Your doctor may be on a system where they are responsible for doing work for you (e.g. refilling your prescriptions, doing whatever insurance paperwork it takes to make your prescriptions go through, keeping track of when you need to get certain tests, etc) without receiving any compensation except when you come in for office visits. One patient like this isn’t so bad. Half your caseload like this means potentially hours of unpaid labor every day. Even if an individual doctor is willing to do this, high-level decision-makers like clinics and hospitals will realize this is a bad deal, make policies to avoid it, and pressure individual doctors to conform to the policies.
Also, your doctor remains very legally liable for anything bad that happens to you while you’re technically under their care, even if you never see them. If you’re very confused and injecting your insulin into your toenails every day, and then you get hyperglycemic, and your doctor never catches this because you never come into the office, you could sue them. So first of all, that means they’re carrying a legal risk for a patient they’re not getting any money from. And second of all, at the trial, your lawyer will ask “How often did you see so-and-so?” and the doctor will say “I haven’t seen them in years, I just kept refilling their prescription without asking any questions because they sent me an email saying I should”. And then they will lose, because being seen every three months is standard of care. Again, even if an individual doctor is overly altruistic and willing to accept this risk, high-level savvier entities like clinics and hospitals will institute and enforce policies against it. The clinic I work at automatically closes your chart and sends you a letter saying you are no longer our patient if you haven’t seen us in X months (I can’t remember what X is off the top of my head). This sounds harsh, but if we didn’t do it, then if you ever got sick after having seen us even once, it would legally be our fault. Every lawyer in the world agrees you should do this, it’s not some particular doctor being a jerk.
Also, a lot of people really do need scheduled appointments. You would be shocked how many people get much worse, are on death’s door, and I only see them when their scheduled three-monthly appointment rolls around, and I ask them “Why didn’t you come in earlier?!” and they just say something like they didn’t want to bother me, or didn’t realize it was so bad, or some other excuse I can’t possibly fathom (to be fair, many of these people are depressed or psychotic). This real medical necessity meshes with (more cynically provides a fig leaf for, but it’s not a fake fig leaf) the financial and legal necessity.
I’m not trying to justify what your doctor did to you. If it were me, I would have refilled your insulin, then sent you a message saying in the future I needed to see you every three months. But I’ve seen patients try to get out of this. They’ll wait until the last possible moment, then send an email saying “I am out of my life-saving medication, you must refill now!” If I send a message saying we should have an appointment on the books before I fill it, they’ll pretend they didn’t see that and just resend “I need my life-saving medication now!” If my receptionist tries to call, they’ll hang up. At some point I start feeling like I’m being held hostage. I really only have one patient who is definitely doing this, but it’s enough that I can understand why some doctors don’t want to have to have this fight and institute a stricter “no refill until appointment is on the books” policy.
I do think there are problems with the system, but they’re more like:
- A legal system that keeps all doctors perpetually afraid of malpractice if they’re not doing this (but what is the alternative?)
- An insurance system that doesn’t let doctors get money except through appointments. If the doctor just charged you a flat fee per year for being their patient, that would remove the financial aspect of the problem. Some concierge doctors do this, but insurances don’t work that way (but insurances are pretty savvy, are they afraid doctors would cheat?)
- The whole idea that you can’t access life-saving medication until an official gives you permission (but what would be the effects of making potentially dangerous medications freely available?)
But I’ve seen patients try to get out of this. They’ll wait until the last possible moment, then send an email saying “I am out of my life-saving medication, you must refill now!” If I send a message saying we should have an appointment on the books before I fill it, they’ll pretend they didn’t see that and just resend “I need my life-saving medication now!”
Insulin is different from the sorts of drugs you prescribe. Most medications, if someone run out, they start suffering health consequences, it’s very unpleasant and it incurs a bit of lasting harm, but they don’t die. Being without access to insulin is about as serious as being without access to water. If you send a message saying there should be an appointment on the books before renewing the prescription, then there’s a real risk that the delay causes them an emergency room visit, or kills them.
I really only have one patient who is definitely doing this, but it’s enough that I can understand why some doctors don’t want to have to have this fight and institute a stricter “no refill until appointment is on the books” policy.
Thanks for chiming in. I was hoping to hear from a practicing doctor.
That all does make sense. A doctor requiring appointments for refills seems understandable now. The system that forces them to do so doesn’t, but that’s a separate issue.
Very late reply: This was a dermatologist who insisted that I had to have a separate appointment for EACH tiny mole to be removed, instead of removing several in one appointment.
I got a new dermatologist after that.
Some people are just thieves. I agree that it’s rare.
(but what would be the effects of making potentially dangerous medications freely available?)
Well, you can already walk into any hardware store and buy all sorts of deadly poisons, no questions asked. So my guess would be not much, except they’d be a lot cheaper.
The conceptual gap between a standard use of a poison from a hardware store and a deadly use is much larger than the gap between a standard use and a deadly use of a medication, so I would expect far more tragedies to come from the medication than from the hardware store poison.
