Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, May 23, 2008

Ethics and the Lazy: the FP Version

The Angry Pharmacist has another awesome post, this time about pharmacists absorbing the cost of medications for lazy medicaid patients, because the kids need the medicine; it's the right thing to do. I applaud his altruism. Granted he's only talking about $18. I wonder what he would have done in my position:

A teen mom who had moved away from home called me because she was worried about blood coming from her baby's ear. I told her there was nothing I could do over the phone; she said she didn't have a ride; I said to call me back if she found one.

She didn't call; she just walked in -- an hour after closing time. The staff had left; I saw her anyway. She said she had noticed the bleeding the day before and that it had stopped by now. There was a tiny bit of dried blood from a scratch in the ear canal; the tympanic membrane was intact. The baby was fine.

Here's the thing, though: the kid was five months old and the only immunizations she'd received were the first two hepatitis B shots; the first in the hospital and the second from me at one month of age. And I still hadn't been paid for that visit or for the shot. She didn't have insurance and didn't seem to realize there was such a thing as Medicaid, or even that her baby needed shots despite the fact that I had told her multiple times during the pregnancy and during the month she'd brought the baby to me (while living with her mother.) Her own mother had washed her hands of them; apparently the baby's father was in jail for murder; I'm pretty sure there were some issues of diminished intellect, possibly borderline MR. Whatever; I was faced with a hypoimmunized infant, a fridge that held the four shots she needed, and the near certainty that I'd never see a dime if I administered them.

It would have cost me $200. The right thing to do was to give the shots.

God help me: I didn't do it.

I told her about the Well Baby Clinic at the Health Department; I gave her their phone number and tried to explain how important it was. I have no idea if she followed through or not.

So what do you think?


At Fri May 23, 06:59:00 AM, Blogger Dr Russell Brown said...

Giving the shots was a possible right thing to do.

Telling her about the Well Baby Clinic was another.

You're running a business.

Take it from me, a GP (Family doctor to you colonials) in the NHS in the UK: free at the point of use equates with patients failing to value the service we provide.

Ok, that's a gross generalisation, but pro bono work can foster a sense of entitlement from some people, which is usually unwarranted and unhelpful.

Its her responsibility to get her kid stabbed, not yours. The fact that you feel responsible is what helps make you the kind of person you are (the Doctor's Disease I call it).

Even if she's got some kind of intellectual impairment, I imagine there is some kind of child welfare system in place in the States. Surely it would be that department's remit to follow up problems like this?

At Fri May 23, 09:16:00 AM, Blogger jen said...

Even if she's got some kind of intellectual impairment, I imagine there is some kind of child welfare system in place in the States. Surely it would be that department's remit to follow up problems like this?
There are *tons* of child welfare agencies, because each state has a separate system, and in many states they leave it up to the counties to actually do the work.
That said, it's a given that they're all overworked and understaffed. If there's an allegation that she actually injured the baby, the baby might be taken away from her. Under some circumstances, they'll work out a plan for her to keep the baby as long as she follows certain directions. But I don't think I've ever heard of children's protective services interfering due to a lack of immunizations (or a lack of health care that hasn't led to the kid getting hospitalized).

I have to agree that referring her to the Well Baby Clinic was "a" right thing to do. Giving her $200 of free shots does nothing to make it more likely she'll get the baby the future care she needs. If anything, it would encourage her to believe it's supposed to work that way - when something goes wrong enough for it to be worth it to her to drag the kid to the doc's office, the doc drops everything and gives the baby whatever the baby needs . . . .

At Fri May 23, 09:28:00 AM, Blogger rlbates said...

Since the shots are available for free to her at the Well Baby Clinic, I see no reason sending her isn't the "right thing to do".

At Fri May 23, 10:19:00 AM, Blogger MedStudentGod (MSG) said...

