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Astral Codex Ten Podcast

Aug 31, 2018

A surprisingly common part of my life: a patient asks me for a doctor’s note for back pain or something. Usually it’s a situation like their work chair hurts their back, and their work won’t let them bring in their own chair unless they have a doctor’s note saying they have back pain, and they have no doctor except me, and their insurance wants them to embark on a three month odyssey of phone calls and waiting lists for them to get one.

In favor of writing the note: It would take me all of five seconds. I completely believe my patients when they say their insurance is demanding the three month odyssey. Or sometimes they don’t have insurance and it would be a major financial burden for them to consult another doctor. Also, I’ve seen these other doctors and they have no objective test for back pain. 90% of the time they just have the patient stand in front of them, make whatever movement it is that hurts their back, ask the patient if it hurt their back, and when the patient says yes, the doctor says “That’s back pain all right, take some aspirin or ibuprofen or whatever”.

Against writing the note: I am a psychiatrist. I usually treat patients via telemedicine, which means that in many cases I have literally never seen their back. All I remember about back pain from medical school is that some people call it “lumbago”, a word that stuck in my head because it sounds like a cryptid or small African nation. I know even less about the ergonomics of chairs, or when people do vs. don’t require better ones. Any note I write about back pain and chair recommendations is going to be a total sham, bordering on medical fraud. I could demand my patient take time off work to come in for an examination, sometimes from several hours away, just so I can do the thing where they bend their back in front of me and tell me it hurts. But that’s kind of just passing the shamminess a little bit down the line in a way that seriously inconveniences them.