Last Schmuck Standing

Much has been written about the doctor-patient relationship. How to start one (call for an appointment); how to end one (ask to have your records transferred if you're a patient; send a registered letter if you're a doctor). If you're a specialist enlisted to treat a specific problem -- an orthopedist consulted for a fracture, for example -- you can discharge the patient from your care once the problem is resolved. I can never do that. The last line of every progress note reads, "Re-check" sometime; two weeks; six months; or the all-purpose "as needed."

I try never to discharge (also termed "fire") patients. Before I'll send someone that certified letter, return-receipt-requested, telling them that I'm only available to them for thirty days more (and then only for emergencies) they have to really piss me off. Usually lying to me about their narcotics (repeatedly; I'm awfully forgiving of lost prescriptions, pills down the sink and so on) is enough to do it. See, my view of these patients isn't that they're just out for the drugs. I know a lot of them have real pain, and I feel responsible for treating it. In fact, most of the time I don't actually discharge the patient from the practice altogether; I just refuse to write narcotics for them. Granted they usually then switch physicians voluntarily; still, I remain available to them if they decide what they really want is medical care.

But what happens when the patient has already been discharged by every other practice in town? Not just in town, but in the entire region. What if they've even been discharged from Pain Management, for heaven's sake, for a positive urine test for illicit drugs? She comes back to me, begging and pleading for the pain meds without which she cannot function, care for her home or her kids. Although I've already been around the block with this woman in the past, I agree to resume her care with the explicit understanding that my goal is to find modalities other than chronic narcotics to manage her back and leg pain.

For awhile, everything is fine. She keeps appointments. She claims to be following the tapering dosage schedule for her medications. Then she starts missing appointments. (They only have one car and she can't get a ride.) She calls for early refills. (The pain was so bad this weekend she just had to take a couple extra.) Finally, she shows up for an appointment with obviously slurred speech. Has she been drinking? Just one beer, although her blood alcohol level is more consistent with four, given her body weight. She has driven to my office while legally intoxicated to receive a prescription for over one hundred narcotic tablets that will only last her two weeks.

Find another doctor, I say.

But doctor, she sobs, where can I go? No one else will take me. You're the only one left.

Finally I manage to come to the obvious conclusion: That this is not my problem. Your situation is entirely of your own making. It is not my fault. You are responsible for the results of your own actions.

Yet it takes weeks longer than it should have. It's tough to be the last schmuck in town.