I echo RLBates sentiments. You're running a business, there are places that will assist her in care for her child, and you have tried to get her to enroll, be aware, etc. already. Giving free shots would only lead to a sense of entitlement from this mother (unfortunate circumstances aside - we make our own beds and should lay in them) for whom a woeful degree of helplessness is already being manifest.

You did OK by me.

At Fri May 23, 11:18:00 AM, Anonymous Anonymous said...

Telling her about the Well Baby Clinic is teaching her to fish. Eating the cost yourself is giving her a fish sandwich with extra tartar sauce.

I also think if she can walk to your office, she can walk to the clinic. Hard to say what will happen, but she needs a chance to step up and be the mom. I'm glad you were there for her after closing time. It's good that she can trust you, too.

Kids roll down the gumball chute and their whole destiny depends on who catches them. It's too much to think about sometimes.

At Fri May 23, 12:32:00 PM, Blogger The Happy Hospitalist said...

the county health department is there for a reason. You are not the county health department. You did nothing wrong.

If the kid was hungry, do you think the grocery store would let her walk out with $200 in free groceries? No, she goes to the pantry for free food.

If you give away all your service, you will have no business left to treat thousands of others.

You did the right thing.

At Fri May 23, 01:25:00 PM, Blogger Midwife with a Knife said...

I have to agree. You did the right thing. You could have given her the shots then and there, but if you did that for every hypoimmunized kiddo, you would eventually go out of business, and then there'd be nobody to look in the kid's ear an hour after closing time.

Sending her to the well baby clinic was the right thing to do. You need to stay in business so you can be available to others!

At Fri May 23, 02:09:00 PM, Anonymous Anonymous said...

Would this have been an appropriate situation to make a report to child welfare? I'm a retired social worker and as you said different states have different guidelines. Also, those guidelines change. If you'd reported the situation to child welfare, possibly a social worker would have visited the mother at home to assess her ability to properly care for the baby. Depending on a number of things the agency might offer the mother regular monitering and assistance in getting the needed immunizations (and applying for medicaid and how to use it). Hard to tell from seeing her in your office whether there are other potential risks to the baby in the home. It's a bit much to ask doctors to be social workers, too. I think basically you did the right thing.

At Fri May 23, 05:59:00 PM, Anonymous Anonymous said...

You did the right thing. I think it would've been bad for you to say "Nope, sorry, good luck" and not give her an option. But you did. If she cares enough about her baby she will get her the shots at a free clinic.

At Fri May 23, 07:06:00 PM, Anonymous Anonymous said...

I agree--you did the right thing. Say you give him the shots this time. Who says she give him the shots he needs in the future? He needs all of them regardless, so if you told her how to get them for free, maybe she'll be more likely to go there to get them next time.

It's not like we all get our medical school for free, free office rent, volunteer office staff, free medications and immunizations to administer... It was really nice of you to see the kid and make sure he was OK, but, if you go out of business, that helps no one.

Please let go of any guilt you have over that one!

At Fri May 23, 08:54:00 PM, Blogger Unknown said...

If the baby needed a shot of an antibiotic or med for pain would you have responded differently? I don't know you; have only started reading this blog very recently, but I get the feeling that that in different circumstances you may have made a different choice. This wasn't urgent or an immediate risk to the baby. There's some time to get the little guy his next shot. Perhaps if you still feel uneasy about this on Monday/or Tuesday your staff could call her to followup?? It sounds as though she needs some social service assistance and this is a hint of that.

At Fri May 23, 08:58:00 PM, Anonymous Anonymous said...

I see a bunch of medical personnel rationalising this decision, but in all honesty, I think the right thing would have been to give the child the shots, given that you knew the baby wouldn't get them the other way. From the tone of your post, it seems you feel that way too. But I'm sure there aren't very many people who would have made that decision.

At Fri May 23, 09:12:00 PM, Blogger The Happy Hospitalist said...

maddy, When I send a patient out of the hospital, I leave my recommendations for treatment and follow up. What they choose to do with that is up to them. I'm not their social worker, financial aid officer, priest, or personal grocery shopper. How do you suppose he should get paid for his vaccines?

At Fri May 23, 09:48:00 PM, Anonymous Anonymous said...

I agree wholeheartedly with everyone her that Dinosaur did the right thing. But, what I think this example underscores is that really the right thing is that we need some form of universal health care in this country. And proper social institutions in place to ensure that everyone actually gets covered.

At Fri May 23, 11:34:00 PM, Anonymous Anonymous said...

Don't let people who you barely know into your office after hours. She could claim sexual harassment and you wouldn't have a leg to stand on. Her baby daddy (I know this one is in jail but there might be other hangers on) might be of the mistaken believe that you have wads of cash or drugs with a street value lying around your office and kill you for them, using her and the kid as the key to get in the door. Your wife may not like it. For these and other good reasons you should not ever let patient slink in after hours.
Just my opinion.

At Sat May 24, 07:45:00 PM, Blogger Lynn Price said...

God help me: I didn't do it.
Good on you, Dino. There really is no free lunch because someone always has to pay. It's true that you're a doc, but you're also a businesswoman. What good does it do to give away free meds if you eventually go out of business?

At Sat May 24, 09:25:00 PM, Anonymous Anonymous said...

You did the right thing, for cryin' out loud. There is a reason there's a Health Department and this woman is it. And anoymous is right--DON'T let people you don't know well into the office after hours when you're by yourself. It's just to dangerous, for all the reasons listed before.

At Sat May 24, 09:42:00 PM, Blogger #1 Dinosaur said...

Just for the record, I've known this mom since she was eight years old. I diagnosed her pregnancy last year when she came in for a "UTI." She recently moved out of her mother's house into a place of her own a few towns over. She is no stranger; I know her all too depressingly well.

At Sun May 25, 12:44:00 AM, Anonymous Anonymous said...

Maddy, There is a program in the USA called Vaccines for Children. The federal government (taxpayers) purchases vaccines and GIVES it to clinics who serve low income populations. At my clinic we give these vaccines to children absolutely FREE. They don't even have to provide proof of income. There are thousands of clinics that do this all over the US. Private doctors like dino have to purchase vaccines for anywhere from $20 to $90 per dose. So why should she use her stock of vaccine when we taxpayers have already bought this child's vaccine? The problem is the irresponsible mother, and no amount of free care can fix that. I see it all the time. I understand your concern. Please look for a clinic in your area to volunteer your time, every free clinic can use volunteers.

At Sun May 25, 01:38:00 PM, Anonymous Anonymous said...

You know that she didn't go, I would have given the shots. Yes I am in solo practice.

At Mon May 26, 11:34:00 AM, Anonymous Anonymous said...

Debbie K NP hit the nail & Dr Dino just doesn't know how to find/bill for it. The Vaccines for Children program is well known among most of us who treat children. My pharmacy shares a parking lot with Planned Parenthood & when they run out of one or MMR, polio or any other (I can't immunize less than 11yo, but can above age 11 as a pharmacist) - they call & I give them vaccine since I have it for the over 11 crowd that gets their immunizations from me. They give it back when they get their supply. They get it absolutely free.

Additionally - you have ZERO liability for vaccinations for anyone - adult or child because all liability is absorbed by VAERS. So - you could have started the series - that would have been better than nothing for this child & you would have been out what??? - a nice dinner with friends? If you had known how to bill it, you wouldn't have even been out that much money.

Altho my spouse is in dentistry & not medicine, he long ago gave up Medicaid as too cumbersome, low payment, time consuming. But, he, like me, will give free treatment to any child under any circumstances. I've given away thousands of dollars of medication & he's done the same with his services for the poor - its much more fulfilling to do that than to give a professional discount to a medical colleague who I know can afford whatever the price is, yet asks for a discount anyway.

I disagree Dr Dino - your patient was that baby who could not speak & you let your feelings about your experiences with mom make your decision.

At Tue May 27, 02:30:00 PM, Blogger Doc said...

