Why I wouldn't give in to Rachel

Fighting for quality medicine has its costs, as this physician learned the hard way.

By Katherine Fisher, DO
Internist/Portland, OR

A patient I'll call Rachel came to my office with a scratchy throat about two years ago. Her exam, including a screen for strep, was negative. I explained to her that she most likely had a viral infection, and that antibiotics wouldn't help. I advised rest and fluids.

"Please," she begged, "I need antibiotics. I'm getting married in four days."

"Taking antibiotics at this stage isn't going to help you get well quicker," I replied. "By your wedding day, this thing will have just about run its course."

"Just the same, I want a prescription."

"I'm sorry, Rachel," I said. "But I don't believe in prescribing antibiotics where there's no clear need for them. When patients take drugs unnecessarily, the bugs can become resistant to the medications."

"I don't give a damn what other people do!" she spat. "I need this to clear up by Saturday."

"You'll feel much better by then if you get some rest. Trust me."

Rachel left the exam room and slammed the door behind her. I looked through her chart. She was 33 years old, and had become a mother at 17. I also found a letter she'd written to me in 1995. In it, she apologized for a previous outburst. "I appreciate all of the help you gave me during the difficult years I had with my daughter," she wrote. "Without your guidance and emotional support, we would never have made it."

In my mind, I wished her well and hoped that her sore throat wouldn't dampen any of the joy of her wedding day. I didn't think anything more of the visit until she called a few months later, insisting that we retroactively okay a referral for a visit to an urgent care center on the same day she had seen me for her sore throat.

We called the urgent care center and learned that the physician there had prescribed azithromycin. Rachel had never requested a referral from us, nor did anyone from the center call us for an approval. One of my assistants phoned Rachel's managed care plan and learned it was against their policy to do "retro-referrals." That was fine with me: At least I didn't have to appear to be the bad guy. The subject was closed—or so I thought.

A month later, Rachel called again. She said she'd spoken to her insurer; it would approve the referral if I called the company personally. I phoned our representative there. It turned out Rachel's point-of-service plan didn't require referrals to go to a "nonpreferred" facility, which included this particular urgent care center. The visit would be paid as an out-of-plan benefit and the charges applied to her deductible. When all was said and done, she owed the urgent care center about $100.

That infuriated Rachel even more. She called my office again and threatened that if I didn't okay the referral, she'd make a lot of noise to her insurer and to the Oregon Board of Medical Examiners. Again, I contacted our rep, who now told me that three months after Rachel's urgent care visit, the company had changed its policy regarding retro-referrals. All I'd have to do is verbally okay the referral, and it would be allowed.

I couldn't help but think how much easier it would've been if I'd acceded to Rachel's request during her office visit. But I couldn't bring myself to give in to her demands—especially not now, with her threats hanging over my head. I told the client rep that I needed time to think about the situation and that I'd call her back.

The next day I received a letter from the insurer's grievance coordinator. It requested Rachel's records from the previous two years, including office notes and lab reports, for a "quality improvement inquiry." Around the same time, Rachel sent me a copy of her lengthy complaint to the state medical board, relating eight years of unhappiness with my care. Among other things, she accused me of denying her antibiotics for colds, and of freezing off some warts instead of burning them off.

In the meantime, I wrote to the health plan, formally requesting that its medical committee determine whether a referral was appropriate in Rachel's case. I've heard nothing back. Nor did I have to sit before the state board to plead my case; they concluded I did nothing wrong. Nevertheless, I suppose I shouldn't be too surprised if someday an ambitious plaintiffs' attorney attempts to cure me of my "negligence."

All this hassle, just because a patient wanted a $7 prescription for amoxicillin. Was it worth it?

 

Katherine Fisher. Why I wouldn't give in to Rachel. Medical Economics 2003;6:93.