When cowardice replaces reason

Dump, Deny, or Defer: insincere solutions for real problems for real people

The patient accidentally washed her newly filled medication bottle with her jeans last night. The pills were a soapy, crumbly lump of mess, and the label was washed out. When she showed the bottle to her pharmacist, the pharmacist explained that there was only way to get a replacement. A lost medication over-ride had to be issued by the insurance company, because the potential risk of prescription drug abuse was too high. The medication is a sleeping pill, Ambien. The patient calmly called me, so the pharmacist got that call from the doctor. The pharmacist’s position on this matter remained crytal clear. No clinical data could blur the clarity of her conviction. The first hand clinical information was not relevant to her. The pharmacy computer records, which she found easily, were not relevant to her. (This patient has filled the same three medications from me, fifty eight times over the past five years, at this same pharmacy. No notes on patient’s behavior in pharmacy record) There was only one way to get a lost medication over-ride: the patient must request it from the insurance company, and then a written appeal justifying an exception must be approved by the insurance company, and then the insurance company will then send that decision to the pharmacist.

The request was done that night. A diagnostic evaluation to rule out substance abuse and a risk benefit analysis of replacing the medicine, (low risk), or depriving her of sleep, (much higher risk.) I dropped off a copy of the two page assessment, copies of the prescription orders, the report from the Prescription Monitoring Program, and photos of the washed out lump of white powder to the pharmacy in the morning, while I was walking my dog, because it is a small neighborhood. I sent copies to the insurance company electronically.

Another pharmacist called me around lunch the next day and explained that nobody could find the documents that were brought in. But, it didn’t matter, because she would refill the medications, because talking to me on the phone was enough reassurance for her.

It is only a single anecdote. What’s the point? People in clinical medicine, the law, the military, or any bureaucracy with high stakes, will recognize how she responded. She was a practiced master of avoiding risk, work, and liability: dump the problem on someone else; defer the problem to the next shift; deny that the problem exists; dispo the problem, which means send them away. While this level of cynicism is galling, common, and not new, our age is adding a more, robotic, steely resolute embrace of shameless deception and hypocrisy.

Especially in health care providers this cynicism is concerning. In their defense, apprehension about sketchy stories involving controlled substances is prudent during an opioid abuse crisis. But the shocking lack of honesty and the immunity to reason was chilling. Clinicians with intimate firsthand knowledge of this person’s suffering and need, (I know her, and the pharmacist at least sees her standing there) are best equipped to make the decision. To defer to adjusters in an insurance company in another state who have never even met the patient - and will never speak to her, is a denial of one’s own reason, moral agency, and humanity. What happens to a society where the majority of people willingly replace their own independent judgment with mental slavery? We might find out.

Individuals choosing not to see and choosing not to choose is the royal road to authoritarianism. Alienation and the inability to negotiate differences based on shared values pave that road.