I’ve written thousands of recommendations to physicians and other healthcare providers throughout my career. I’ve gotten over the fear of failure so to speak, but there’s always still a little doubt in the back of my mind when a physician doesn’t do what I’m recommending. Here are some strategies I employ to help combat this challenge.

• My first step to ensure that the physician actually received and reviewed my recommendation. When writing recommendations to physicians, you will likely encounter some providers throughout your career who will have a tendency to ignore recommendations or not have systems in place around them to receive them on a consistent basis. A lot of this depends upon the location you are working in. If you are in a retail pharmacy with no relationship with the provider, this may be a very big challenge for you.
• Next, I review how I wrote the recommendation and affirm that what I am asking makes sense. If this passes my review, then I look to other reasons as to why they didn’t accept it. I also try to ensure that I provided enough information in my recommendation to allow the physician to adequately assess the situation while at the same time walking the line of not overwhelming them with unimportant details.
• Review the documentation or ask them about their rationale. It may be an issue that is controversial or something that they have been personally burned on in the past. Some providers are better about documenting their rationale for not accepting a recommendation than others, so how you handle this process can be very provider specific.
• Ask a colleague about your recommendation. There may be a few bits of information that they can help shed some light on.
  • A colleague may have more experience working with that provider and have had a similar situation happen to them
  • They may think of questions that hadn’t occurred to you
  • They may tell you (nicely) that you are wrong or that they would have approached it differently
• Determine the clinical seriousness of not doing something. Are you asking to discontinue a supplement that is not causing adverse effects? You’ll be likely to let this go and save your energy for another recommendation that may be riskier to a patient.
• Rewrite the recommendation using new information obtained or information that you did not include before. More data and information can help provide a more convincing argument as to why a medication change is necessary. If you wrote a recommendation to reduce insulin because they had a blood sugar of 60 last week and omitted that have had 8 addition episodes of blood sugars less than 70 in the past two months, this is an oversight on your part. Hopefully, the physician would catch that, but it may depend upon how information was delivered to them or the urgency of other medical concerns going on for that patient.
• Discuss the situation with the patient, caregivers, or staff that is taking care of the patient. In the situation of hypoglycemia where a provider doesn’t want to reduce a sulfonylurea, educate the patient and/or caregivers about this risk. Encourage them to report future symptoms of hypoglycemia to the primary care provider. This may help jog their memory of your recommendation and that this issue has been problematic before for the patient.
• Enlist help from a superior. I haven’t had to do this more than a few times in my career, but I have had situations where I felt my specific recommendation rose to the level of life-threatening if nothing was done. I remember one specific situation where the director of nursing and I approached the medical director about a clinical situation and the medical director handled it beautifully. It was a situation involving a very high potassium level and the patient was on medications that could elevate the potassium.
• Let it go. This depends a little bit on the setting as in LTC, providers are responsible for responding to pharmacist recommendations, but in other situations, I may just let it go and agree to disagree. Whether to let it go or not has a strong dependence upon your determination of the clinical seriousness of the medication issue.

If you are looking for more real-life pearls on writing recommendations to physicians, be sure to check out my Guide to Writing Medication Recommendations!