Adjusting med:do you talk to doc or nurse | ADHD Information
Thanks for replying, Evvy. Yes, I will try to make it even more clearthan I did last time when I leave a message with the receptionist.
But, in all reality, I don't think it's the doctor not wanting the calls; I
think it's the nurse thinking she can take most of the calls because
she (thinks she) knows enough to do so (or receptionists, also trying
to minimize the doctors' calls. Don't know. FWIW, this is a 7 doctor
pediatrics group within the big Clinic in our city).
But what I'm really looking for is how typical it is, when people are
trying to get to the right dosage and right med, to do this just via
the nurse, vs. dealing directly with the doctor. That is, maybe I'm
wrong and nurses in general really are competent to handle this part
of the process. But maybe on the other hand, no one else *ever*
deals with the nurse, and in addition, everyone does spend 3 min
every week (or however long) on the phone with the doctor and so it
shouldn't be out of the ordinary for me to talk to the doctor
frequently. (The day after I saw the doc at the restaurant, and
therefore asked specifically for the doc when I called, the nurse
didn't call back until midafternoon when I was at my son's school
picking him up. The message she left was something like "I don't
know whether you were wanting to make an appt with Dr. XXX or
just tell me what things were" -- well, neither, but when I called
back and asked again for the doctor, the nurse was given the
phone.)
In other words, more ammo to tell this person that she really isn't
the one to be making these decisions, if that's the case.
CJ
CJ-
The nurse is returning your phone calls because that is part of her job. However, anything discussed in your phone calls is required to be recorded in your son's chart and should be reviewed with the Dr. The nurse does not make decisions about the prescription or dosing of ANY medication because that is completely out of her scope of practice (unless she is a nurse practitioner, which wasn't what I interpreted from your original post).
The next time your call is returned by the nurse, you should tell her directly that you want to speak w/ the Dr. If she tells you you need to make an appt to do that (which should never be the case), then I would either change pediatricians or find a pediatric specialist who has experience with AD/HD (a neurologist, pediatric psychiatrist, or pediatric neurodevelopmental specialist) to manage your son's AD/HD care.
You definitely need the teacher's input to help make dosage decisions, but s/he should only act as a consultant. You also need to consider how he behaves at home and how he interacts w/ his peers. If you feel there is still room for improvement on any front then an increase is probably justified.
Hope this helps- feel free to PM me if you need further clarification. I have been a pediatric RN for 13 years and the parent of a child w/ AD/HD for 11 1/2 !!
Lisa
CJ,
I really don't want to take the position of pointing the finger, but it certainly could have been the doc's mistake with the adderall xr goof up. It depends on his level of investment in your son and his management. That's why I suggested finding a doc who manages ADHD as a specialty to handle your son's care.
As for the nurse, if she is a nurse practitioner, she can write and sign for prescriptions in some states, but NOT for controlled substances (which Adderall is). She could write the script and sign the docs name, but she would absolutely need to have it approved by the doc- to do so without his knowledge would be malpractice. If she is giving you the impression that she can make that decision independently, she is mistaken and her license would be at risk. The regulations for advanced practice nurses (APN's) are governed by the state, so each one may be a little different. I am most familiar with NJ, PA, and DE.. Since you obviously have internet savvy, you could visit the website for your state board of nursing ( google _______ state board of nursing) and see what the regulations are for each level of nursing (LPN, RN, APN) in your state. If it is not obvious on the website just send them an email and they should get back to you with the answer.
Don't let anyone, regardless of the letters after their name, discourage you from being your child's advocate. As an RN, I personally feel that patient advocacy is my most important role, but not everyone is like me. If you feel that your son's care is not being managed well enough, look elsewhere. If you need help figuring out where to turn, I'll be happy to give you any advice that I can.
Keep the faith!! You know what's best for your child.
