What happens if you let patients buy refills without a prescription? Would they consume too much of it?
No. Prescriptions don’t specify precise dosages, because those are adjusted much too frequently for direct doctor involvement.
Would there be any sort of risk of them selling the excess to others?
No. There is no secondary market for insulin, because primary-market insulin is easily available at the price of a plane ticket, and improperly stored insulin is unsafe and indistinguishable. Furthermore, no one is trying to restrict access (other than as a way to extract money).
Is there a medical reason why the doctor might not prescribe more insulin if he examines the patient and finds something new?
No. Type 1 diabetics continue to require insulin 100% of the time, no exceptions.
On that note, I wonder if the doctor is coming from a place of worrying about covering his ass and getting sued if he prescribes more insulin without the exam.
In fact, by refusing to prescribe, this doctor created a considerable risk. If the person in the story hadn’t managed to get a prescription, and had died, a malpractice lawsuit would probably succeed.
Yeah, that all makes a lot of sense. Thanks for the reply.
So now I’m finding myself very curious as to what possibly could have been this doctors motivation for acting this way. Why would he have such a strong preference to see the patient so soon? And why would he be so reluctant to give the patient insulin in the meantime?
True maliciousness and desire to cause harm seems unlikely, so what could it be?
My first thought is some sort of twisted ego. “You don’t say no to me! I’m the doctor! I am the one who knows when I do and don’t need to see you!”
That seems somewhat plausible, but also seems to introduce other questions. Why would the doctor want to see the patient in the first place? More revenue? I guess that’s possible but doesn’t seem likely to me. Maybe the patient has other complications and the doctor cares about the patient and wants to see the patient more frequently to make sure they’re alright. That seems to contradict the subsequent “you don’t get your lifesaving medicine unless you listen to me” attitude, but I guess it could just be that ego is his stronger drive, or just that he’s inconsistent.
Now that I think about it more, the thing that seems most likely to me actually is that the doctor may have come across a good(seeming) reason to have this policy in the past, and just follows it blindly now. Idk though, what would that good reason even be?
To me too, a mindset of “I am the authority on this topic” from the doctor sounds likely.
I would not be surprised if the doctor adopted a rule of “always discuss treatment in person” as health issues often are very emotional and patients may be ill-informed: Meeting in person is a plus for establishing trust between doctor and patient, which will be essential for handling such situations. This reason doesn’t really apply to the case presented by Zvi, but it seems reasonable that at least some motivation for the doctor’s behaviour comes from a sloppy application of this rule. It seems to me that the doctor (and nurse) dismissed the possibility that someone could actually have a reason for not visiting right now and then got stuck in their positions.
If the doctor also doesn’t reflect on their role as doctor in a consequentialist way, for some situations they might value shown respect (“If your doctor says you should meet them now, you should meet them now”) more than the actual improvement in their patient’s lives.
I wonder how the doctor would react if Zvi’s friend would point out his motivation for keeping his schedule while actively endorsing the importance of his doctor’s opinion. This should happen in person, as phone communication is (even) less good at correcting misinterpretations. If I am right, this could allow the doctor to be assured that their value of shown respect is safe. And possibly this lets the doctor be open to the point of Zvi’s friend.
- - - Apart from this, I am quite distraught by the almost active distrust in their patient’s decisions on the side of this doctor and nurse. If this really is typical for the American medical system, there will be massive associated problems ..
Doctors valuing their position as an authority, and caring enough about this to threaten to withhold vital care until their authority is affirmed, seems like it would necessarily entail the kind of distrust you’re worried about. The paradigm of epistemic authority is one where information can only flow down power gradients—there’s no way someone with lower rank would know something that someone with higher rank is ignorant of.
Obviously this is a terrible paradigm for any kind of healing that requires knowing about the patient.
I would not be surprised if the doctor adopted a rule of “always discuss treatment in person” as health issues often are very emotional and patients may be ill-informed
Ah, that does seem plausible. Along with the hypotheses that he sloppily applies this to diabetics who need insulin, and it subsequently became an ego contest.
I wonder how the doctor would react if Zvi’s friend would point out his motivation for keeping his schedule while actively endorsing the importance of his doctor’s opinion.
I too suspect that the doctor would have responded much better. I’ve been learning more and more that when you give people an out that lets them maintain their ego, they often are happy to take it. The places where people get really stubborn is when giving in would compromise their ego.
But of course, it’s 100% not acceptable for a doctor to let their ego get in the way of life saving medicine, and it is extremely understandable for someone being denied life saving medicine to overlook all of this.
Keep in mind doctors are optimizing for patients of average ability wrt not acting insanely on their instructions. I found a lot more sympathy for people in positions of authority when I gained experience with the breath taking number of ways people can alter what seem to be very simple instructions.
