Veterinarians working as both W-2 associates, and 1099 contractors, often believe they are required to practice medicine in a manner defined by their employers. Although it is true that veterinary practices often have a set of norms for the way certain cases are handled at their hospitals, veterinarians should remember that they are never required to practice in a way that contradicts their own medical judgement and moral conscience. In fact, veterinary medical boards and state licensing agencies include language supporting this in their rules and statutes.
So where do you draw the line?
The line is different for each of us, but a good rule-of-thumb is to consider how you would defend your decisions and actions if you were to end up in court. Another thing to consider is whether or not your decisions and actions allow you to sleep at night, or keep you up anxious with worry and regret.
Consider this scenario…
Mrs.Smith calls in requesting a refill of Tramadol for her arthritic, senior dog, Fluffy. You review the medical records and see that Dr. X, the practice owner, prescribed the medication four months prior (with no directions regarding number of authorized refills) and Mrs. Smith has been calling in to have the medication filled at the local pharmacy every 30-40 days consistently since that time. You are an associate vet and have never met Mrs. Smith, nor examined Fluffy, at any point in the past. Today is Dr. X’s day off and Dr. X cannot be reached. What do you do? Are you obligated to authorize the refill?
Whether you are a veterinary associate, or perhaps a relief vet in the same situation, the answer is no, you are not obligated to authorize the refill. Even if Mrs. Smith happens to be a long term client with a long list of pets, or maybe the BFF of the head technician, and even if the practice manager is pressuring you to “just do it because Dr. X would”, the answer is still no, you are not obligated to authorize the refill (and I would encourage you not to do so).
Bottom Line: You are being asked to prescribe medication outside of a doctor-client-patient relationship, and that puts your license at risk. You worked for years to earn the right to hold that license, and you have the right to protect your good standing.
Does that mean you don’t care about Fluffy’s illness and need for medication? No. Does that mean you are not willing to provide Mrs. Smith with great customer service? Absolutely not. There is a solution that will both provide Mrs. Smith and Fluffy with the refill requested, and protect your license (and conscience) at the same time: request Mrs. Smith bring Fluffy in for an examination to establish the doctor-client-patient relationship and provide you with the opportunity to evaluate Fluffy and authorize the refill, if appropriate.
In all likelihood, Mrs. Smith, the BFF vet tech and the practice manager may all get bent out of shape when you outline your terms, but stand firm. They are pushing back because it is inconvenient for them, or forces them to have an uncomfortable conversation, not because your requirement is ridiculous or unfounded.
There is likely to be a money objection: “Mrs. Smith doesn’t want to pay for an exam when it’s not needed”. We have already established the exam is needed, but there remains the option to offer a one-time, complementary exam in this unique situation in order to remove the barrier between Fluffy and her needed medication.
Unfortunately, this option is often followed by the time objection: “Mrs. Smith doesn’t have time to bring Fluffy in for an exam.” At this point, Mrs. Smith has a choice, she can find the time to bring Fluffy in, or she can wait until Dr. X is back in the office and try again with the hopes of a different outcome. The choice is now in the hands of the owner.
At this point you have done your job, you have offered a reasonable, medically sound, financially viable, and compassionate solution. You have made a decision that is in the best interest of the owner and patient, and also in the best interest of your veterinary license and your conscience. But don’t forget one final, crucial step: DOCUMENT EVERYTHING. A simple note in the medical record will go a long way toward squashing misconception and misunderstanding regarding this scenario in the future.
DD/MM/YY, TIME, Mrs. Smith called requesting a refill of Tramadol for Fluffy to be called in to the pharmacy. Original prescription was written by Dr. X on DD/MM/YY, authorized refills were not indicated. Advised Mrs. Smith to bring Fluffy in for a complementary exam so I could evaluate Fluffy, and establish the doctor-client-patient relationship required to authorize the refill, if appropriate. Mrs. Smith declined appointment. Refill not authorized. YY,DVM
Final Tip: Establishing best practice of including a number of authorized refills at the time of original prescription often eliminates these uncomfortable situations and also provides support staff with information needed to appropriately handle these requests on their own. In this case, had Dr. X authorized 6 refills at the time of the original prescription (or some point after), the pharmacy would have already had that information, or, staff could have called in the refill on Dr. X’s behalf based on Dr. X’s prior orders, independent of you.
Coming Soon: Part 2 of this series, a surgical scenario