Nobody’s going to self-diagnose and inject themselves with poison from a hardware store.
I don’t think it’s necessarily greed.
Your doctor may be on a system where they are responsible for doing work for you (e.g. refilling your prescriptions, doing whatever insurance paperwork it takes to make your prescriptions go through, keeping track of when you need to get certain tests, etc) without receiving any compensation except when you come in for office visits. One patient like this isn’t so bad. Half your caseload like this means potentially hours of unpaid labor every day. Even if an individual doctor is willing to do this, high-level decision-makers like clinics and hospitals will realize this is a bad deal, make policies to avoid it, and pressure individual doctors to conform to the policies.
Also, your doctor remains very legally liable for anything bad that happens to you while you’re technically under their care, even if you never see them. If you’re very confused and injecting your insulin into your toenails every day, and then you get hyperglycemic, and your doctor never catches this because you never come into the office, you could sue them. So first of all, that means they’re carrying a legal risk for a patient they’re not getting any money from. And second of all, at the trial, your lawyer will ask “How often did you see so-and-so?” and the doctor will say “I haven’t seen them in years, I just kept refilling their prescription without asking any questions because they sent me an email saying I should”. And then they will lose, because being seen every three months is standard of care. Again, even if an individual doctor is overly altruistic and willing to accept this risk, high-level savvier entities like clinics and hospitals will institute and enforce policies against it. The clinic I work at automatically closes your chart and sends you a letter saying you are no longer our patient if you haven’t seen us in X months (I can’t remember what X is off the top of my head). This sounds harsh, but if we didn’t do it, then if you ever got sick after having seen us even once, it would legally be our fault. Every lawyer in the world agrees you should do this, it’s not some particular doctor being a jerk.
Also, a lot of people really do need scheduled appointments. You would be shocked how many people get much worse, are on death’s door, and I only see them when their scheduled three-monthly appointment rolls around, and I ask them “Why didn’t you come in earlier?!” and they just say something like they didn’t want to bother me, or didn’t realize it was so bad, or some other excuse I can’t possibly fathom (to be fair, many of these people are depressed or psychotic). This real medical necessity meshes with (more cynically provides a fig leaf for, but it’s not a fake fig leaf) the financial and legal necessity.
I’m not trying to justify what your doctor did to you. If it were me, I would have refilled your insulin, then sent you a message saying in the future I needed to see you every three months. But I’ve seen patients try to get out of this. They’ll wait until the last possible moment, then send an email saying “I am out of my life-saving medication, you must refill now!” If I send a message saying we should have an appointment on the books before I fill it, they’ll pretend they didn’t see that and just resend “I need my life-saving medication now!” If my receptionist tries to call, they’ll hang up. At some point I start feeling like I’m being held hostage. I really only have one patient who is definitely doing this, but it’s enough that I can understand why some doctors don’t want to have to have this fight and institute a stricter “no refill until appointment is on the books” policy.
I do think there are problems with the system, but they’re more like:
- A legal system that keeps all doctors perpetually afraid of malpractice if they’re not doing this (but what is the alternative?)
- An insurance system that doesn’t let doctors get money except through appointments. If the doctor just charged you a flat fee per year for being their patient, that would remove the financial aspect of the problem. Some concierge doctors do this, but insurances don’t work that way (but insurances are pretty savvy, are they afraid doctors would cheat?)
- The whole idea that you can’t access life-saving medication until an official gives you permission (but what would be the effects of making potentially dangerous medications freely available?)
It’s already OTC in Canada, and nothing bad has happened as a result.
Insulin is different from the sorts of drugs you prescribe. Most medications, if someone run out, they start suffering health consequences, it’s very unpleasant and it incurs a bit of lasting harm, but they don’t die. Being without access to insulin is about as serious as being without access to water. If you send a message saying there should be an appointment on the books before renewing the prescription, then there’s a real risk that the delay causes them an emergency room visit, or kills them.
But Zvi’s friend had an appointment on the books? It was just that it was a couple weeks away.
Otherwise, thanks very much for commenting on this, good to get a doctor’s perspective.
Why not just dump that one patient?
Thanks for chiming in. I was hoping to hear from a practicing doctor.
That all does make sense. A doctor requiring appointments for refills seems understandable now. The system that forces them to do so doesn’t, but that’s a separate issue.
Very late reply: This was a dermatologist who insisted that I had to have a separate appointment for EACH tiny mole to be removed, instead of removing several in one appointment.
I got a new dermatologist after that.
Some people are just thieves. I agree that it’s rare.
Well, you can already walk into any hardware store and buy all sorts of deadly poisons, no questions asked. So my guess would be not much, except they’d be a lot cheaper.
The conceptual gap between a standard use of a poison from a hardware store and a deadly use is much larger than the gap between a standard use and a deadly use of a medication, so I would expect far more tragedies to come from the medication than from the hardware store poison.
Nobody’s going to self-diagnose and inject themselves with poison from a hardware store.