A killing in Kentucky

March 5, 2010

I didn't know Dennis "Denny" Sandlin, MD, personally, but the colleagues we have in common tell me he was a great human being.

I didn't know Dennis "Denny" Sandlin, MD, personally, although I would have liked to. During his life, we both practiced primary care in Kentucky. The colleagues and friends we have in common tell me he was a great human being and, as the saying goes, a dedicated physician on the front lines of healthcare delivery.

The term "front lines" came to represent its most dire meaning December 8 when "disgruntled patient" John Combs allegedly shot my unarmed colleague in the head at point-blank range in a clinic corridor, killing him. The reason? Police say Sandlin requested a urine sample before providing Combs with prescriptions for controlled substances.

For decades physicians, medical organizations, and politicians have spoken about the need to expand the accessibility of physicians to rural American in general and to rural Kentucky in particular. Sandlin's death, as with any homicide, is not only a horrendous calamity for his family. It also is a chilling wake-up call for physicians and the community.

Peace officers, soldiers, and firefighters consciously put their lives on the line every day for their communities. Primary care physicians are beginning to realize that they do as well. The killing of Sandlin deprives the thousands of other patients he cared for of his potentially lifesaving presence and efforts. And yet even that deprivation is not where this ends.

Because of the drug issues, declining reimbursements, and a plethora of other challenges, physicians already were leaving rural Kentucky. Entire counties are without a single primary care physician. Because of this heinous crime, recruiting new physicians to enter these areas has become considerably more difficult. Physicians with whom I have spoken have accelerated their plans to leave practices in Eastern Kentucky.

Thousands of additional patients may face a future without physicians to help them because they won't be there to see them. More than one man died on that Tuesday morning. Pieces of the spirits of his family and pieces of the spirits of all physicians died with him. In the future, hundreds, likely thousands of patients are more likely to die because Sandlin and other physicians like him won't be in Eastern Kentucky to care for them.

Health policy leaders and people of good conscience feel that answers to epidemic prescription drug use, and the attendant violence, must exist. Medical Economics has published pieces about the danger of narcotic-seeking patients as well as subsequent opinion pieces. A series of meetings is being conducted throughout Kentucky in response to this murder. These town hall-style meetings include discussions of the problems of abuse of prescription drugs, improving the safety of healthcare providers, and expanding drug treatment and drug abuse prevention.

At the first of these meetings, one physician suggested allowing a 72-hour hold in a jail cell or psychiatric facility for potentially abusive, drug-seeking patients. A district judge proposed giving medical professionals access to patients' court records (Combs has three prior criminal convictions).

These are interesting suggestions, but the facts of this episode demonstrate the futility of such proposals. Clinic staff did report Combs' combative behavior and threats to a Perry County deputy at 9:30 a.m., by which time Combs had left the premises. Clinic staff declined to press charges, and although Combs was wanted on an outstanding bench warrant, the deputy assumed he would just go shop some other clinic and did not track him down and arrest him before he returned to the clinic two hours later for the fateful encounter.

Answers for how medical personnel "in the trenches" should deal with the grim reality of the risks they face are unlikely to come from such meetings. We each must draw our own conclusions from the death of our comrade. We can consider practical options in the layout and safety protocols of our office buildings and suites. We can and we must improve and maintain our own levels of awareness and abilities to set boundaries, de-escalate situations, and if need be, defend ourselves. Indeed, Sandlin himself had one time in the past knocked out a confrontational drug-seeking patient, family members have said.

We in the trenches must take these tactical, active steps now, while the politicians and community leaders debate issues of policy and strategy in the "war on drugs" in the relative safety of "HQ." But we as a community, as a profession, and as a nation always must remember that on December 8, this was not a loss of one physician, or a loss by a family, but a loss of thousands. Losses too precious to repeat or replace.

Gregory A. Hood, MD, practices internal medicine in Lexington, Kentucky. He is a member of Medical Economics' editorial advisory board. Send your feedback to meletters@advanstar.com