THE HEARTBREAK OF PSORIASIS
Enfield, CT, USA
on October 16, 2006
A nineteen-year-old girl reluctantly comes to the office on a Friday afternoon with complaints of low-grade fever, head congestion, cough, and sore throat of two-days’ duration. Past medical history includes recurrent sinusitis and early-onset psoriasis at 4 years of age. She is the older of two siblings, raised by a single parent. Previously covered by state-sponsored medical insurance, she lost coverage on her 19th birthday.
Physical examination reveals an obese adolescent female with flat affect. Her arms, legs, neck, and ears are covered with silver-grey patches with surrounding erythema. Nasal mucosa is swollen, boggy, and slightly bluish; posterior pharynx is mildly inflamed with purulent PND; neck is supple with no adenopathy; chest is clear to auscultation.
Assessment: (1) aeroallergies, (2) mucopurulent sinusitis, (3) uncontrolled generalizd psoriasis
Plan: (1) long-acting anti-allergic medication, (2) oral decongestant, (3) saline nasal spray, (4) oral antibiotics
Discussion: The patient is reticent to accept a prescription for amoxicillin. She states that oral antibiotics historically have made her psoriasis worse. On further questioning, the patient reveals that her psoriasis had cleared completely on a regimen of Enbrel over the past two years. When she lost her health insurance, her dermatologist at University Hospital refused to render further care; she was unable to pay out-of-pocket for the medication and experienced a subsequent flare of psoriasis. At one point during the visit she makes the comment that when her skin cleared up, she felt like a new person. For the first time in her life she went to the beach and boldly wore a swimming suit. That ended with the resurgence of her skin condition.
(1) What are the ethical implications of treating only insured patients, regardless of the need for care based on the severity of the condition?
(2) Should expensive drugs be made available to under- or uninsured patients gratis?
(3) As practitioners of medicine, what are our responsibilities to our patients when they come to us in need?