Family doctors are still not permitted to prescribe isotretinoin (Roaccutane) in Australia. The drug, used only for severe cystic acne, can be dangerous to fetuses and has been linked (inconclusively) with suicidal ideation and behaviour.
We’re all pre-pregnant until proven otherwise, of course, and even then our protestations are to be viewed with suspicion.
So which super-duper-specialists are considered to be so much better than GPs at offering comprehensive whole-person care, simultaneously monitoring psychiatric state and at counselling on family planning and prescribing contraception – to the point that GPs are banned from participating in this type of treatment?
Psychiatrists? Gynaecologists?
No. Dermatologists.
Can anyone explain to me how this makes sense?
Edited to add (27 Nov 2008 @1405): Correction: It’s actually dermatologists and internal medicine specialists (general physicians). Source.
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It’s not that dermatologists are better at counseling or prescribing birth control. They are better able to determine which cases of acne are severe enough to warrant treatment with Accutane. I agree with you about the “prepregnant” idiocy, but am also aware that, at least in the US, liability concerns are a bigger driver of the monitoring and limiting of the drug than anything else.
I wouldn’t prescribe Accutane, and I would be deeply concerned about any primary care doc who would do so. It’s outside the appropriate scope of practice.
When I went to a dermatologist to get my script I asked about the links to depression and suicide ideation and the doctors response was that it was a campaign being waged by the parents of one person who took his life and “it may make you feel a little flat, but so will the pill, once you stop taking it you’ll be fine”. Then he gave me a 12 month script for both. Didn’t fill me with confidence.
I think it’s a “gatekeeper” issue rather than an actual health issue – just they’ve put the wrong gatekeeper on it! A GP/specialist partnership (as happens with a lot of post-cancer, IVF and ADHD medications) would be far better at monitoring the specific issues of Roaccutane than a dermatologist in a city 2 hours away who books appointments 6 months in advance or more.
Skin experts are in a better position to assess the benefits and risks of skin medication? Is that really that hard to understand? Sure they might not have any more ability than your average GP to deal with the side effects, however did you consider than maybe specialist knowledge is required to determine if the medication would be effective in the first place, or whether there are better alternatives available to drugs? Or specialist knowledge to understand the risk factors in specialist skin treatment?
r s ths jst nthr “MG th gbbrmnt s tryng t stp nythng brtn rltd” prnd rnt?
[First and last chance, Desipis: don’t be a pain in the arse. ~L]
Well yeah, taking it out of the hands of a *general* practitioner and putting it in the hands of someone only seen to be doing their job if they clear your skin up…
“We’re all pre-pregnant until proven otherwise, of course, and even then our protestations are to be viewed with suspicion.”
Tell me about it – a couple of weeks ago I went to see a GP, who asked me FOUR TIMES in a ten minute consult if I was quite sure I wasn’t pregnant.
Jay: have you worked in the Australian context? Our scope of practice and also our breadth of training seems to be quite different from how things function in North America – particularly in rural and regional practice. In other words, what lilacsigil and observer said.
Perhaps if you could talk about some other things you’d consider to be outside your scope of practice, and particular the ones that are grey areas or close to the line, it might be easier to compare?
Either way, with these rules, there is absolutely no requirement that anyone with actual mental health or family planning skills co-sign off on a Roaccutane script – instead, only those with deep-and-narrow skin training can do so. Assessing the severity of the acne is not the only clinical skill involved, yet the legislation only takes that task into account. I suspect this is because of a devaluation of the skills that family practitioners possess – “if a GP can do it, of course any doctor can do it just as well!” – and that’s both insulting to dedicated GPs, and dangerously wrong.
I also, in case I wasn’t clear, reject the idea that GPs can’t possibly be qualified to assess the severity of acne! By that standard, plus the reality that you can kill a person stone dead with all sorts of medication, it sounds like we should be barred from prescribing antihypertensives for refractory high blood pressure, or antibiotics for community-acquired pneumonia, warfarin for DVT, oral meds for NIDDM, antidepressants for depression…
What differentiates isotretinoin from all of these?
