Deep breath.

I have to get this one off my chest this morning, and you’re just going to have to bear with me. If you need to skip this tirade and come back for more ED goodness tomorrow, that’s fine with me. Not going to hurt my feelings at all. Really. Shoo.

This acerbic and vitriolic post was inspired by two very specific things. One was the brief but very fine offering by my friend Jordan (please show him some reader love and peruse it here). The other was the occasion of my clinic office staff coming to me yesterday, sheepishly, in great exasperation, tired and beaten, yet another time, asking what I wanted to do about a stack of denials by insurance companies and managed care entities.

A large part of what I do nowadays, if you haven’t figured this one out yet, is talk to people, diagnose mental illnesses and psychiatric problems, huddle with my patients and come up with a workable game plan to help them get better. Now, a big part of that in my profession, since I am a medical doctor by training, is the prescription of pills and potions to effect symptom relief.

I write prescriptions.

I listen, hear about symptoms, try to make sense of them, target the worst ones, find a drug or drugs that might help, IF that is appropriate (another blog post, that. Wait, scribble scribble scribble, note made, okay, fine) and write a prescription for it that I hand to you, my patient. I hand this prescription to you, my patient, because you are the one who came to me complaining that you feel bad, and it is you I want to help get better. This is a contract, an agreement, one might even say a doctor-patient relationship that we have. A sacred trust, a bond that we enter into voluntarily.

You talk to me; I listen to you. You trust me. You give me great leeway, even though you have done your own Googling, to do what is right for you, my patient. After all, what am I doing here if not for that. If I’m not working for you, who am I working for?

Oh, wait, I see a hand in the back. Yes, you in the thousand dollar navy pin stripe suit and rep tie. Yes, go ahead. You have a comment?


Could everybody up here in the front hear the gentleman’s comment? No? Well, let me synopsize it for you.

He said that I no longer work for you, my patient, but that I am now beholden to him, as he and his company now manage my clinical decisions for me. They decide which drugs I write for, how many times a year I can see you, which procedures I can order to figure out what is going on with you (so I don’t have to just, like, guess-isn’t that a novel concept?) and when your treatment is over.

Now, one of my readers and friends told me that I was using too many offensive words in a post or two the other day, and I respect her as a lady and a reader so I’m going to tone that down a little.


I went to school for twenty-three years and paid a heck of a lot of money to go to college, medical school and do four years of residency training. Do you think I did that just for my health? (pun entirely intended) I did it so that I could get a big fancy piece of paper from a Board that said I could call myself a doctor. I then took that piece of paper to a testing center to get another piece of paper from another Board that said I knew what I was doing and was pretty good at it. I keep two other little pieces of paper in my wallet that say I can do this in Georgia and South Carolina. I don’t play a doctor on TV. I AM a doctor.

And now, someone on the other end of the phone, or the fax machine, or the keyboard, sends my office staff other pieces of paper that tell me that I can’t use this drug or that drug. We’d rather you try something from this list instead. How about X or Y or Z?

How about you get the f— out of my office (Apologies to my friend and to all of you, dear readers, but this really makes me so angry) and let me do my job? How about you let me practice medicine? How about you get out of my exam room and let me have this private conversation with my patient, the one who is sitting right there in front of me and is asking for my help because they trust me to make the right choices and do the right thing for them, not for some large company or group that only looks at the bottom line?

I chose to prescribe, oh, let’s say just for kicks, Vyvanse because it is a pro-drug that best serves my patient, is not as likely to be sold or abused, is easy for this child to take once a day in the morning, will most likely be well tolerated and will help his symptoms. No, I do NOT want to use generic methylphenidate or dextroamphetamine instead. If I did, I would most likely have written a prescription for one of those, wouldn’t I?

Oh, I’m sorry, you don’t understand my rationale?

Maybe if you went to medical school for four years and did four years of residency and twenty hours or more of continuing medical education a year and had twenty-six years of clinical experience in this part of the country, you would understand my decisions. Until then, you should really take your high school diploma (you do have one of those, right?) and your scripted responses and your generic fax forms and emails and put them where the sun don’t shine, as we say here in the south.

Back off.

We who practice medicine are getting really tired of this.

We’re getting angry.

We’re getting jaded and cynical and frustrated and we are feeling impotent and powerless.

We are making coerced, default decisions based on what you tell us we must do, not based on what we were taught to do in the best interest of our patients.

Manage what you need to manage. Crunch your numbers. Play with your spreadsheets. Carve out your benefits. Opt in. Opt out. I really don’t care.


Just let me do what I know how to do. What I am well-trained to do. What I love to do.

Let me be a doctor.

22 thoughts on “Pre-Awfulization

  1. Now, now, Dr. Smith. Don’t hold back. Tell us how you really feel.

    All I can say is I’m glad I am not a practicing APRNin the US, let alone a physician. Would there be any point to a massive refusal to comply by physicians? A large-scale decision to prescribe ONLY based on medical rationale? If it was big enough, would that have any influence?

