What to Do About “Frequent Flyers” in Medical Practice

The topic of this thread is the ethics involved in the attention and care by healthcare providers of patients who make repeated visits to the physician’s office or to the emergency room which on clinical evaluation could be considered excessive, unnecessary and perhaps in some cases part of a malignant habit or simply out of loneliness. The patient population this thread is concerned about are called “frequent-visit patients” though perhaps a less sympathetic way but the way some professionals seem to be calling them, in an airline lingo, “frequent flyers”.

I want you to read two articles which dissects in rather great detail who these patients are, what appears to be their motivation or diagnosis and how best in our current medical system to manage their propensity for these repeated visits.

The first is a blog article (December 13 2007) by a hospitalist who classifies the particular such “flyers” in his experience into categories of motivation or condition: pain, mental illness, drug abuse, social issues, nursing home patients, dialysis patients, “low functioning” patients, single organ end-stage disease and finally the patients with chronic multi-organ failure.

The second article is from the American Academy of Family Physicians website May 2003 titled “Caring for Frequent-Visit Patients” by a semi-retired family physician. He takes a somewhat different categorization of these patients into: patients with rational questions, misinformed patients, patients who are ashamed or embarrassed, patients with mental disorders, drug seekers, lonely dependent patients, the “worried well” and finally patients who “don’t want to get well”.

My opinion after reading these articles is that those patients who have chronic or end-stage diseases which specifically do require frequent visits for monitoring and support, even though they may represent a burden to the physician in terms of the care of more acute illness patients, they should be in a separate category with regard to the ethics of their care. I cannot find any reason to debate whether they disserve the attention and care they need or whether such care is justified. They need the care and providing the care is ethical. However, some may argue that treating some end-stage diseases represents unethical use of scarce resources.

It is the other classes of frequent visitors, some might argue whether the physician should take the time and attention to attempt to satisfy the needs of those patients yet at the same time be responsible for the care of others who need active medical attention. If the condition of these patients is one of some mental, emotional or social need or some habit that motivates them to request frequent attention and treatment, how often and how much should a physician “give in” to their requests? Should there be triage of these patients amongst all the other patients with regard to attention and care, considering keeping the system ethically just with the need to provide the time for care and to conserve available resources for those who require them for more acute or “bodily” needs rather than mental or behavioral demands? If doctors and nurses disregard these “frequent flyers” what should and will happen to them? And is this attitude what the profession of medicine is all about? Finally, should those patients who make the frequent visits to doctor's offices or emergency rooms bear any ethical responsibility for any harms to others this may produce in our current medical system? Any thoughts? ..Maurice.