The Good the Bad and the Ugly

As with everything in life, in medicine you get the good and the bad: good doctors and bad doctors; good patients and bad patients.

I recently had a very bad patient.

I work at an NGO and we operate on donations. Patients also have to make a contribution. If someone says they are unable to pay and they live within our catchment area, we send someone out to do a home visit and assess the situation and if indeed they cannot afford medical care, we treat them for free. If, however, they do not fall within our catchment area, we refer them to a facility close to where they live where they can receive free care. This makes sense right?

I had a patient recently who said she could afford to attend our clinic (they are told our fees when they come to reception to open a file). After I'd seen her though, when she was to pay before her file could be sent to the pharmacy, she could suddenly no longer afford to pay. The medical superintendent was called, she assessed the situation and cancelled her medication (it was chronic medication). She made a note in the patient's file saying that if she was unable to pay next time, she must be referred somewhere else. Some people might think this is harsh, but you must bear in mind that we have to buy the medication - we don't get it for free - and pay for equipment etc. and if someone who can afford to pay doesn't, that may well be detrimental to someone who really can't afford to pay.

A month later she was back. I asked up front if she could pay and she said that she could, but then afterwards claimed she could only pay part of the fees. I let it slide because, this time, she had a serious condition and I admitted her to the inpatient unit. She was transferred to another hospital the next day because her test results showed she had a condition that we could not treat (the medication is too expensive so we can't afford to stock it - we only have stat doses). Two days later she was back. She said that they had refused to admit her at the other hospital and had sent her home with the medication. Now, as bongi from other things amanzi has already mentioned, you can't always believe what patients tell you. She may very well have refused to stay there. She probably did.

She told me that she still had symptoms and wanted medication - she said that she had paid at the previous visit (although she'd only paid part of the fees) and had been discharged without any meds and therefore wanted some now. I explained that she would have to take the medication that she already had for a while before she would start to feel better and gave her a follow up date to come get her chronic medication (she didn't have any money that day). Two days later she was back again. She wanted her chronic medication. This time she said that she did have money, although only enough to pay what she still owed, not enough for the consultation that day. I was fed up! I just wanted to get rid of her now, so I decided not to charge her for that day and only asked that she pay the money she already owed. I wrote the prescription, but I made a note next to it to the pharmacy instructing them not to dispense unless she paid. A little while later a staff member came to me to say that the patient had said that she doesn't have any money. I'd had enough. I cancelled her prescription and wrote a letter to a clinic where she was already attending on a regular basis to take over her management entirely.

I have no doubt that she'll be back.

Sad Update...

...on that patient I spoke about in failure. She was admitted for 3 days, rehydrated and then discharged in an apparent stable condition. She died in the car on her way home. I was extremely upset about it, but as my boyfriend pointed out to me, she was going to die anyway. The disease had already gotten the best of her.