Lisa
[QUOTE=Wonder Woman] I really don't want to take the position ofpointing the finger, but it certainly could have been the doc's
mistake with the adderall xr goof up. It depends on his level of
investment in your son and his management. That's why I suggested
finding a doc who manages ADHD as a specialty to handle your son's
care.[/QUOTE]
Yeah, I can actually see several ways it could have happened: I am
fairly confident the nurse filled out the form, the handwriting looked
like a different note from her. the signature might or might not have
been the same -- sigs are so different. the NAME of the sig was the
MDs. So (a) the MD could have signed without focussing on the
words on the scrip (what comes to mind is a subordinate handing a
superior a whole bunch of forms to sign with something for personal
gain buried in the middle -- on a sitcom or something?), (b) she (the
MD) saw but didn't notice the difference/missing XR, or (c) the nurse
signed the doctor's name.
FWIW, this doctor has been phenomenal in working with us in this
kid's earlier issues (birth hypoxia, needed services under IDEA part C
til 3, plus other more mundane things more recently) as well as our
younger son, who has Down Syndrome -- she even made it over for
younger son's birth, and has made sure that appts for him are longer
than usual, and spent lots of extra time with me before he was born
answering all my questions. It may not be she's not invested
but that even though most general pediatricians probably think they
can manage these things, we really do need to find a specialist (like
you recommended earlier) -- if I can find one reasonably nearby. (I
will be checking our online insurance doctor finder as soon as it is
up again.) It's the nurse. I know of at least one family who won't see
this doctor because of this nurse.
[QUOTE]As for the nurse, if she is a nurse practitioner, she can
write and sign for prescriptions in some states, but NOT for
controlled substances (which Adderall is). She could write
the script and sign the docs name, but she would absolutely need to
have it approved by the doc- to do so without his knowledge would
be malpractice.[/QUOTE]
Could it be that she said something like "this is the renewal of XYZ's
Adderall prescription" or "I am writing a renewal of XYZ's Adderall"
without being specific and without the doctor actually looking at the
form? And maybe the doctor wouldn't have 100% expected to hear
XR in that exchange, and was assuming that the charts had the
correct thing? (The charts may have been incorrect, if indeed
they were, because of problems I heard about in the transcription
department. not an excuse, but is a reason.) Of course, this is if she
even had the ability to do that, which I don't yet know.
[QUOTE]If she is giving you the impression that she can make that
decision independently, she is mistaken and her license would be at
risk. The regulations for advanced practice nurses (APN's) are
governed by the state, so each one may be a little different. I am
most familiar with NJ, PA, and DE.. Since you obviously have internet
savvy, you could visit the website for your state board of nursing (
google _______ state board of nursing) and see what the regulations
are for each level of nursing (LPN, RN, APN) in your state. If it is not
obvious on the website just send them an email and they should get
back to you with the answer.[/QUOTE]
Thanks for the suggestion. I'll do that. I do know internet, but know
very little about medicine (what I know I know from "ER" and we
all know how accurate that is!). She is giving me the
impression that I don't need to talk to the doctor, but I'll find out
tomorrow if she still implies that in the face of obvious need for
SOME change, or if it is only when we don't need to change. She has
also given me the impression that the main thing that would initiate
an increase is the teacher feeling that my son isn't yet behaving as
she wants him to. (I'm not saying exactly what the nurse said, but
that's the gist.)
[quote]
Don't let anyone, regardless of the letters after their name,
discourage you from being your child's advocate. As an RN, I
personally feel that patient advocacy is my most important role, but
not everyone is like me. If you feel that your son's care is not being
managed well enough, look elsewhere. If you need help
figuring out where to turn, I'll be happy to give you any advice that I
can.
Keep the faith!! You know what's best for your child.
Lisa[/QUOTE]
Thanks again, Lisa! unfortunately, I know about having to be my
sons' advocate -- too much! I'm just learning how to deal with it in
this particular setting. Good practice for younger son coming along
the way with his issues!
CJLisa,
Thanks for your helpful response. I don't know what level of
nurse she is... there was also a goofup with his second month's
prescription where she was the only one I know for sure was
involved [can Nurse Practioners sign a prescription form for the
doctor? in the doctor's name? or would they sign their own name?
The form said Adderall instead of Adderall XR, and we didn't realize
until we got it home that it was the wrong stuff -- she claimed the
charts didn't show XR, but *someone* filled it out for XR the month
before... Unless the MD doesn't check the form the nurse fills out
and shoves under her face, I find it hard to fathom that the doctor
made that mistake]
Anyway, am I to take from what you said that if there is a
change warranted that she would have to confer with the doctor first
and call me back? That she wouldn't "make the decision"
directly in the initial conversation with me? Because I got the distinct
impression from her the last couple times I talked to her (when we
didn't change, to be sure) that though she would inform the doc of
everything, that her say-so was enough. Maybe the difference is that
we weren't changing.
