Rogue patients

The New York Times had yet another article this weekend about rogue doctors and how they are abusing the system. We all acknowledge that such colleagues exist and that they contribute to excess health care costs. But somewhere in the plans to develop a health care reform package, something should be said about rogue patients. I am not referring to those who twist our arms to pursue every conceivable test = they are genuinely concerned about their health and we need to use all our skills to help them understand why we are not pursuing extremely unlikely conditions with expensive unnecessary studies. I’m referring to patients who are trying to scam the system. They are fortunately few in number (just as rogue doctors are few in number), but over the years a few stand out in my memory.

Case 1: I saw in consultation a 44-year-old woman hospitalized because her diabetes was out of control. After careful history and physical examination, I concluded that her diabetes could no longer be controlled with oral medications and appropriate lifestyle changes and that she would be best managed with insulin. However, she was employed as a school bus driver, and I suspected that she would lose her job if I prescribed insulin. I discussed this with her in detail and concluded that we would do the best possible job without insulin, so she would not put her job in jeopardy. She was livid and convinced her primary care physician to go ahead and prescribe insulin. Why? She would rather go on disability than continue to work for a living.

Case 2: A patient I am caring for as an outpatient also had diabetes that was not well controlled but could be managed without insulin. The regimen I planned for her called for frequent checking of her blood sugar as her therapy was being increased, and she requested that I write a note to her employers seeking a leave of absence for a few weeks while she was getting started on this new program. Not an unreasonable request, and I readily agreed. She did an excellent job, and her blood sugars came under good control after four weeks. Again at her request I wrote another note to her employers stating that she was now ready to return to her former duties without restriction. She did not get annoyed but was clearly not satisfied. “What about my backache? I can’t do the work they want me to!” I politely explained that this was something she would have to take up with her primary care physician only to be told that he would not agree to this which is why she let her diabetes get out of control.

Case 3: A young man turned up at a charity clinic wanting a refill on his medication. There are thousands of health care workers and lay people who volunteer their services all over the country to those in need of care but do not have insurance. Demand for these services has gone up dramatically during this economic downturn and the community has responded rapidly. Major medical laboratories have offered to provide services for no cost for many of these clinics. The local representatives of the hated pharmaceutical companies keep the clinics supplied with whatever samples they can without fuss or strings attached — just doing what they can to be of service. Back to my young man! I told him he was in luck and gave him a three-month supply of his needed medication, and he refused it. He wanted the generic levothyroxine not the brand name product I offered him. No amount of explanation would satisfy him, and he became obstructive and abusive. I wrote him a prescription for the generic medication with the costs having to come out of his pocket.

Case 4: A patient was under my care for gender identity change — I was managing his hormone therapy and he was doing well. At a scheduled clinic visit he politely asked me to petition Medicaid to pay for his breast implants because the hormones weren’t doing a good enough job in that regard. I was quite taken aback by that request, but that was nothing compared to what followed. “You just don’t understand, doctor. I’m on disability for depression, and if I have bigger breasts I won’t be so depressed.” It was hard to keep a straight face.