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Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St, Pomona, CA

A Rock and a Hard Place

Over the last few weeks, I've had some "interesting" patients. One of the challenges to practice building in California is that my group takes call at several county hospitals where we see Medicaid patients. As most physicians know, these are not the most desirable patients due to their greater number of comorbidities, higher social "complications", and remarkably poor reimbursement. What I find most challenging, though, is trying to wade through all of the nonsense to get down to the truth of the situation. This is particularly challenging when it comes to pain and non-medical issues. The real challenge is to keep from becoming too jaundiced when dealing with questionable patients, while continuing to provide quality care.

Somehow, it seems that Medicaid patients suffer greater amounts of pain for the same relative injury when compared with fully insured patients. Obviously, this is not likely to be actually true. Poor insurance may correlate with higher pain, but it is surely not a causative factor. More likely, these patients receive less medical care with subsequently more advanced issues when their complications occur. So, it is safe to say that medical issues are often more complex with this group of patients.

But there's always the underlying concern with "secondary gain." This past week, I performed an incision and drainage on a diabetic patient with a severe lower extremity abscess. The patient had a brewing infection for several weeks that was apparently missed at three other hospitals. My guess is that the other medical professionals missed this developing infection because the patient came across unreliable to them. I don't blame them if that was the mistake. The patient came across strange to me also by acting histrionic to even the most minor touch, regardless of body location. After an ankle arthrocentesis, the patient spent the next fifteen minutes moaning and crying to the point that even a friend seemed to be losing patience. Unfortunately for both the patient and me, I had to perform an incision and drainage with bucketfuls of pus coming out of everywhere. A bad situation. Postoperatively, after pre-dosing the patient with a healthy dose of pain medications, I performed the first dressing change, which was a screaming nightmare for all involved. Literally screaming, despite the pain meds.

Here's the interesting part, though. Just a couple of minutes after completing the dressing change, the patient asked me again about an issue that had come up previously: workman's compensation. The patient first noticed the symptoms at work, feeling a "popping" while walking, and though this infection had nothing to do with work, the patient continued to spin the situation in that direction, for the obvious potential monetary benefits. It is likely the symptoms progressively worsened over time and this was the first clinically evident symptom.

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Pan Talar Arthrodesis
Lawrence DiDomenico, DPM, FACFAS

This is a challenging situation because the patient clearly had a major lower extremity infection that required a major surgical procedure with understandably high levels of pain. I needed to be sensitive to this and not disregard my patient's needs. On the other hand, the patient – uninsured and not likely to return to work any time soon – demonstrated suspicious motivations.

I dealt with this situation in the only way I knew how: I was honest. I expressed my empathy to the patient's pain, while explaining the nature of what was happening. We discussed the high chance of limb loss with this infection and the likely long term recovery that would be necessary. But at the same time, I told the patient I did not think this was a work-related issue and would have to indicate that to a workman's comp adjustor if asked. Did I believe the patient's pain? Yes. Did I believe the pain was worsened by the high anxiety level? Yes. Did I trust the patient's motivations with regard to the insurance claim? Probably not. Am I going to continue to treat her to the best of my abilities despite everything else? You bet. What else is there to do?

This type of situation is one in which the doctor is at a perpetual disadvantage. We have to trust our patients to some extent. If we go too far and don't trust anyone, then our job is impossible. On the other hand, we can't be too naive and believe everything they say either. Until I learn mindreading, my motto will be "trust but verify."