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No Doctor in the House 

Sometimes not asking your physician questions can be hazardous to your health.

When Ruben Morales, his wife and daughter moved to Tucson last December, they were excited over the possibilities. Joyce Morales was starting a new job she knew she'd enjoy--one that also provided decent benefits. Among those benefits was a health plan.

Medical coverage is important for the Morales family, since Ruben has diabetes, hypertension and high cholesterol. Before the move here, Ruben's Florida physician prescribed several medications that were successfully managing those conditions.

Because the couple didn't know anyone in Tucson they could ask for a recommendation, they chose an endocrinologist from Joyce's health plan who was located near their home. Since Ruben's medical records from Florida indicated his diabetes was under control, and a blood test taken in Tucson indicated his cholesterol level had decreased, you would think his local doctor would say, "Keep doing what you're doing."

You would be wrong.

Ruben's first impression of Dr. Mariali Garcia was not positive. But he's the kind of guy willing to cut people a lot of slack, so he chalked up his feelings to, "Maybe she was having a rough day." He found her cold and distant. That assessment could describe many people, not only doctors, and it certainly does not speak to anyone's competency, but when Garcia changed his diabetes prescription and did not address the issue of refills for his other medications, alarms went off for Joyce.

On April 3, she faxed Garcia a letter expressing her concerns. It's a polite letter that doesn't pull any punches. Joyce asked the doctor what her intentions were regarding the cholesterol and hypertension prescriptions. She inquired as to the results of the lab work Ruben had gotten done before his first visit to Garcia: Was his cholesterol under control, and were his liver enzymes OK?

Joyce expressed particular concern over a switch in diabetes medication, to Avandia. After listing the drugs her husband had been taking, she asked, "That seems to be working well for him so why the change?" Joyce also pointed out Ruben had "a problem with liver enzymes in the past," and the similarity between Avandia and a drug that had been recalled "because of its tendency to cause liver failure." "It (Avandia) also carries a risk of cardiac arrest due to fluid overload," wrote Joyce.

In a letter dated April 9, six days after Joyce's fax, Garcia responded with her own letter in which she states, "I had asked that you both come into the office so that we could go over the questions, and an office visit was scheduled for 1:45 p.m. on April 9, 2003. This visit was canceled by Mr. Morales and a return office visit was not scheduled. I feel that my ability to care for you may be compromised. You will be requiring further medical care which I will no longer be providing to you."

Here's where the story gets tricky.

On April 14, Joyce Morales wrote to Dr. Garcia and laid out a peculiar series of events. According to the letter, Garcia's office phoned Joyce on April 8 "with the offer to come in and speak with you personally on April 9." During the phone call, Joyce agreed to a request to bring a release from her husband giving the doctor permission to discuss his case. But by the time she got home from work the evening of April 8, a message was waiting on the Morales' answering machine to the effect that a release was inadequate and that Ruben would have to be present at the next day's meeting.

Since Ruben couldn't make it on such short notice, he called Garcia's office the morning of April 9 to cancel the appointment. "He was unable to reschedule at that time as he was not aware of my schedule," Joyce writes. But any rescheduling attempt turned out to be moot in light of the letter she received from Garcia, "essentially firing my husband" from Garcia's medical practice.

Doctors are not obligated to accept any patient who walks through the door. If a physician feels, for whatever reason, that she cannot provide the level of care needed for a particular patient, then it is her obligation to tell the patient to find an alternative.

Having heard Ruben's side of the story, I wanted to hear from Dr. Garcia. Within an hour of a call to her office, I received a call from a guarded but otherwise pleasant chap who identified himself as Leslie Tennen, Garcia's Phoenix-based attorney. Doctors, of course, cannot discuss their patients, or ex-patients, even if a complaint has been filed. And while her attorney would not address Ruben's case, he did say doctors might dismiss patients they felt were "uncooperative" or "non-compliant." The Arizona Medical Board is currently investigating Ruben's allegations.

On Sept. 10, several months after Joyce Morales expressed her concern about the drug Avandia, Reuters news agency reported that a study linked the drug to "fluid buildup and heart failure in some patients." The findings were published in the Mayo Clinic Proceedings, according to Reuters.

I asked a doctor I know what he would have done in the same situation, and if he had any thoughts on why Garcia felt she could no longer provide care to Morales. "Some doctors are better at explaining things than others. Some doctors feel threatened by questions. I would have requested a meeting with the patient and spouse after hours," he said.

We're not likely to ever know what Garcia was thinking when she prescribed Avandia or why she dismissed Morales. But one thing is certain: "Doctor knows best" could prove a dangerous assumption.

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