Health Care Hostages

Picture this:

You have a health problem. A chronic one, that requires a regular supply of prescription treatments, whether they be medications, physical therapy, medical supplies, or what-have-you. You’ve had a lot going on in your life lately and you know you haven’t been keeping up on things like you should have been. Maybe it’s because of this health problem that you haven’t, because you’re in pain, or your mental health is in the tank. In any case, your rent is past due, the car’s check engine light is on, you’re child’s school is calling again…

You call your doctor because you need a renewal of your order, and they tell you they won’t do it unless you get an appointment first, or labs, or fill out some papers.

Is this right? Is it justifiable? To be held hostage like this?

Well… it depends on the exact circumstance. Let’s take a step back, and have a look:

Suppose you haven’t seen your doctor in five years. A lot can happen in that time. When you finally do go in, they’re basically starting from scratch. Anything over a year old is probably worth rechecking (labs, imaging, and so forth). So, in that case, yeah, you need that appointment. A lot of what we do is very individual-dependent and the one constant about life, is change. So cut your doc a break and get in there, even though it means taking time off work, getting a babysitter, scrounging in the couch cushions for the copay, and calling an Uber.

What about if there’s something new in your life? You’ve developed a health problem you’ve not experienced before? I’ve told folks many times that nothing beats eyes on the target (this is why I regarded telehealth during the pandemic as a necessary evil). Again, set yourself and your provider up for success and get in there so they can see firsthand what’s up. They’re not just reading your vitals and looking over your labs. They’re watching how you sit, walk, talk, and breathe. They’re examining your skin and how you answer questions. There’s a lot that goes on from the second they walk in the room that’s relevant that you just can’t get on a video call. (And I’ve been known to ask my front desk staff how the patient looked in the waiting room!) They may even see something unexpected while they’re looking other things over that can really add insight to the situation. I’ve had that happen many times.

But what if it’s a stable problem? Just a refill on your Zoloft? Again, it depends. A lot of meds, especially those used in mental health, can really trash your immune system and the right thing to do  is monitor labs or vital signs, sometimes quite frequently. To not do so would put you at risk for some serious complications that are worse than what you’re dealing with now. Other very common meds are hard on your kidneys, or your liver. For the same reasons, these systems need to be monitored regularly.

On the other hand, I’ve seen doctors take this attitude to extremes. When I was a resident doing my obstetrics rotations it seemed very common for OB-GYN’s to refuse to refill birth control prescriptions unless the patient came in for her annual pap. This made no sense to me. Sure, we want to do screenings to prevent disease, but if the consequence of withholding meds is a possible pregnancy with all the risks that entails, is it worth it? As it was, a few years later new pap recommendations were published that greatly reduced the number of screenings and made a lot of those (let’s call them what they were) bullyings unnecessary. (However, Depo shots are different and fall into that high-risk med category. Getting a shot while unknowingly pregnant can lead to some serious consequences).

Likewise for depression meds. Was it right to threaten stopping treatment for the sake of a checkup? Even fairly benign drugs like the SSRIs (Zoloft, Paxil, and so forth) can be nasty if high doses are stopped suddenly. And often folks are put on these meds due to suicidal thoughts. Again, is the risk of the untreated condition worth extorting a visit out of the patient?

And then one gets into the moral issue of denying care altogether. A trend I saw all too often among pediatricians especially was to refuse care to children whose parents declined vaccinations. There’s been plenty of talk in our society about (and by) anti-vaxxers, but I’ve done a lot of work in the Amish community and they have historically avoided immunizations, more so on religious grounds (or more faith in their own healing) rather than what some celebrity said on social media. Do they not deserve to get their strep throats treated just because they didn’t get their MMR? It made me feel those docs were more worried about their malpractice premiums or their corporate overlords than actually caring for sick folks. I had my shots, and so did my kids. I wasn’t worried that I was going to bring something home. And I always tried to keep the appointments moving so no one was hanging out in the waiting room for too long. I understand the epidemiological risks, the concept of herd immunity, and all of it, but at the end of the day we as doctors are treating an individual sitting in front of us, a living person with hopes, dreams, fears, and responsibilities. We are in a position to help them and, according to society, are obligated by that position to do so. And a core principle of medical care is still that the patient has autonomy. They can choose for themselves. It’s the whole reason we have this thing called ‘informed consent’. Is it truly morally right to tell a suffering human being that you could help, but you flat-out won’t, because of some administrative rule? Or worse, because your personal opinions are at odds with their health choices?

Another aspect of this hostage-taking is when political goals get in the way of health care. Here in Ohio there’s an imminent collision right now between the dexter-side of the political spectrum and the transgender community over whether or not transition-specific care is even going to be allowed. The political side of the issue wants to make such things unavailable unless the patient is being managed by an endocrinologist, a psychiatrist, and a medical ethicist. Now it may not be a bad idea to suggest these experts be consulted, but I get wary of requiring anything as a blanket condition. If we’re going to just legislate how everything is to be done, why have licenses and medical boards at all? After all, any fool can follow a script.

I consider my role with my patients as a consultant, or a facilitator. They have the problem, I have the insight to suggest a solution. I know what will help them, and how it will coexist with everything else they have going on. But it’s their body, and their life. They get to choose. They’re the ones that will be living with the consequences of whatever we as a team decide to do – good or bad. It’s my responsibility to explain everything to them in a way they can understand. I’m the one who needs to show why my solution is the best – or conversely, listen to the patient’s opinion because they may have another (maybe even better!) idea (it’s another core principle that we learn from our patients). Because I can tell you, if your patient doesn’t want to follow your advice, they probably won’t so you’d better work something out with them, and make them a partner in the decision making.

People are people, and we are all different. And as long as we’re being honest with our doctors, no policy maker in a marbled hall, think tank, or national association will know better than they, what we need.

And as physicians, if we’re not treating our patients as individuals we aren’t really doctors at all. We’re only puppets in lab coats.