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Restriction of Practice: Fear or Anger?
I recently suggested to the leadership of my local branch of the American Society of Addiction Medicine that as a way of protesting the DEA's unnecessarily disruptive and wasteful methods of conducting audits, that we encourage members to do as I have done: I have made a decision to stop accepting new opiate addicted patients for treatment with buprenorphine and to make that fact known. One of them replied,
"I'm not sure I understand your recommendation to stop accepting patients(?) We are fully within our rights to treat patients. It is unnecessary to curb our professional activity unless any individual MD is exceeding the 100 patient limit; or if, of course, a given physician simply wants to discontinue for their own purposes such as retirement or the pursuit of other professional goals.
"I think that it is also important to underscore (to you) that treatment access remains a problem, and to the extent we magnify the impact of this situation, it may have the effect of discouraging physicians from pursuing this path in a manner that is disproportional to the regulatory risk of the prescribing activity. We have an ethical obligation to both our patients and our colleagues to not let our fear or [sic] audit translate into excessive fear of obtaining a SAMHSA DATA Waiver."
Doctor, it is not fear, but anger, and the wish to draw attention to, and possibly solve, a larger problem that motivates my decision. I still recall sitting in a lecture hall in medical school in the early 70's when one of my classmates briefly spoke out to challenge a legitimate wrong, but quickly withdrew. Out of fear. Since then it has seemed to me that medical schools, whether intentionally or not, select for conformists and cowards. Surgeons may represent an exception. Most physicians seem to fear that rocking the boat or taking action or an unpopular position will threaten their status or income. The rest might cite the rationale that we must fulfill an ethical obligation to treat all those people in need. And the legislators and regulators take full advantage. I can hear them now: "Let's just add a few more regulations. The doctors will just suck it up."
I chose not to risk being accused of Medicare fraud: I opted out. The result: I care for few older patients who enjoy more privacy because I am not required to bill Medicare for my services to them.
I dislike the terms of insurance contracts, including managed care: I enter into no such contracts. The result: Patients either pay cash or go elsewhere. And my patients do not need to worry that I will compromise their care to enhance my standing with the insurer.
I prefer not to be bound by HIPAA: Because I do not bill electronically, HIPAA does not apply to me. The result: State law, case law, and ethical considerations, not govern most of my privacy practices. The rest is between myself and my patients.
I choose not to be subject to the FCC's Red Flag Rules by not meeting the FCC definition of a "lender." The result: I cannot let my patients carry a balance.
For most physicians these and other distractions from patient care already lead to limitations of practice, increased time spent on non-clinical duties, and manipulation of physicians to "fill out forms" many of which address questions with which physicians should not be involved. Some doctors retire when they've had enough. Others stop accepting any new patients. For still others a patient may have to wait six months to get an appointment. Some become administrators, forensic experts, journalists, or legislators, or learn how to inject Botox. At the same time we hear that we as doctors should take better care of ourselves, spending more time with family, getting "therapy", or working shorter hours. You cannot have it both ways. You don't want rationing of health care? You already have it.
Of all specialties a physician in addiction medicine should recognize "enabling," a core concept in Alanon, in action. By continually giving in to these encroachments on patient care we become responsible for their perpetuation. The ultimate consequence for this obedient acquiescence to over-regulation is reduced access to care, which I read recently may have contributed to the deaths of 40,000 people. A doctor has a choice: She can spend 10 minutes treating a patient or she can obediently, and without charging, complete a preauthorization for a drug so an insurer can make more profit. He can perform a medical procedure or spend two hours reading about how to avoid going to jail for improper coding.
The net result for me is that while I could probably care for 100 patients per week I may care for 10. After all the public invested in my education and training I spend my time writing blog posts when I could be practicing medicine. You cannot hold a gun to my head to force me to practice. If you convict me of a crime and/or revoke my license, who will care for those patients? Send me to jail, and I have a right to medical care. For free. Make my day.
Perhaps we cannot ethically go on strike. Or perhaps ethically we should. You can certainly limit your practice. But if you do, do it out of anger, not out of fear, and make it known. I would stop practicing altogether today if I could, and when I think of how many other docs probably feel the same way, that scares me, and makes me angry.
And what about the doctor who says I should not stop accepting new buprenorphine patients? He also mentioned he's on sabbatical.