I first realized something was amiss when I picked up my prescriptions and the pharmacist explained that she could not fill the anti-malarial medications as prescribed: "Your medication plan only pays for 30 days of pills, and your prescription was for five pills." The pharmacist continued: "Your PBM [that's an acronym for pharmacy benefits management company, the type of company that coordinates many peoples' medication coverage] only fills this medication for 30 days at a time. And 5 pills would last 35 days."

Expert logician that I am, I countered with some math of my own: "Well four pills, taken weekly, only lasts 28 days. If they really want to give me 30 days of coverage, they need to give me a fifth pill." I thought it was insane to pay a whole extra co-pay to get my fifth and last pill, a co-pay I'd have to pay for my two sons too since all three of us were traveling together.

But the pharmacist was unpersuaded: "Sorry, four pills is it. You'll need another prescription for the last pill."

Irked, I handed over my credit card and hastily signed the bill, too bothered by the conversation to look closely at the bottom line.

When I got home and told my wife Paula about the saga of the fifth pill, she calmly looked at the bill and asked me: "If you were so concerned about a $10 co-pay, why didn't you notice that the antibiotic you were given cost almost $200?"


I should give you some background to this story. A couple of weeks before my trip to the pharmacy, my wife and I had decided to take our sons to Belize for the holidays. She travels internationally for her job, so she was up to date on all of her immunizations and was well stocked with travel medications. But the boys and I had to scramble to get ready in time. We had to start our anti-malarial pills before departing, for instance, and also needed to get typhoid and hepatitis injections early enough for our immune systems to respond. So we went to our family physician, a kind and personal man who had taken care of my boys' ailments over the past year. He looked up Belize in the CDC website and prescribed everything we needed. Among the medications was an antibiotic we could take if we developed traveler's diarrhea. That was the prescription that set me back almost $200.

I spoke with the physician after my trip to the pharmacy, to explain that we needed new prescriptions for the anti-malarial medications. He apologized for the screw up. I told him it was no problem, but I did wonder about the price of the antibiotics: "Did you know how much those antibiotics cost?"

"No," he said. "I had no idea."

"Couldn't we have settled on a less expensive antibiotic?"

"Well I mentioned the name of the pill when I prescribed it," he replied in a courteous tone, "and you didn't have any objection."

Okay, a bit more explanation here. I was a patient in this particular scenario, but I am also a primary care physician. It is often awkward for people like me to seek care from other primary care physicians. I worry that other primary care physicians will defer to me. But I don't like the idea of being my own doctor. As the old saying goes: "The doctor who cares for his own ailments has a fool for a patient." In addition, I worry that my physicians leave things unsaid when communicating with me, because they assume I can fill in the blanks. As in: "If I mention that antibiotic and he says okay, it will be because he knows what the alternatives are and agrees that this choice is best."

That assumption was as wrong as a walk through a Belizean jungle without mosquito repellant. Because, you see, I know almost nothing about travel medicine. In my 15 plus years practicing in the VA health system, no patient has ever come to me asking for travel medications.

To be clear, I didn't end up with expensive antibiotics simply because my doctor thought I knew what I was getting. Instead, as I talked to him further, he tried to justify his prescription decision: "Peter," he said to me when I told him the cost of my drug, "I got back from a third-world country recently and the antibiotic I took there left a metallic taste in my mouth for a week. I would gladly have paid $200 to avoid that fate."

"Good for you," I thought. "But wouldn't it have been nice to find out whether I, your patient, wanted to spend $200 that way?"

In the last few decades, medical schools have been teaching us doctors to inform patients about their treatment alternatives, so our patients can pick the alternative that best fits with their individual values. Which raises the question I'd love your input on:

Should doctors take the time to figure out the cost of treatment alternatives and communicate such information to their patients?

After you chime in with your ideas, I'll take a crack at this question myself.

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