Wednesday, 1 June 2011

As directed.

Writing a prescription is a relatively simple exercise provided one knows a bit about drugs, can read and write and most importantly can do it safely. There are lots of short essays on how to do so and if you haven’t already done so, and believe us many doctors have never done so, the British National Forumlary is a good place to start. A few years ago the Medical Protection Society published a booklet on prescribing.

These were full of common sense things like don’t use Latin initials for example t.d.s. instead write it in English as “three times a day”. A lot of doctors still use the Latin abbreviations which are useful as a form of medical shorthand but can cause confusion in certain situations.

Another top tip was to only use the abbreviation mg (milligrams) and not use the abbreviation μg for micrograms which the article showed various ways that handwriting could convert the symbol μ into the letter m. Not to dissimilar to look at but a thousand fold variation in a dose that with some drugs could be very lethal so this was a good one to avoid.

For many years these simple principles have kept us going but in the recent past two organizations, both non medical ones, have decided like all impudent and ignorant children that they know better and would learn us doctors to do proper like what they does.

The first shot across the bows of HMS Smooth Prescribing was from the Al Quaeda school of radical pharmacists. On one of their many visits to educate those more knowledgable than they, they had decreed a jihad after issuing a fatwa against the term “as directed” (a.d. to use its Latin short hand) appearing on prescriptions.

This simple term had become verboten in radical pharmacist circles and as such was now the source of a witch hunt as all true religious and science based zealots do embark on after reading holy scrolls from a Midlands “University” famed for the production of many social service graduates and media studies types all highly useful in healthcare.

The zealots persevered but those of us with memory and experience played them at their own game. What about patients on insulin who may need to daily change their insulin based on current blood sugars?

No “as directed” is not acceptable the scripture says so. So we will need to write a prescription with a specific dose for each insulin injection 4 times a day for every diabetic on insulin every day when we do not know their blood sugar readings?

Yes the prophet Keele is most precise on the interpretation of the holy scriptures for “as directed” is now heresy and the prophet is all wise. OK lets play the prophet’s game and guess what?

Eventually when it became unworkable the radical pharmacists accepted that the term “as directed” might just be useful. For thing like insulin and warfarin and bum cream and a whole load of other things where regular doseage is not required, cannot be predetermined and is dependant on variable feedback from blood tests and worse still the needs of a patient according to their lifestyle.

Patients involved in selfcare prescribing using their own judgement who needs them went the zealots of radical pharmacy all that is required is that the label is written as per the prophet’s will. We do not involve patients in “academic” pharmacy.

Unfortunatley we do involve patients for it is their symptoms that often determine when a drug needs to be used and unlike “academic” pharmacists we do not have the luxury of being able to sit next to each and everyone of our patients so that if they develop an itch, or rash or a pain we can instantly write a prescription dictating when, where and how often to apply a medicine. This is why the term “as directed” is useful and if a patient is sensible, rational and understands what the drug is used for there is rarely a problem.

Scratch one revolution. The revolutionary zealots crawled back into their tents in a far desert and we thought sense had prevailed until this week when the fedayeen branch of radical pharmacy reared it increasing ugly and gorgan like head when a colleague in a neighbouring practice, while the on call doctor, was requested to visit 27 patients to do urgent medication reviews at a residential home.

Could this be that a chance inspection of 27 inmates in one the Grim Reaper’s departure lounges had noticed that 27 of their residents had stopped breathing 3 weeks ago and there was a needle and syringe and an empty ampoule of 100mg of Diamorphine by the side of each decaying corpse? Were the last doctors to have visited none other than Dr H Shipman and Dr Ubani?

Of course not it was far more serious than your average day in GP land. Apparantly the home concerned had had an inspection by the Blair Quality Commission C(B)QC and someone had been upset by the fact that a few patients dared to have the blasphemous words “as directed” on their medication.

Now pharmacists and C(B)QC employees live in a magical world of excellence where nothing wrong ever happens. This is why we need more and more inspections by the local villages idiots who have failed throughout their lives to do anything useful and no-one liked at school.

We have seen the local parmaceutal advisers at work locally now their fellow zealots are at work with the C(B)QC. Worse still the zealots had affixed parts of their holy scriptures to the offending prescriptions saying that there were no directions as to how often to administer the medicines or even to which part of the body.

The first few of the presriptions so purified and freed from mortal sin by the zealots’ inspection were for creams. One was for a patient with widespread eczema which varied on a day to day basis both in terms of location and intensity and was treated with a mixture of steroids and moisturizers. The patient had had eczema since childhood and although physically infirmed was mentally able to dictate how to use the creams for best effect.

A disease that is variable in time, location and severity requiring differing amounts of medication at different times and locations cannot be prescribed for on every single occurrence in today’s NHS but despite this self evident truth attached to the offending prescriptions was the holy scriptures dictating that as directed should be removed and precise locations and timings be written instead.

Several other creams had been similarly cleansed by the zealots and all were conditions that varied as above.

So what did our professional colleague do in the face of the terror of the new Spanish Inquistion? Well they considered their professional responsibilities remembering that they were responsible for any prescriptions they signed. Those who did the inspection had long since galloped off and their faces were hidden under pointed hats with only their eyes visible and so there was no idea what qualifications (if any) they had.

The prescriptions had all be written correctly from a medical point of view, the staff at the home knew what they were doing and so did the patients and so passive resistance was employed.

Praise be to the Party for ensuring that no-one is too thick to fail and if you do you can always inspect something and take full no responsibility for your inactions. If you prescribe and make an error it comes back to haunt you. The ability to prescribe is hard won and carries with it responsibility.

The ability to prescribe responsibily to meet the needs of patients not those of protocols must come first for it is they that we as doctors are there to serve and protect. Of course if you want doctors to spend all day writing prescriptions and not seeing you just dial CQC PHARMACY for instant help.


1 comment:

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