Regulatory capture, in practice, means that if you circumvent the existing players they can have you arrested. Many many people are trying to figure out how to supply insulin to diabetics in the US, but no dice so far.
No. Prescriptions don’t specify precise dosages, because those are adjusted much too frequently for direct doctor involvement.
No. There is no secondary market for insulin, because primary-market insulin is easily available at the price of a plane ticket, and improperly stored insulin is unsafe and indistinguishable. Furthermore, no one is trying to restrict access (other than as a way to extract money).
No. Type 1 diabetics continue to require insulin 100% of the time, no exceptions.
In fact, by refusing to prescribe, this doctor created a considerable risk. If the person in the story hadn’t managed to get a prescription, and had died, a malpractice lawsuit would probably succeed.
Yeah, that all makes a lot of sense. Thanks for the reply.
So now I’m finding myself very curious as to what possibly could have been this doctors motivation for acting this way. Why would he have such a strong preference to see the patient so soon? And why would he be so reluctant to give the patient insulin in the meantime?
True maliciousness and desire to cause harm seems unlikely, so what could it be?
My first thought is some sort of twisted ego. “You don’t say no to me! I’m the doctor! I am the one who knows when I do and don’t need to see you!”
That seems somewhat plausible, but also seems to introduce other questions. Why would the doctor want to see the patient in the first place? More revenue? I guess that’s possible but doesn’t seem likely to me. Maybe the patient has other complications and the doctor cares about the patient and wants to see the patient more frequently to make sure they’re alright. That seems to contradict the subsequent “you don’t get your lifesaving medicine unless you listen to me” attitude, but I guess it could just be that ego is his stronger drive, or just that he’s inconsistent.
Now that I think about it more, the thing that seems most likely to me actually is that the doctor may have come across a good(seeming) reason to have this policy in the past, and just follows it blindly now. Idk though, what would that good reason even be?
To me too, a mindset of “I am the authority on this topic” from the doctor sounds likely.
I would not be surprised if the doctor adopted a rule of “always discuss treatment in person” as health issues often are very emotional and patients may be ill-informed: Meeting in person is a plus for establishing trust between doctor and patient, which will be essential for handling such situations. This reason doesn’t really apply to the case presented by Zvi, but it seems reasonable that at least some motivation for the doctor’s behaviour comes from a sloppy application of this rule. It seems to me that the doctor (and nurse) dismissed the possibility that someone could actually have a reason for not visiting right now and then got stuck in their positions.
If the doctor also doesn’t reflect on their role as doctor in a consequentialist way, for some situations they might value shown respect (“If your doctor says you should meet them now, you should meet them now”) more than the actual improvement in their patient’s lives.
I wonder how the doctor would react if Zvi’s friend would point out his motivation for keeping his schedule while actively endorsing the importance of his doctor’s opinion. This should happen in person, as phone communication is (even) less good at correcting misinterpretations.
If I am right, this could allow the doctor to be assured that their value of shown respect is safe. And possibly this lets the doctor be open to the point of Zvi’s friend.
- - -
Apart from this, I am quite distraught by the almost active distrust in their patient’s decisions on the side of this doctor and nurse. If this really is typical for the American medical system, there will be massive associated problems ..
Doctors valuing their position as an authority, and caring enough about this to threaten to withhold vital care until their authority is affirmed, seems like it would necessarily entail the kind of distrust you’re worried about. The paradigm of epistemic authority is one where information can only flow down power gradients—there’s no way someone with lower rank would know something that someone with higher rank is ignorant of.
Obviously this is a terrible paradigm for any kind of healing that requires knowing about the patient.
Ah, that does seem plausible. Along with the hypotheses that he sloppily applies this to diabetics who need insulin, and it subsequently became an ego contest.
I too suspect that the doctor would have responded much better. I’ve been learning more and more that when you give people an out that lets them maintain their ego, they often are happy to take it. The places where people get really stubborn is when giving in would compromise their ego.
But of course, it’s 100% not acceptable for a doctor to let their ego get in the way of life saving medicine, and it is extremely understandable for someone being denied life saving medicine to overlook all of this.
Keep in mind doctors are optimizing for patients of average ability wrt not acting insanely on their instructions. I found a lot more sympathy for people in positions of authority when I gained experience with the breath taking number of ways people can alter what seem to be very simple instructions.
Gotcha. Maybe it could make sense to apply it to diabetics then.
Regulatory capture, in practice, means that if you circumvent the existing players they can have you arrested. Many many people are trying to figure out how to supply insulin to diabetics in the US, but no dice so far.