Tales from the office


Hilda complained that her neurologist was rude. The doctor accused Hilda of having a poor memory and being incompetent to take care of her own affairs. He insisted that Hilda get an MRI scan of the brain to identify signs of brain deterioration. And he wanted her to take a new medicine. At age 89, Hilda still lived independently. At her visit today she expressed fear that the MRI results might show deficits and force her into a nursing home. She was adamant that she wasn’t stupid and helpless as the neurologist seemed to insinuate. She wanted to refuse the MRI. And she didn’t want to take medicine.

The problem was, Hilda recently had a mini-stroke. That means she had a temporary occlusion of a blood vessel in the brain that caused transient stroke-like symptoms. Her right face had lost muscle tone for a few minutes, then returned back to normal when the occlusion spontaneously cleared. The temporary paralysis was a warning sign that a stroke was eminent.

After hearing her concerns, I performed a Mini-Mental State Exam to screen her for dementia. I asked her basic questions like the current date and her address. I quizzed her memory and recall skills. She performed somewhat poorly. She had diminished short-term memory that indicated mild dementia. And recurrent mini-strokes were probably the cause. I agreed with the plan of starting medicine and getting the MRI scan. I wanted to convince her.

I find that most of my elderly patients feel guilty when confronted with the diagnosis of dementia (of which Alzheimers is one type). They think that the label means they are stupid. They feel somehow responsible for their illness. They feel defensive at the accusation of such a terrible thing, as if they had caused it.

I reassured her of the truth: that she was an obviously intelligent person who was being let down by her own brain. I explained that it wasn’t her fault that problems were occurring. She was not responsible for the changes. With some more discussion, she agreed to start preventive medicine and get diagnostic tests like an MRI of her brain. But I kept to myself the fact that regardless of her workup and treatment, her worst fears may soon be realized, and she may be forced into a nursing home.


After ten years of smoking, Jim felt ready to quit. Although he enjoyed cigarettes after a meal and with a stiff drink, he wanted to do the best thing for his health. At our last appointment, I had given him a prescription for Zyban. Although far from perfect, it’s one of only two oral medicines (Chantix is the other) that can help people quit smoking. Zyban is actually the common antidepressant Wellbutrin, but repackaged by the drug manufacturer with a different name to avoid the potential social stigma of taking an antidepressant.

Jim came in for his appointment and hadn’t purchased the Zyban. He said it wasn’t covered by his insurance and would cost well over $150. But, the pharmacist had whispered to him to get a prescription from his doctor for Wellbutrin. His insurance would think it’s meant for depression and fill it for his normal low co-pay. He asked me for the Wellbutrin.

I feel torn with these kinds of requests. On the one hand, I’d love to help my patients quit smoking. And because it’s in the patient’s best health interest, the insurance company seemingly should pay. Moreover, the insurers could save money in the long run. On the other hand, it would be fraudulent for me to directly lie to an insurance company.

As I was explaining my dilemma to the patient, he quickly added that, like anyone, he sometimes did feel depressed. So maybe he could simply have the medicine for a mild intermittent case of depression.

In the end, I felt it would be dishonest to outright lie. But I did feel comfortable with giving him a prescription for Wellbutrin and clearly documenting that it was for smoking cessation. If the insurance company somehow (mistakenly?) decided to pay, so be it.

5 responses to “Tales from the office”

  1. Dave says:

    Love the post, Doctor.

    I disagree with you about the Zyban thing, though. Did the drug company really relable Wellbutrin as Zyban to help people avoid the stigma, or because they figured they could get more money for it by selling it as a different product with a different FDA-approved use? Are there patent issues involved that help them get a longer hold on their intellectual “property” by creating Zyban?

    And why will the insurance company pay for one and not the other? Quitting smoking sounds like about as important a thing as treating mild, intermittent depression — at least they’re both admirable things for a doctor to be involved with.

    It sounds like either the drug company or the insurance company or both has made decisions that are motivated by profit to the detriment of the patient’s welfare. As a doctor, your obligation is first to your patient. And as a human being, your obligation is first to another human being, not a corporation. In your place, I’d have prescribed the Welbutrin without qualms.

  2. Cedric Cedarbrook, MD says:

    Thanks for your comment. You bring up some tough questions and I don’t really know all the answers. But I’ll tell you my reasoning, right or wrong.

    I agree that my obligation is to my patient first. That’s why from the very start I gave him a prescription for the Zyban. I want him to quit smoking, and if the medicine helps (it only has a meager

  3. Cedric Cedarbrook, MD says:

    (My last comment was posted incompletely. I hope the full text posts this time. Sorry for the length.)

    Thanks for your comment. You bring up some tough questions and I don’t really know all the answers. But I’ll tell you my reasoning, right or wrong.

    I agree that my obligation is to my patient first. That’s why from the very start I gave him a prescription for the Zyban. I want him to quit smoking, and if the medicine helps (it only has a meager rate of success at one year out) then I’m delighted. But put in context, it’s not a miracle life-saving medicine.

    Why Zyban and not Wellbutrin? Many reasons. One is for accuracy in the medical record. Writing for Zyban makes all current and future readers of the chart aware why the patient is taking it and gets rid of any confusion over the diagnosis. Using the name Zyban also allows for better safety. Zyban is used at a standardized dose, while Wellbutrin comes in three different formulations and multiple dose levels that could be accidentally interchanged. Moreover, using the name Zyban cuts the risk of overuse. Unfortunately, when a patient is started on a medicine intended for short-term use, without proper attention the medicine can easily get refilled longer than intended. The problem is that Wellbutrin can be used indefinitely, while Zyban is used about three months then stopped. Because of the low but real risk of seizures and other medication reactions, it’s best to use the Zyban for the shortest course necessary. Using the name Zyban hopefully helps the doctor stop the medicine after the appropriate short interval.

    I don’t know the actual reason why Zyban and Wellbutrin, the same medicine, have different names. I’ve heard many rumors, and in my post I decided to use the one about stigma with respect to depression. To be fair, that is certainly not the whole answer. The reason is probably a combination of the safety issues I mentioned above, marketing (the depression stigma), patent issues, profits, and other reasons I don’t know. I’d like to read a thorough independent analysis of the issue.

    Back to the patient: he didn’t really have mild, intermittent depression. That was a white lie her used to lobby for the Wellbutrin. Also, if the medicine was important to him, he could have bought it that first day. He doesn’t need to rely on his insurance. We all must take responsibility for our own health. And the money he could save by not having to purchase cigarettes would more than cover the cost of the prescription. He wouldn’t lose a cent.

    Doctors don’t have control over insurance companies. (I wish we did, but we’d probably make just as many poor choices.) The insurers constantly change their preferred medications based on what they deem is best for themselves and their patients. I’d like to think patients have some control over their insurer. They can switch insurance if it doesn’t cover the services they want. But we all know it’s not that simple. And many of my patients (and I myself) purposefully choose the cheapest plan in hopes of saving money. We often get what we pay for.

    Another issue that I didn’t mention in my post is that when I write a prescription for Wellbutrin, I usually get a form faxed to me from the patient’s insurance asking if the drug is intended for smoking cessation or depression. Lying about the reason is insurance fraud, and could result in the loss of my medical license. I fill out the form honestly.

    In the end, I can see people disagreeing with my decision. But it’s certainly a complicated issue.

  4. Dave says:

    Dr.. C — I figured the ethical situation was probbly more complicated than your original post, and sure enough. It sounds like there are very good reasons that have to do with patient safety, etc., for the choice you made. And you are put in a very difficult situation as a doctor by the regulations about reporting the use for which you prescribed the medication, the possibility of losing your license, etc. I would definitely be interested in knowing why there’s this Zyban/Wellbutrin split and whether it does help big companies profit at the expense of patients and doctors. And even though Zyban isn’t a panacea, it seems the insurance comany should cover it if it’s helpful, since smoking is such a terrible thing for one’s health. Of course, that’s not something you as a doctor can change.

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