Your Doctor as Social Worker? Or "beam me up Scotty, there’s no intelligent life here".

Most people assume that with the “MD” after your name it garners some form of respect, just because of the degree and expertise, the job you have to do. Maybe it did “in the day”, but certainly no longer. Physicians are looked on with contempt; looked at as an easy target for a frivolous lawsuit; spends as much time pushing paper and doing social work as caring for patients. The social work aspect of practice is increasing at an alarming rate and is directly proportional to the change in the demographics of our hospital patient population. In other words, the poorer the patient, the more services have to be arranged for them after discharge.

Don’t get me wrong. I don’t mind helping people who need help, but the people who utilize these other services the most are the ones who “abuse” the services always. Take for example a member of the working poor who simply doesn’t have health insurance. This type of patient worries about how long they will be in the hospital because of the hospital bill. They are anxious to get better so they can be discharged sooner. They are also the ones that ask “how much” their prescriptions cost and will ask if cheaper alternatives are available.

On the other hand we have the hard core professional patients. These are the ones with repeated admissions for the same problem. They hop from ED to ED and frequently get multiple prescriptions from several different doctors for, guess what, narcotics. They have developed their own specialized complaint that is difficult to disprove by exam or by laboratory study. If the ED doc believes the story or has never seen them before, they get admitted.

The admission isn’t the bad part. It’s the discharge. From the date they are admitted until discharge, and sometimes long afterward, they are consuming vast amounts of resources.

Here are some of my favorites;

A young woman admitted with stomach pain and maybe diarrhea, who likely has a mild case of stomach flu. Most of us would take care of it at home with fluids, acetaminophen and rest. She, of course needs large amounts of narcotics to control a pain we can’t locate with any exam or test. No diarrhea during her stay in the hospital, either. Appetite seemed OK and she was out of her room smoking whenever someone was looking for her. After several days, she was discharged but refused to leave saying she had no where to go. We were amazed. She had a place when she was admitted.

The answer, of course, was simple but new to me. She and her mother lived together. During her hospital stay, the patient’s boyfriend and mother decided to “hook up”. Since mom thought it would create a problem with all of them living together, she decided to kick her daughter out, leaving her homeless. Needless to say, our social worker had to put her thinking cap on. Eventually the patient was given a cab voucher, a voucher for prescriptions and, with the assistance of the social worker, located a family member willing to take her in.

My best stories are the alcoholics. They party 24/7 with reckless abandon. That is until they truly get sick or run out of money. One such person came to us after having a case of the stomach flu of the month. His routine was to drink 12-18 beers per day, a few Long Island Iced Teas, a bottle of wine and whatever else he could get his hands on. During sporting events, he would have 7-8 beers at the game PLUS his usual at home. Where the hell do these guys get the money?

His family brought him in because he wasn’t acting right. After talking to the family, I knew right away the guy was going through withdrawal. To be perfectly honest, I wish they had brought him in sooner. It would have been easier and safer to give him a drink and send him home than to let him detox and go through DT’s. But that wasn’t to be. He did go through withdrawal and he did go through DT’s; for three weeks. He laid in our ICU, nearly unconscious, for three weeks. All because of alcohol. We are not a detox or treatment facility.

When he woke up, we sent him home because he refused outpatient treatment and didn’t even want any information for any treatment programs. He’ll be back.

Another of our alcoholic friends comes in often. Sometimes for falling down, sometimes for pain and sometimes just because he’ s drunk and has no where else to go. One such night he came in sooooo inebriated, that after several hours of “sleep” he was still too dunk to go home. So, the ED admitted him. When he finally woke up, I discharged him. But before he would leave, he wanted another meal, another shower, a new change of clothes and new shoes. The hospital gave it to him and then we gave him a a cab voucher to get home. Should’ve given him the cab voucher in the first place.

One of our most infamous frequent fliers is a diabetic aged 20 years. She’s had her diabetes long enough to know how to take care of the basics. That means that she should be able to keep herself out of the hospital. She splits her time between us and another hospital across town. She’ll spend a few days with us, stay out 1-2 days then spend a few days with them. The cycle repeats. She comes in with Diabetic Ketoacidosis, the most severe and critical illness a Type I diabetic can have next to acute hypoglycemia (low blood sugar). It is always serious and often life threatening. She knows full well that she isn’t taking her insulin like she’s supposed to. Soon she’s going to push it too far and die. She doesn’t seem to care.

She always does well while she’s with us meaning she’s not the “brittle” diabetic people hear of. We always go over her insulin regimen, what to do when her sugars are high and refill all of her medicines when she’s discharged. She also gets vouchers to get her meds refilled at the pharmacy. As often as she’s gotten vouchers from us, she’ll accumulate a year’s supply in about 3 months.

The best of all, and the predictor of things to come, was a young man who presented to the ED with belly pain. He had fever, white count (sign of infection), nausea and right lower quadrant pain. First thing we all think of is appendicitis.The ED physician ordered a CAT scan which the radiologist read as acute appendicitis. This is a surgical diagnosis and he needed an operation. The surgeon on call came in, examined the patient, looked at the CAT scan and then went to talk to the young man’s mother.

He introduced himself, explained what his exam, blood work and CAT scan showed, then proceeded to explain that her son needed surgery, an appendectomy. Her response was “You’re wrong and I’m going to sue you!”

That doctor finished the surgery then took himself off of the call schedule for the ED. Another pair of skilled hands has bitten the dust.

Their stories differ a little but the theme is the same. I did this to myself; yes I’m still going to smoke; no I’m not taking my meds like I’m supposed to; no I’m not going to see the doctor you found for me;I came by ambulance, can I have a ride home; can I get my meds for free; can I stay another day; no I want the stronger pain pills; well, Dr. X will give them to me, why won’t you; I’m going to sue.

And you all wonder why healthcare is in crisis; why more and more doctors are looking for a way out; why there are fewer applicants to Medical School; why costs are skyrocketing; why liability insurance premiums are outrageous?

Take a good look around. The finger of responsibility needs to be pointing back at the person looking in the mirror. The gravy train needs to be stopped before the whole thing derails.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.


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