America’s physicians provide excellent medical care – but they also face the frustrating economics of running medical practices or teaching centers that constantly struggle to stay financially solvent. Their struggles are not merely due to the absence of adequately insured patients. To explain requires unpleasant truths.

Sadly, some of the hard truths of medicine are considered unspeakable. We can whisper them to one another, but never in a public venue. Physicians have written to me over the years, in response to columns I have published, and have said, “Thanks for telling the truth; I’ll lose my job if I do it!”

We cannot study these truths, for they violate the underlying social bias of politics and academia – which is that those suffering from medical ills only do so because the nation and the medical profession have not provided enough for them. However, those in practice have ample evidence to the contrary. Some facts are self-evident.

Even as we know that our citizens need access to affordable health care, we in medicine simultaneously recognize the truth that many patients are going to abuse and misuse any gift of subsidized care that the nation gives them. This is a simple fact of human nature. A thing that is “free” always costs someone else money. And the recipient of a “free” thing frequently values it at exactly zero.

Those of us who practice in this nation’s emergency departments understand that there is a subset of patients who seek our care day after day, night after night, with conditions and complaints that not only fail to qualify as emergencies, but that are actually habitual manipulations of the system put in place to provide care for them. Their numbers are small compared to those truly needing care, but their presence serves to disrupt necessary work, increase wait-times, cause unneeded drama and significantly increase the costs to those genuinely sick and injured. In fact, according to the AMA, uncompensated emergency care cost $4.2 billion in 2001. Most of these patients needed the care they received. Many did not.

The emergency department where I practice sees some 37,000 patients each year. Last year, 200 of those patients accounted for 15 percent of the total. That is, some 27 visits per patient. Again, some are chronically ill. Far too many are not. But it’s difficult, if not impossible, to quantify that number nationally. It isn’t nice, after all.

Using myriad falsehoods and distortions, our abusing patients seek pain medications, which they take improperly or sell. They come so that the hospital can delay their incarceration for drunk driving, drug abuse or assault (by complaining of chest pain, seizure or suicidal thoughts). They come because their friends are patients, or they are bored.

A significant number of our patients are relatively young and healthy, but have been granted disability for vague, nonverifiable complaints of back pain, headache, anxiety or a host of other subjective symptoms that result in their lack of productivity and frequent addiction to sedating pharmaceuticals, which they abuse, share and sell with impunity. All this they do with state and federal money. (This is, of course, partly the fault of physicians and state disability boards.)

But perhaps the most pernicious, the most devastating unmentionable truth, is that all too many of our citizens absolutely refuse to do anything to improve their own health; and they will not try to improve no matter how much insurance we provide, whether free or at a discount. Neither insurance nor primary-care access will motivate them to stop smoking, reduce their alcohol intake, cease and desist from abusing narcotics or stimulants, disengage themselves from frequent, violent encounters, or behave in a responsible manner in regard to their sexual mores and reproduction. The importance of these interventions is already well-known to the public, and yet our hospitals constantly deal with the consequences of these many negative lifestyle decisions.

I try to love even my most difficult patients. I understand that many are victims of generational abuse. But I also love my country and know that history has lessons. Welfare laid waste generations of families with misguided charity. And our recent economic miseries were, in part, conceived in the guilt-based largesse of subprime mortgages.

As well-meaning health-care reform legislation looms, I prophesy hard times ahead if we genuinely believe that we can simultaneously reduce the cost of health care even as we give more of it away to those who abuse a costly gift with neither accountability nor consequence for their actions.


Edwin Leap, M.D., has been in medical practice in South Carolina since 1993. He writes an op-ed column twice monthly for the Greenville News and writes a monthly column for Emergency Medicine News, a Lippincott publication. Last year, his blog was listed as a notable medical blog by the Los Angeles Times.

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