If we eliminate – by legislation – from family practice all of the more-than-trivial diagnosis and all of the dangerous medications, what’s left?
Family doctors are under an ethical obligation to recognise their limitations and avoid diagnosing and prescribing when they feel they don’t have the skills for it. Nothing’s stopping you, Jay, as you feel uncomfortable and/or untrained with treating acne, from referring. What’s the basis for stopping every single other GP in Australia from treating it, regardless of their skill level?
I don’t know whether they still send people on roaccutane off for liver function tests but it makes no sense to me to insist on a dermatologist monitoring for these side effects which are all outside their area of speciality. A GP can send them off for the same tests.
I’d reject the idea that members of the public can’t possibly provide an accurate assessment of the severity of acne. Or depression. Maybe we should just let anyone hand out meds.
It’s not about what GP’s are possibly capable of, it’s about ensuring those that do make the assessment and hand out risky medications definitely are qualified.
Desipis, your tone is snide and your comments, in deliberately misinterpreting the point of others comments are tedious.
No one here is suggesting letting these medications be handed out by anyone medically unqualified. Please explain to us (since you clearly think we are all morons unable to understand the simplest of logic) what qualifications a dermatoligist has to assess the possible foetal risks or mental health risks of the potential (non-skin-related) side effects of this medication that a GP doesn’t have/couldn’t obtain?
That’s the whole point. And before you go there, my tone is flat out bluntness (which can possibly be cast as rudeness). Snide is a whole different thing.
I’m not arguing that dermatologists are more qualified in that manner. But medical decisions are made weighing the risks of the treatment against the possible benefits in the context of other treatments. It’s this second half of the equation which covers how they are better qualified to make such an assessment.
Which “other treatments”, Desipis, and in what way are dermatologists better placed to assess them? Can you elaborate and explain this argument? I’m not understanding it right now.
Can you speak to my other examples, or explain what exactly makes Roaccutane different from them?
I don’t know. I’m not a dermatologist. Being specialised in skin and skin treatment I’d assume they’d have greater awareness of skin issues than a GP.
There’s a limit on what one person can know, and a GP should be orientated towards the common ailments and have enough awareness to refer specialist cases. I haven’t checked any stats, but all of your examples appear to be quite common ailments, where as I believe severe acne is not all that common.
Ugh, I posted a piece on this bit of beaurocratic bullshit on my own blog a couple of months ago…
At that point, the head of the Australasian College of Dermatologists (Dr Stephen Shumack) was saying that because Roaccutane can lead to gross abnormalities in a foetus in utero, that allowing GP’s to prescribe Roaccutane would (brace yourselves) lead to an increase in abortions!!! I am not making this up. This was followed by a lot of windbagging about how ‘ooooh we need to make sure things like pregnancy are properly screened for in Roaccutane candidates blah blah blah…’ As if, somehow, a dermatologist is more qualified to administer a basic pregnancy test and give sound advice on contraception than a family GP.
It’s astonishing that someone who made it through medical school would expect anyone with half a brain to swallow this crap. It seems very likely to me that this is more about dermatologists’ concern about hanging onto a lucrative part of their private medical practices, as opposed to any concern about foetal health – and I’d prefer for them not to insult my intelligence by dressing it up as such.
And here’s the link to the original story… http://news.smh.com.au/national/acne-drug-may-lead-to-more-abortions-20080825-41u2.html
(Sorry, I’m not real au fait with hyperlinks!)
Prevalence? I hadn’t anticipated that argument. Severe acne has a point prevalence of around 1-2% (0.5-6%, depending on the source you look at). Coincidentally enough, it’s very similar to the annual incidence of pneumonia, and it’s a whole lot more common than diagnosed DVT. Severe acne is hardly a rare disease.
[Incidentally, the illness I have is quite a bit less common than that, and yet I’ve found specialists to be , without exception, useless, compared to my GP.]
Which other illnesses of around the 0.5-5% prevalence range should GPs be legally barred from treating? What should the threshold level be?
I’d argue that severe acne is actually quite common. Myself and four people close to me have been on Roaccutane at least once. Depression is also common. Given that roaccutane has a problematic effect on mood that is not entirely understood the lack of care/caution/experience in the field on the part of the person prescribing that particular drug worries me.
