You're Fired

Some say a physician has the right to choose whomever he or she wishes to treat, but to me that sounds like a smokescreen for the right to be racist, sexist, elitist, or bigoted. I prefer to treat everyone who comes to me (insurance or other financial arrangements permitting). However, just as I have a duty to treat my patients, they have duties in return. Unfortunately, just what those duties are is not always clear in practice.

Danny Michaels showed up in my office a few years ago, transferring his care from another physician after going on welfare. He shuffled into the exam room with a distinct limp and explained to me that he had ruptured a ligament in his knee many years before. At the time, doctors had advised him against having it repaired. However, this made the joint unstable, and he now complained that it hurt constantly. A quick exam confirmed the knee's instability.

I started to discuss my approach to the management of chronic pain, but Danny cut me off. "Doctor," he said with more than a touch of drama, "I've tried all those things and nothing works. I need to get my oxycodone back!"

Oxycodone is a narcotic that creates euphoria in some people and consequently has a high abuse potential. I explained to Danny that our clinic policy is not to start any narcotics without documentation of both the condition being managed and prior prescribing of that medication.

"No problem," he told me. "I'll get you everything you need by next week." He limped out of the exam room and made another appointment.

A week later he was back with copies of both his prior physician's notes and imaging studies of his knee. Everything appeared in order, so I prescribed a small supply of oxycodone and counseled him about using over-the-counter medications when his pain was less severe. He was all smiles, thanked me profusely, and told my staff on his way out the door what an understanding and caring physician I was.

Two weeks later, Danny was back, complaining of knee pain and wanting a refill of his prescription.

"You used up the entire prescription already?" I asked.

"You didn't give me very many," he said. "I live on a hill and my knee just throbs when I have to walk up and down the street to get to the bus station."

"So how many are you using a day?"

"Three," he said, almost pouting. "Sometimes I have to use four."

I let out a low whistle. "That's a lot." At this rate, he'd go through ninety to one hundred twenty tablets a month.

Danny shrugged. "All I know is what works for me."

I pondered this for a moment. The abuse potential was real, but I prefer to give patients the benefit of the doubt. "Okay," I said. "I'll give you ninety tablets a month. If your rate of use remains stable, we can simply meet monthly for refills."

"Thank you, doctor," he gushed. "You are the best, kindest, smartest doctor I've ever had." I cringed.

We settled into a comfortable routine. Every month Danny came to the office and got a refill of his ninety oxycodone tablets. We occasionally chatted about other minor medical issues. Once he asked for some paperwork to help him obtain subsidies for public transportation. I was happy to oblige.

Then, one day, he arrived four hours late. We squeezed him into the last remaining appointment slot of the day, and I asked what had caused the delay. He told me there was a problem with the ferry boat.

"You take a ferry boat?" I asked, completely taken aback. "Where exactly do you live?"

"Why, Doctor, I live in Bremerton," he replied. "I have to take a bus to the ferry, take the ferry into Seattle, and then take two more buses to get here. It's hard to get to your office."

I didn't know what to make of that. It was an oddly long journey for a man with a bad knee, especially since he had to...