I completely agree the teacher's input is important, and this teacher
has been really wonderful in letting us know what's going on, in
pretty good detail. It's just the subtle but important distinction
between her being the main arbiter vs. just one very important
source of information that I think the nurse is on the wrong side of,
at least with her words to me.
Thanks again for your input! Your voice of experience is what I need!
CJHi,
My son has been on Adderall XR (10 mg) since 4/8. We are working
with a psychologist and our pediatrician (who does the actual
prescribing). I've called the pediatrician every couple weeks to give
feedback as to how he is doing, but only the nurse calls back. I get
the impression this is her doing, not the MDs. She acts as if she's all
I need to talk to. In fact the last time, I had run into the MD in a
restaurant the day before, and asked her (very briefly!) if it would be
ok for me to talk to her specifically (not sure what the protocols are
for phone consults), and she said yes, but the nurse still returned
the call, even after I told the receptionist I wanted to talk to the
doctor.
Both times I've checked in so far, we stayed the course on the meds
because he was doing very well. The nurse's comment the first time
(when I tried to ask about how we'd determine if we stay at one
amount or change) was that it was up to the teacher -- if he is doing
well enough in class then we stay. (Isn't that putting too much on the
teacher?)
Is this reasonable to only talk to the nurse? I think we may need to
be increasing the dose, or going to a different form factor; in the last
week it apparently has started wearing off earlier and earlier, around
lunch the last two days. I am not sure the nurse should be holding
so much power in making the decision, but I don't know how to go
about getting her to not intercept my call again without my implying
I don't think she's good enough or qualified. FWIW, I don't care much
for the nurse, but I really really like the doctor -- she's been
awesome in health issues that both my kids have had.
Now, maybe to be able to access the doctor I have to make (and pay
copay) for an in person appt; I'm just about ready to do that.
Am I wrong in thinking that the nurse should not be making
decisions about his dose, especially if we do need to change either
dose or type (e.g., go to not XR, more times per day), and that a
doctor is the best one to discuss the pros and cons of different med
options with? Or is this typical?
thanks so much for any input,
CJ
There's absolutely nothing wrong with calling your doc's office and asking for a call back from the doctor. Just say that it's a personal matter that will take only 3 mintutes to discuss on the phone. If your doctor won't call you back then it's a sign that he/she is just looking for the office visit $$...
Just my opinion.
Sorry it took me so long to follow up.Last week (after I first posted) the nurse did indeed talk to the doctor
because of the possible need for increase, and the doctor is the one
who ordered the increase. It still was the case that I called the
receptionist and asked to talk to the doctor but the nurse was the
one who called back. Her answers to my questions, that time, were
reasonable and there was less reason to push for the doctor... but I
think she would not have passed it on even when it would make
more sense (and take less time) for me to just talk to the doctor...
and her attitude toward me is still annoying -- when I asked about
how long it takes to fine tune the dosage she said something to the
effect of most people don't take very long (or very many dosage
changes) to get to the right amount -- and that is not at all what I
get from this forum or others I have read. (I've been taking both
kids to this team for 7 years, so it's not just because of this issue
that I feel this way about the nurse, but I still like the doctor VERY
much).
Anyway, I need to call AGAIN tomorrow, because this last week he's
been having a TERRIBLE time getting to sleep -- so we've got to find
a good middle ground... just in time for summer break and a totally
different daily environment.
Thanks everyone for your replies.
CJlgmtseawa38494.8621759259
Being a registered nurse, I can tell you that ANY advice given by a doctor that is relayed through a nurse is a "DOCTOR'S ORDER" . This is by law, and documented in the patient's chart. Don't think that the nurse is making the decisions of medication adjustment, because that would be practicing w/out a license and order for dismissal of licensure!! If you have any doubt, you are entitiled by law to the whole medical record by requesting that medical record. Hope this helps.
Ali Southern Nurse W/ son w/ ADHD
