com

But it still sends e-refill requests on these drugs, when it knows I can’t refill them! You’d think it would have some way of filtering requests for controlled and noncontrolled substances, and sending the former by fax. It’s legal to send the refill request by fax, but one wonders: How much more secure is a fax to my office than the Internet?

So when an approval for a refill request for a controlled drug comes up online, I have this choice: I can ignore it and hope they’ll eventually fax me something, or I can try to approve it online.

When I do the latter it says, "This is prohibited. Click on the ‘contact me’ button to have the requesting pharmacy contact you by another method."

Sounds like a good idea, right? But when I do that, I’ve learned that all it does is tell the pharmacy that I denied it, which isn’t even close to the truth. So they tell the patient I denied it, and the patient gets angry and yells at my office.

I’ve verified this sad tale with different patients and local pharmacists. Because of getting burned like this, I now just ignore online controlled drug requests and wait until the patient or pharmacy contacts me. How efficient is that?

Another issue I have with our e-prescribing system is writing mega-pill amounts. It won’t allow greater than 999 pills per refill. I have no idea why.

For most scripts this isn’t an issue. But it occasionally crops up, usually with 90-day supplies of carbidopa-levodopa (Sinemet) or gabapentin (Neurontin). When that occurs, I’m pretty much stuck ordering the 999 or mailing the patient a paper script.

I don’t think e-prescribing is a time saver, either. The script I could write by hand in less than 1 minute often takes 3-5 minutes to send online if it’s a new script, or a new patient, or both.

Friends of mine who work in pharmacies tell me it hasn’t cut back on medication errors, either. And a quick search of the Internet finds similar complaints from both sides, so apparently I’m not alone.

I have nothing against progress, or technology, or even saving paper. Yet, requiring a technology to be used before it’s ready for prime time only replaces one set of problems with another – to the detriment of the patient.

How many of you out there use e-prescribing to get the Medicare bonus? Raise your hands. And how many of you with your hands up really find it’s easier than regular prescribing? I thought so.

I use it, too, although I am far from enamored with it. But, like most of you, I take Medicare, and don’t want to lose the bonus (or eventually be penalized). How do I hate thee? Let me count the ways.

My biggest gripe is controlled substances, an area where technology has clearly outstripped regulation. I can understand wanting to control some drugs, such as those on schedule II or maybe even schedule III, but my e-prescribing system won’t let me refill even minor things, like pregabalin (Lyrica) or zolpidem (Ambien). Here in Arizona, it also won’t let me fill carisoprodol (Soma) or Fioricet (acetaminophen, butalbital, and caffeine).

©Brian Jackson/iStockphoto.com

But it still sends e-refill requests on these drugs, when it knows I can’t refill them! You’d think it would have some way of filtering requests for controlled and noncontrolled substances, and sending the former by fax. It’s legal to send the refill request by fax, but one wonders: How much more secure is a fax to my office than the Internet?

So when an approval for a refill request for a controlled drug comes up online, I have this choice: I can ignore it and hope they’ll eventually fax me something, or I can try to approve it online.

When I do the latter it says, "This is prohibited. Click on the ‘contact me’ button to have the requesting pharmacy contact you by another method."

Sounds like a good idea, right? But when I do that, I’ve learned that all it does is tell the pharmacy that I denied it, which isn’t even close to the truth. So they tell the patient I denied it, and the patient gets angry and yells at my office.

I’ve verified this sad tale with different patients and local pharmacists. Because of getting burned like this, I now just ignore online controlled drug requests and wait until the patient or pharmacy contacts me. How efficient is that?

Another issue I have with our e-prescribing system is writing mega-pill amounts. It won’t allow greater than 999 pills per refill. I have no idea why.

For most scripts this isn’t an issue. But it occasionally crops up, usually with 90-day supplies of carbidopa-levodopa (Sinemet) or gabapentin (Neurontin). When that occurs, I’m pretty much stuck ordering the 999 or mailing the patient a paper script.

I don’t think e-prescribing is a time saver, either. The script I could write by hand in less than 1 minute often takes 3-5 minutes to send online if it’s a new script, or a new patient, or both.

Friends of mine who work in pharmacies tell me it hasn’t cut back on medication errors, either. And a quick search of the Internet finds similar complaints from both sides, so apparently I’m not alone.

I have nothing against progress, or technology, or even saving paper. Yet, requiring a technology to be used before it’s ready for prime time only replaces one set of problems with another – to the detriment of the patient.

How many of you out there use e-prescribing to get the Medicare bonus? Raise your hands. And how many of you with your hands up really find it’s easier than regular prescribing? I thought so.

I use it, too, although I am far from enamored with it. But, like most of you, I take Medicare, and don’t want to lose the bonus (or eventually be penalized). How do I hate thee? Let me count the ways.

My biggest gripe is controlled substances, an area where technology has clearly outstripped regulation. I can understand wanting to control some drugs, such as those on schedule II or maybe even schedule III, but my e-prescribing system won’t let me refill even minor things, like pregabalin (Lyrica) or zolpidem (Ambien). Here in Arizona, it also won’t let me fill carisoprodol (Soma) or Fioricet (acetaminophen, butalbital, and caffeine).

©Brian Jackson/iStockphoto.com

But it still sends e-refill requests on these drugs, when it knows I can’t refill them! You’d think it would have some way of filtering requests for controlled and noncontrolled substances, and sending the former by fax. It’s legal to send the refill request by fax, but one wonders: How much more secure is a fax to my office than the Internet?

So when an approval for a refill request for a controlled drug comes up online, I have this choice: I can ignore it and hope they’ll eventually fax me something, or I can try to approve it online.

When I do the latter it says, "This is prohibited. Click on the ‘contact me’ button to have the requesting pharmacy contact you by another method."

Sounds like a good idea, right? But when I do that, I’ve learned that all it does is tell the pharmacy that I denied it, which isn’t even close to the truth. So they tell the patient I denied it, and the patient gets angry and yells at my office.

I’ve verified this sad tale with different patients and local pharmacists. Because of getting burned like this, I now just ignore online controlled drug requests and wait until the patient or pharmacy contacts me. How efficient is that?

Another issue I have with our e-prescribing system is writing mega-pill amounts. It won’t allow greater than 999 pills per refill. I have no idea why.

For most scripts this isn’t an issue. But it occasionally crops up, usually with 90-day supplies of carbidopa-levodopa (Sinemet) or gabapentin (Neurontin). When that occurs, I’m pretty much stuck ordering the 999 or mailing the patient a paper script.

I don’t think e-prescribing is a time saver, either. The script I could write by hand in less than 1 minute often takes 3-5 minutes to send online if it’s a new script, or a new patient, or both.

Friends of mine who work in pharmacies tell me it hasn’t cut back on medication errors, either. And a quick search of the Internet finds similar complaints from both sides, so apparently I’m not alone.

I have nothing against progress, or technology, or even saving paper. Yet, requiring a technology to be used before it’s ready for prime time only replaces one set of problems with another – to the detriment of the patient.