Beware patients bearing grudges, and bills

Is this kind of extortion the new version of begging to be bulk billed?

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In the past few weeks I’ve had three instances of unprecedented behaviour.  

A patient for whom I’d prescribed a non-PBS medication for a clinical need had an ill-effect some weeks after commencing and discontinued it; on review appointment several months later I was asked to cover some of the cost of the medication, given that it was expensive.  

Another patient I saw for some procedural work saw another practitioner out of hours privately for a concern she had related to our work together; I was forwarded an email of the non-urgent events and a bill and asked to cover the cost.  

A third was a new patient booking for some cosmetic skin concerns who stated: “I want these removed but it appears you want me to attend twice so you earn more money.”   

I sought medicolegal advice for the first one, and the lawyer simply scoffed: “What? No, no refund.”  

I explained to the patient that I could not be responsible, in prescribing a medication, for any unexpected untoward effects, that it was unreasonable to expect me to share in the cost of it, and that this had effectively terminated the therapeutic relationship. 

With the second patient, I was caught off guard and did in fact reimburse her, but it didn’t sit well with me. On return to clinic the next day I looked over the photos in the clinical file and determined that I’d done nothing wrong based on the knowledge I had at the time. More importantly, any further appointments would now be fraught – if I were to undertake any procedures e.g. a biopsy, and they had an unexpected (or expected) side-effect, and the patient saw someone else during my non-clinic hours, I’d be expected to pay for that too.  

With the third, I did an assessment and then, given it was a non-Medicare rebatable procedure, provided a quote for removal and encouraged them to go and think about it; there would be no second consultation cost and the fee would be the same if the procedure was done on the day or a different one.  

These incidents blew my mind. In my 23 years as a doctor, I haven’t seen anything like them.  

The anxiety they caused me, however, reminded me very much of the anxiety I felt years ago when I terminated a therapeutic relationship for the first time. The patient had said something in passing as they exited my room at the end of a consult that felt like a subtle threat.  

In the more recent cases, I sent a letter ending the relationship. A friend joked: “You need better patients, Imaan!”  

But I wonder if this sort of extortion is the new “can you please bulk bill me, doc?”  

Cost of living is at an all-time high, so it makes sense that people don’t want to waste more money on what they see as mistakes on their doctor’s part, on care that results in further care and cost to them.  

The problem is that medicine is as much an art as it is a science. We spend decades learning how to safely assess, diagnose and prescribe and then, especially if we are reliant on drugs and procedures that interact with a patient’s biology, we may still see something unexpected.  

Covid has, anecdotally, brought about staggering amounts of anxiety especially around health, coupled with a new distrust of doctors. So it also makes sense that instead of waiting till clinic was next on to seek help, a patient might seek reassurance elsewhere – but in doing so, they are entirely liable for any bill incurred.  

Nonetheless, I spent the day yesterday refining my consent form for medically necessary procedures which now includes a blurb on what can be an expected side-effect and how to seek help for it; additionally, that if they choose to seek an opinion elsewhere in my absence I’m not liable for the expense.  

A few weeks ago, I did this consent for non-PBS medications too, which I now email and discuss with patients and get them to sign.  

Is it just me?  

Back when we were all mostly bulk billing (and there was less concern about Medicare fraud) and patients could not have cared less what was being charged, I used to say that patients would care the moment they had to get their wallets out.  

It would seem that the day has arrived and it brings with it new challenges.  

As a largely procedural GP, my spiel to all patients contemplating anything non-PBS or off label or procedural with me (I get referred benign skin lesions on faces more and more regularly) is now: “If we remove this and you end up with a scar, which may be a different colour to the rest of your skin, will that be an improvement or make it worse?”  

With medically necessary procedures including suspicious lesions, given 50% of my demographic is skin of colour, I usually say: “There will be a scar; it may take up to 12 months to settle and flatten but the aftercare advice is crucial to helping you with that.”  

I also say “We offer complimentary review for the first few days if you are ever concerned about infection or anything else. Just contact us and we will squeeze you in.”  

Now I’m going to have to figure out a way to also say “… but if you choose to see someone else privately instead then that’s your financial responsibility.”  

When I was a young medical student more than two decades ago, I don’t recall these issues around boundaries and expectations ever being discussed; nor do I really recall them being taught as an accredited O&G registrar nor as a GP trainee – not around money, anyway.  

It seems the time has finally come to be overt about the covert thing that we all hate talking about, because the alternative is deepening fear and suspicion in what should be a mutually beneficial therapeutic relationship.  

Dr Imaan Joshi is a Sydney GP; she tweets @imaanjoshi.