Also wrt GPs – when I go to a GP and say “I need another course of roaccutane, my acne is back as bad as before” five years after the first course, why do I have to go to a dermatologist to get the peice of paper? (Aside from the usual assumption on the part of doctors that the patient is a complete idiot.) Especially when my specific concerns about suicide ideation (given the pre-existing mental health problems in my family) are shrugged off?
Err prevalence != annual incidence. A prevalence of 1% would result in an annual incidence of around 15 per 100,000 (assuming only on incidence per person, AFAIK there’s a very high success rate with the treatment). With an average patient base of 1-2,000 an average GP could go 5 to 10 years between treating severe acne. With incidence of ~1% a GP would be treating about once a month, which means they will be much more likely to remain up to date with knowledge of the illness and treatments.
The prevalence of DVT is about 5% much higher than the numbers you gave for acne, but the major issue here is that warfarin is used to treat quite a range of blood/heart issues and so its use would be more common than just the incidence of DVT.
Your numbers are off. The number I gave is point prevalence – the percentage of people who have it right this minute. I don’t know how you’re translating that into an annual incidence of 15 per 100 000. Are you thinking that it’s not PP but a lifetime prevalence or lifetime incidence figure, or something like that?
A “smell test” can confirm that your numbers are way out – 5 to 10 years between a patient with the problem, when there’s a point prevalence of around 1% – how does that work? I wonder how I’ve seen handfuls, perhaps dozens – in a shortish (so far), part-time career, without being particularly different from my colleagues? Is observer existing in a peculiar bubble of severe acne that we should helicopter an epidemiologist into to investigate?
And where are you getting a 5% incidence of diagnosed DVT from the emedicine link?
“but the major issue here is that warfarin is used to treat quite a range of blood/heart issues and so its use would be more common than just the incidence of DVT.”
But Warfarin doses are generally managed by a specialist at the Pathology provider, as you have to have blood tests to check how thin your blood is, and the lab calls with a new dose depending on the results.
Huh, eaten by the spaminator when I didn’t even have a single link…
Just goes to show how differently things are managed from place to place. I’ve never ever managed warfarin doses that way, nor do I know anyone who has. How does the pathologist, who has never laid eyes on the person concerned let alone talked with them, know when there are issues that may alter warfarin needs (diet changes, herbal medicines, antibiotics or other medication changes)? Who writes the INR orders and prescriptions?
KM:
Do you have a link to your piece, KM?
My best friend is on some drug that means she can’t carry to term, that’s she’ll miscarry. I don’t know if it’s for the epilepsy, the Crohn’s or something else. So she’s obsessive about BC. Her GP handles it, because her GP knows what drugs she’s already on, what lifestyle she leads, what her diet is like and what other supplements she takes.
I’ve had GPs make shitty decisions (like prescribing me hardcore anti-inflammatories and assuring me they’re okay to take with my existing anti-inflammatories and painkillers when in fact it ended up fucking up my stomach so badly I can’t take any anti-inflammatories, or anything that has the potential to hurt my stomach). I’ve had GPs who worked wonders with my existing meds/lifestyle/diet issues. I’ve not had a specialist have any of that understanding, because as a specialist, they’ve got a narrow field that means they work on a very small area and don’t (generally) work with the whole patient. Just that one sick bit.
I’d rather see a GP who could prescribe anti-d’s if I needed them, if the roaccutane was depressing me, and BC so I didn’t get pregnant. Not see a dermatologist. Then a psychiatrist. Then the GP.
“Just goes to show how differently things are managed from place to place. I’ve never ever managed warfarin doses that way, nor do I know anyone who has. How does the pathologist, who has never laid eyes on the person concerned let alone talked with them, know when there are issues that may alter warfarin needs (diet changes, herbal medicines, antibiotics or other medication changes)? Who writes the INR orders and prescriptions?”
Isn’t that interesting? The cardiologist prescribed Mr H’s in the first place, and the GP wrote new prescriptions. But the pathology lab was managing the dose.