Friday, June 19, 2009

More on off-label prescribing

I was fortunate enough to get great training (SUNY-Upstate for MD and Oregon for residency/child fellowship). After graduating I promised myself I would be true to my psychodynamic roots (Hal Boeverman RIP), do thorough evaluations and provide the finest psychiatric care possible. After leaving Oregon I happened to travel through Montana on the way to visit my family back in NY State. I was smitten.

I am always amazed at the differences between academic and community psychiatrists.

Fortunately a job was available in Billings, and here I have been ever since. I felt like quite the bright young thing arriving in the hinterlands and remember being appalled when the first thing my nurse asked me for was a presigned book of prescriptions, since she did most of the refills. I was horrified at the thought! The signature is sacred! I soon figured out that my nurse knew more about child psychiatry than I ever would, and the scrips were signed.

Now we do everything via computer, and I just sign the controlled substances. I also found out that I had inherited a practice of hundreds upon hundreds of children and adolescents. Our four-man clinic runs the only child unit for hundreds of miles in all directions. It is not uncommon for people to drive ten hours for an appointment. I quickly abandoned my idealistic hope of providing exquisite care for the few, and began my life’s work of providing pretty decent care for many. And obviously, I have become fairly comfortable with the 90-min evaluations and the 25-min med check.

But when I see an article like Dr. Edersheims’s excellent piece on off label prescribing of atypicals, I have this horrible mixture of guilt and despair. Edersheim nicely makes an argument for how to handle the vagaries of off-label prescribing, but if I tried to practice even a fifth of her ideals regarding extra info, collecting articles, more monitoring, increased consultation, I would never make it past my 9:00 appointment.

The reality is I have a 10 year old from Lewistown hallucinating in my office and the next patient is a 14-year-old from Billings who has broken up with a boyfriend and wants to die. The other reality is that I am about it. Therapists are rare in rural Montana. Pediatricians and family practitioners don’t want to go near this stuff. So of course I am going to go off-label.

I am a general child psychiatrist; everything (practically) is off-label. And it seems to me we have gotten so defensive and fixated about medication side effects (which can be horrible!) that we as a profession go into denial about what happens if we don’t treat these conditions. We have just a relative few weapons for a lot of chronic, dangerous illnesses. They need to be prescribed as intelligently as possible, but we also need to understand that those of us in the field need to treat a lot people quickly and efficiently and to not underestimate the morbidity and mortality of ignoring the plight of folks who need “off-label” treatment.

Jim Peak MD
Billings, MT

1 comment:

  1. Ronald Pies MD, Editor in ChiefJune 21, 2009 at 8:00 PM

    I'd like to thank Dr. Peak--a fellow Upstate Medical U. alum!--for his candid and clear-eyed appraisal of "real life" practice in child psychiatry. And, Dr. Peak should have all of our thanks for "holding down the fort" in the hinterlands of Montana!

    Dr. Peak is absolutely right to point out that (metaphorically speaking), when you are up to your hindquarters in alligators, you
    do not have the luxury of determining the chemical composition of the swamp! The pressing urgency of very sick patients in one's waiting room sometimes must take priority, even when we wish we had more randomized, controlled studies to back up our "off label" prescription--and even when we wish we had an hour and twenty-five minutes, instead of twenty-five, to do our evaluation of the patient; assess the dynamics of the family system; and provide a thorough informed consent process, vis-a-vis our treatment plan.

    At the same time, all of us can do more to acquaint ourselves and our patients with the risks and benefits of the medication (and other treatments, including psychotherapy) that we prescribe. We can do more to scrutinize the "hype" that often characterizes advertising for some of these medications. And, we can do more, using pre-printed informational hand-outs, to disclose the risks and benefits of medication, so that when the patient and family leave our office, they have something to reinforce what the psychiatrist said, in the midst of a family psychiatric crisis. Often left out of such risk/benefit discussions, as I think Dr. Peak would agree, are the risks of the patient's NOT taking the recommended medication, or not entering psychotherapy.

    Risk-benefit discussions of this sort are especially important when dealing with "off label" uses of medication. And, let us be clear: however we may delegate authority in our own practice--whether to nurse practitioners or physician assistants--we physicians are the ones who will be held ultimately responsible for our patient's well-being, under the "Captain of the Ship" doctrine ("respondeat superior", if you prefer the lawyers' Latin).

    Finally, I completely agree with Dr. Peak that we must not make a fetish of the "off label" designation, focusing only on the risks of such medication, rather than on the tremendous morbidity and mortality associated with many of the diseases we treat. --Best regards,
    Ron Pies

    Ronald Pies MD