Today, I played the role of a social worker.
This is one thing I dislike about playing doctor: Money.
Medications, and the service of medicine, ain't cheap. And when you put that together with a patient who is financially desperate, makes for a difficult, sometimes heart-wrenching situation. You learn about the best way to treat a disease in medical school and residency, but they don't teach you how to treat a patient who can't pay.
True, some pharmaceuticals have drug-assistance programs to help these patients, but these things don't always work. Case in mind, this one patient with a macroprolactinoma who for the last one year has been receiving free medications after they accepted my explanations for medical necessity. But for some reason, when it came time for a renewal, I was told by the hotline rep today that things were 'on backorder' and may take months to arrive. How long, he couldn't say. But strangely enough, he suggested that while they didn't have any to give to my patient now, my patient could try purchasing it from a pharmacy. So it was phonecalls to the drug company, to the patient, then drug company, then our social services, then their local doctors, and then dictating another letter of medical necessity to the drug company for the patient.
What IS the price of health? Would I be willing to pay $800 for 6 weeks worth of medications, or risk having that tumor in my head grow and potentially make me lose my vision, or make my nipples discharge milk?
Or, as we so often see in the hospital, would I be willing to bankrupt my family for a surgery that may prolong life only for 5 years or so? Or save the eyesight in my one good eye? Would I wish for my family to spend $200,000 on my hospital bill if I were to be admitted for sepsis in the context of terminal cancer?
After all, being doctors we aren't usually called to deal with these things. We just order the tests, often unbelievably expensive ones, or give them the prescriptions, or bill them for our time (admittedly, I've been guilty of billing less than I can if the patients are financially challenged). Often we don't think twice when we so conveniently click 'Sella MRI' on the computerised order form. It just takes me 3 mouseclicks.
When they run into problems with money, we're often not the ones they talk to. It's usually the nurses or the social workers or pastors.
Sometimes, it makes me feel guilty to think that I've committed a patient to an expensive medication or procedure. Because, after all, maybe he can live with that tumor. Maybe it's not worth the money. Maybe we could cut corners and do that MRI every 2 years instead of every 1. Because for some patients, the money makes a big difference. Something I see frequently at the local Free Clinic; patients not checking their blood sugars as suggested in an attempt to make the glucometer strips last longer, or taking half the recommended pills to stretch things. No such things as X-rays, or MRIs, even comprehensive blood tests. You just have to make do with what you can. Because, God knows the patients can't pay for it.
Not optimal care, but such is the harsh reality for these patients. Because if I were in their shoes, between a single MRI scan of my head that means mumbo-jumbo to everyone except my doctors, and being able to pay for my daughter's school textbooks, the choice is clear.
I hope that patient gets his cabergoline soon.