Doctors should ask about financial safety

In most states, doctors are mandated to ask their patients if they feel physically “safe at home.” With an aging population, perhaps another question should be added: are you financially safe?

Two examples suggest the problem.

“Trudy” had always managed her financial matters, even complex transactions. Aging, however, had made her short-term memory a bit more problematic and her focus diminished by TIAs. Even though her daughter shared responsibility on some of her financial dealings, Trudy signed off on a confusing form that threatened her fiscal security.

The unscrupulous company she had dealt with went after the daughter, insisting her mother had signed a legal contract and threatening court action if she also did not sign. Trudy’s lawyer was called and resolved the problem, but it might not have been.

“Fred,” in contrast, had his diabetes in control during the first three weeks of the month. By the last week, however, he was no longer taking his medications and was eating more carbohydrates as his glucose levels rose. Unwilling to tell his family he was having trouble stretching his small social security income, his health continued to be compromised.

Clearly, it is the responsibility of family members to keep an eye on their aging relatives and their monetary needs. Sometimes, however, the family does not know what is happening while their aging relatives are afraid to admit any problems from inability to make key financial decisions to loss of funds.

Or unfortunately, the family itself is abusing their elder in financial terms. Physicians with elderly patients often have the trust to make this extremely sensitive query. With shortened visit times and complex medical problems, it is perhaps unfair to add one more thing to the doctor’s responsibility. Yet financial challenges for the elderly can have immediate and long-term consequences for their health.

Perhaps it is time for the doctor to raise this question on a regular basis.

Susan M. Reverby is a medical historian.

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  • guest

    Or, perhaps it’s time for the doctor to have social worker who can screen for such things? I am sensitive to this issue, but honestly, one of the most pressing problems facing medicine today is the multitude of regulatory requirements for how the doctor spends his or her time with the patient, the fulfillment and documentation of which frequently leave the doctor with very limited time to spend on the things that the patient actually wanted to be seen for.

    • ShawQuality

      It probably depends on your type of practice. Certainly an urgent care doc is focused on the problem before him. An internist who works with a nurse, social worker, and has a connection with the home health people will eventually sort this out fairly well.

      • guest

        And who pays for that social worker?

        • ShawQuality

          i guess that is why solo practice is dying. Healthcare is too complicated to do everything yourself. It takes a team anymore.

    • SarahJ89

      Yes. When I broke my arm I was asked about alcohol, drug use and if I “felt safe” at home. In front of three strangers and my husband–the most likely perpetrator of arm-breaking abuse.

      This sort of thing really does not increase anyone’s respect for the medical community. It makes you look like idiots, frankly. And uncaring idiots, to boot. Most people do *not* know these bizarre, seemingly irrelevant questions are required to get your brownie points. I now refuse to answer them. I don’t want to support a bad system.

      • SarahJ89

        My husband, by the way, is a kind and gentle soul. My ex, however, was physically abusive. I would have paid dearly if I’d answered a question like that in any way truthfully. Plus he would have stuck by me like a barnacle to make sure no one talked to me from then on.

      • guest

        We’re quite aware that it makes us look like idiots, but we get in trouble if we don’t do it. And the typical ED physician is under very significant time pressure, so does not have time to ask all people to step out of the room in order to ask these mandated questions.

        • EmilyAnon

          Doesn’t HIPAA or other privacy rules apply when you’re questioning a patient about possible domestic abuse? Even if the patient hides the truth, provocative questioning could open a can of worms to the detriment of the victim if the abuser is in the room.

        • SarahJ89

          I figured you are aware since you’re not idiots. I used to work for a state agency. I got so tired of opening my mouth and watching silly stuff come out. You didn’t create this system and sadly, most people do not understand the origins of these questions.

  • southerndoc1

    No, medical historians should ask about financial safety.

  • Margalit Gur-Arie

    I think they should add an accountant to the care team and ask for the most recent tax return to file in the chart, or have real time interoperability with the IRS.

    • guest

      Brilliant, someone should suggest this to some congressional commission so they can look into enacting the appropriate legislation.

      • T H

        Please do not do this. Some REMF will think you’re being serious.

  • ShawQuality

    Why blame the government or payers for everything when a lot of the problem comes down to the increased complexity of medicine today? Our patients are sicker with more other diseases interfering with the problem on which we focus. Instead of 4 medications, they are on 14. I’m tired of these posts being dominated by people who want to rant against Obamacare and the insurance companies. Sign me out of here.

    • T H

      ShawQuality: If you do not want to read about such things, perhaps you SHOULD sign out.

      The reason I blame those who write and push such laws is because whether or not grandma and grandpa are being taken advantage of by predatory marketing and investment bankers is NOT a medical issue: it is a legal and social issue. I do not go to a lawyer or policeman when I’m having angina, so why would people come to me when they’re having legal problems?

    • guest

      “A lot of the problem comes down to the increased complexity of medicine today.”

      The increasingly complex world of medicine is exactly why increased governmental intrusion into the work we do is a bigger and bigger problem. Here’s an example from something I just read tonight: CMS has a big push on for “pay for performance,” meaning that there’s an emphasis on paying for quality care. What’s not to love, right? Who doesn’t like quality care?

      But– how do you measure quality of care? There’s the problem. It’s not done in an individualized or detailed way by raters. It’s done by mandating physician self-reports about whether they have met quality benchmarks that are of dubious relevance. For example, in my field, Physician Quality Reporting System measure 9 is about whether a patient with major depression was prescribed an antidepressant and stayed on it for 12 weeks.

      BUT: what if the patient was prescribed an antidepressant, had intolerable sexual side effects which made him more depressed and so then requested that he be treated with cognitive behavioral therapy, which is also an evidence-based treatment for depression. A psychiatrist who agreed to try this approach would be providing the patient with evidence based care which respected the patient’s preferences for treatment. In other words, the patient would have a good chance of recovering from his depression while not experiencing side effects and also feeling that his doctor had respected his treatment preferences. But according to CMS, that doctor would not have provided quality care to his patient.

      This is a problem for doctors, but it’s also going to be a problem for patients in the future, as they realize that increasingly, their preferences for care are superceded by what CMS has mandated as “quality care.”

  • T H

    Medicalization of social issues is part of the noose that gov’t is using to kill physicians.

    • DoubtfulGuest

      Thank you. This so often backfires for patients, as well.

    • guest

      Exactly. The government doesn’t have the resources to maintain a decent safety net, so all of us become “mandatory reporters,” subject to criminal prosecution if we fail to report any indication of abuse, even the most far-fetched, to the appropriate agency….

  • DoubtfulGuest

    Seriously, we need to quit piling all the psycho-socio-economic stuff in doctors’ laps, except when they have specific training in these areas. Patients hear through popular media that we should “tell the doctor everything”. We don’t know what the line is in terms of reporting these issues as a source of stress in our lives, versus expecting the doctor to fix them and completely overshadowing the medical basis for our visit. Then we pay the price because doctors get mad at us. It looks like they’re really just tired. Thanks for listening.

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