    Or would patients suffer even more in the interim?


  2. Good luck with bringing humanity back to medicine and being able to practice what you know best. It’s not just like that in America. England and Wales (well, the whole of the UK, really) is just as bad with the managers breathing down doctors’ necks and the load of beaurocratic crap. And what they don’t realise in their efforts to save money (as that’s all it comes down to) is that it’s just making things worse all round.


  3. Knot,

    Yes, I need to work on being more expressive.

    If I refused to comply and just wrote what I wanted, this is what would happen.

    1) Patients would not be able to afford the $30, $100, or $600 that the prescriptions might cost them at a retail pharmacy. They would just blow it off and not get it filled, or they would get ten pills and then not go back, not telling me because of embarrassment. In either case, there would be no meds taken, and people who do not take needed medications invariably get sick and relapse. It might be a week, a month, or six months, but it would happen.

    2) That patient would then go into crisis, going to the ED after hours, or getting admitted to a psychiatric hospital, the best place in the entire world to get timely, efficient, cost-effective care. (sarcasm all mine)

    3) Six months later, after they have missed their first or second follow up appointment with me, we’re back square one. In an illness such as schizophrenia, that usually does not mean getting back to pre-admission baseline, but a slowly declining level of functioning over time.

    4) Patient assistance programs are helpful for expensive brand name drugs, but these are going away slowly but surely, especially as fewer new drugs are coming out of the pipeline in mental health in the last 5-10 years.



  4. Val

    I know, but what is the alternative? Do we just throw our hands up and give up?

    It’s not only about the money, and even when it IS, they can’t see that some of these tactics save money in the short run, but certainly not in the long run.



  5. Thanks for your reply.

    I understand what you’re saying, and that was just my sign carrying, protest marching, Vietnam War era inner student rebel talking, but isn’t there ANYTHING to do? This is diabolical.


  6. Don’t know.
    The frustrating part with all of this to me as a practicing clinician is that I am already having to spend so much time in and out of the office on paperwork, electronic medical record documentation, and other issues that this is just one more thing on the heap. It’s often easier to just throw your hands up adn say “What-ever!” and order a four dollar medication from WalMart than hassle with the letters, faxbacks and other tools available, just to be told no over and over again.
    I know that sounds tired and cynical, but at least for me it’s the truth.



  7. Amen and amen!!!! I work as a homecare manager and we are just about ready to start shooting folks with even Medicare HMO’s. I could write for days, but we feel your pain, most definitely feeling your pain. We have orders from great doctors for great care for patients who truly, TRULY need the care we provide, only to be told by these “case managers” (who are paid on incentive for the money they “save” the Medicare program, or whatever insurance program the patien migh be so “lucky as to have. We then have to tell the ppatient that we can only do “this much” and that their insurance refuses to pay for anything more. “But I have Medicare!” or “But I’ve paid for this insurance for 40 years!” Yes, we fully understand. At this point, these patients make up about 30% of our census, but the man hours and hassle takes about 60% of our office time. Not to mention having to explain to these great doctors why we are not able to do all that needs to be done for their patients. And now, hospitals are going to be penalized for readmissions for patients, who could have easdily been kept at home for 1/10th the cost. I’m with ya! Have no clue what else to do at this point!!!!!


  8. STANDING ovation here! My sympthy goes out to your patients and to you for having to put up with an incompetent government. Obama started tearing this great country down before he was elected president. He started many years ago when he was with acorn and fought to allow any “breathing” person in this country to buy a home ….. hence the mortgage/economic crisis! I won’t get on my soapbox but I see Americans getting fed up with the politicians of today, now if they will only stand up and fight for their rights!! Your frustration came out loud and clear my friend.


  9. No, you definitely don’t give up. I suppose it’s a matter of getting as many other doctors to speak out as possible, and then finding a way to be heard. Difficult. Hopefully not impossible.


  10. These problems started long before Obama. They started in the ’90’s with “managed care”. All we can do is fight the battle every day and come back and fight it again tomorrow. We CAN and we WILl make a difference. Our patients need us!


  11. Consider submitting this to Kevin Pho, MD’s curated blog or to Participatory Medicine. This post is extremely important and deserves a wide(r) audience. Also: tag it #pharma when posting to Twitter.


  12. One of my doctors insists I take a brand name drug and writes DO NOT SUBSTITUTE in big letters on the prescription. I still get people at the pharmacy trying to give me the generic instead.


  13. Penny,

    I really believe that it is going to take an outcry from not just doctors, but nurses and social workers and counselors and physical therapists and everybody else to change this system, if it is to change at all.



  14. Denese,

    Yes, but as Paula says later in this thread, I think it also started well before Obama. Some things are going to be made worse by Obamacare, but managed care and its problems happened well before that.



  15. Yes, I really can’t remember the last time I purposefully wrote a brand name prescription and put those words there. The default now is just generic by habit.


  16. I like it when you’re mad (pun intended!!! 😀 ).
    At someone else but me.
    We have the same issue here with generic drugs.
    It it can help.


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