I think it depends on why you made the decision. For example, if your intent was to connect the patient with a viable resource for treatment (and follow-up!), then okay. If you were just ticked off at the mom, then not okay. The latter is not likely given that you agreed to see the kid, after hours, nonetheless. Availability and location of the local free clinic may also be a guiding factor.
On the whole, your choice sounds perfectly appropriate.
BTW, lock your doors after hours, some may enter looking for more than just treatment!

At Tue May 27, 05:21:00 PM, Blogger E said...

so hard, because as a physician i can argue for both sides (not giving the shots, giving the shots) as well as see the other side.

i think you did nothing wrong in this situation. you presumably had already given the patient visit for free to see the child in the first place. you were under no obligation to "throw in" the vaccine for free.

add to that, attempting to connect her with the proper resource for the vaccines that the child will need both now and in the future was in many ways more responsible than "taking care" of the problem (no vaccines) which is not emergent/immediate.

At Tue May 27, 11:59:00 PM, Anonymous Anonymous said...

I would do the same... because this is young babay, and needs more shots and chekups and care. You showed her how take an initiative. She coming late for visit with a potential ear infection, not getting vaccination,... she has to learn to take some steps! Hopefully.
You might send a social worker to check up on them also.

At Wed May 28, 11:43:00 AM, Anonymous Anonymous said...

To answer your question, if the drug in question in my case was say a hefty run of Cleocin suspension (trade name only) or something else that cost $200, I wouldn't of given them out without some sort of money guarantee.

I may play a dick online, however I really am not one in real life (surprise) but good deeds don't pay my electric bill nor put food on the table. I have my shit together, so is it too much for other people to somehow get some of theirs?

Home health nurses got on my shit last week because I wouldn't advance the patient $5k dollars worth of Vancocin caps for her C.Diff (third one in a row, fucking non-compliant patient) while the doctor was getting the prior auth. She bawked when I asked her for HER credit card number in case the PA got denied. It was MY job to eat this, not hers.

Its a fine line we walk from being a hero who gets stepped on and is forced to eat ramen vs being a total dick who wont give everyone everything for free just because the nanny-government does.

You did the right thing.

At Tue Jun 03, 01:46:00 AM, Blogger Manda said...

My boss is frequently giving away the proverbial free lunch at our preschool. Now they are all trying to take advantage and feel entitled to do so. There are social services in place for a reason.

At Tue Jun 03, 08:26:00 AM, Anonymous Anonymous said...

If we had single-payer comprehensive healthcare for everyone, docs like Dino wouldn't be put in this position. The shots would be in the fridge, AND already paid for.

OK the shots are paid for now anyway, but now the mother has to run around and find Well Baby Clinic, fill out a gazillion forms, jump through some more hoops. No wonder a lot of people (Moms, and otherwise) don't get care until it is the last resort.

I am sick and tired of this crazy quilt medical system we have now. Simple,SINGLE-PAYER, comprehensive care for ALL. NOW.

I'll GLADLY pay higher taxes if it takes away the co-pays, deductibles, run-arounds to Well Baby Clinic, and paperwork.

At Mon Jun 09, 06:07:00 PM, Anonymous Anonymous said...

If you think that single payor will result in your finding Dino in his office an hour after his office closed, dream on.

You will more likely find unresponsive, uncaring, unavilable, and technologically deficient care typical of the VA.

At Wed Jun 18, 11:21:00 PM, Anonymous Anonymous said...

I don't understand. Why would anybody wish to pay that kind of money for something they can get for free? Why would anyone go to a private doctor like you for vaccinations otherwise provided gratis, unless they were, say, neurotic about the MMR and wanted to pay to have separate vaccinations instead (like some over-anxious media-manipulated parents with more money than sense do here in the UK)?

Obviously, I don't know the situation in the US, and I'm guessing to many patients it's pretty much "free" from you because it's on their insurance or something, but it seems weird.

No criticism of you intended, obviously(you run a business, right?), just very curious.


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