To the Editor:

The approach to medication refills described in “Rethinking Refills” [October 2002, page 55] is flawed. Using protocols to delegate this clinical function to medical assistants reinforces the false notion that prescription management is a clerical function best handled over the phone.

A prescription implies that a clinician knows the status of a patient’s condition and indications and contraindications for therapy, including potential interactions with medications that may have been prescribed by other clinicians. There are certainly medications that do not require ongoing physician monitoring. They are called over-the-counter medications.

When prescriptions expire, patients should be taught to think “follow-up appointment” rather than “call in for a refill.” A refill request starts a cascade of nonreimbursed expenses for a physician. Furthermore, in the absence of any recent clinical information, these refills must be for smaller amounts that will only generate another phone request at a later date. And these phone calls will greatly increase the staff time needed to process the requests, increasing the largest component of overhead for a primary care practice. This system is self-exacerbating. Medications should simply be refilled at office visits (for up to a year) when the relevant condition can be appropriately evaluated, discussed, documented and reimbursed.

Direct-to-consumer drug marketing and the pervasive “medicalization” of all ills has encouraged our patients to feel that doctors are little more than hoops they must jump through to get the medications they want. We need not encourage this idea by lowering medication management to a clerical task. Instead, we should insist that giving proper consideration to each prescription is among the highest-level cognitive services primary care physicians provide.

Author’s response:

I dispute your assessment of the article as “flawed” because I do not think our points of view are that dissimilar. The point of the article was to share how I went from using refills as a means for ensuring that patients receive needed follow-up visits to a more reliable system. While we write prescriptions for the maximum interval possible to ensure that patients have access to the medications they need, we use a return-visit tickler system and open-access scheduling to assure patient follow-up.

Using an automatic refill protocol would be a mistake in some offices, including those with unreliable recall systems. And I agree that a medication refill is a clinical event that I should get paid for when indicated. However, I do not accept the political and bureaucratic system that determines which drugs are over-the-counter, nor do I use it as a guide for determining which drugs do or do not require supervision. How can one say prenatal vitamins require direct supervision yet Afrin nasal spray should be left to the consumer?

The refill protocol ensures that I see those patients whose medical indications require it rather than those whose refill needs have to do with access issues. This means I have more time to see other patients.

I share your frustration with the current environment for the practice of medicine, and I am working to improve it.