We’ve all been there: You glance at your clinic schedule and see a name that gives you a feeling of dread, because you know you are failing the patient. Generally, these patients fall into one of two categories: Maintaining the patient’s remission requires an unconscionable amount of steroids, or the patient continues to relapse despite your best efforts. You know what you need to try next, but you are equally certain that it will be a battle, because the drug you have in mind is too new, too expensive or both. What do we do now?
Sometimes, we lie. I know this because in 1999, Daniel Sulmasy conducted a study in which he contacted 471 randomly selected physicians and presented them with a number of hypothetical scenarios.1 With each scenario, participating physicians were asked if they would be willing to use incorrect or ambiguous documentation to ensure the patient would be able to obtain a procedure that he or she needed. Of the 169 physicians who responded to the survey, approximately half thought that some form of deception was justifiable if the patient required coronary bypass surgery, arterial revascularization or intravenous pain medications.
We lie, but we feel guilty about lying. In Sulmasy’s study, a quarter of respondents indicated that deception was never justifiable. Of the physicians who thought that deception could be justified, many wrote long, free-text comments justifying that deception. One interesting theme emerged: physicians who worked in areas with high penetration of managed care markets were more likely to condone bending the truth. “This finding is consistent with the hypothesis,” Sulmasy writes, “that, as managed care brings more restrictions to a market, physicians practicing in that market become more willing to support deception as a means of circumventing these restrictions.”
The more things change, the more they remain the same. In 2013, the ACR’s Committee on Ethics surveyed members to identify ethical issues that affected rheumatologists. Not surprisingly, many of the respondents identified “embellishing coding … as a way to obtain medications who would otherwise not be covered by their insurance” as an important ethical issue.2 In fact, over half of respondents noted that “the high cost of treatment for patients” was the most common ethical issue that they encountered.
Ethics aside, the legal term for bending the truth to obtain a drug or a service for your patient is fraud. It also shouldn’t be necessary. Will Harvey, MD, MSc, member-at-large of the ACR’s Board of Directors, went to Washington on Feb. 7, 2018, to explain this to the U.S. Senate Special Committee on Aging.3 In his testimony, he explained truths that, to us, are self-evident:
