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one thing stood out: He never let go of the bed’s handrail. Normally, a person having a grand mal seizure loses total body control and is incapable of holding or grasping anything. I opened his eyelids, and his eyes followed me. I knew exactly what was going on. I leaned over and whispered in his ear, “Stop it, I know you’re faking.” He didn’t respond.
    It was rarely that easy to determine when a patient was just seeking drugs, though. Among the “frequent fliers,” having a documentable disease made the hustle easier. And it soon became clear to me that prescription drug abuse, once the nasty little secretof the rich and famous, was now a huge twenty-first-century problem in urban neighborhoods. These new addicts weren’t hiding out in abandoned houses, shooting up behind closed doors; their drugs of choice were administered by professionals in the cool, clean corridors of the E.R. And the unwitting dealers in this game weren’t working the streets with Glocks hidden in their pants, they had fancy degrees and wore white lab coats. That’s what bothered me the most: I started to feel like a high-class drug dealer.
    When I mentioned to Ann and LaShawn that they’d been spotted in the emergency room at University Hospital the previous day, neither seemed fazed. Both said something like, “I was in pain, and University was close to where I was.”
    So I treated them. I felt I had no choice. Number one, I didn’t want to take the risk of failing to treat a patient who was really in pain. State law requires that I provide medical care to everyone who comes to the hospital seeking it, and I couldn’t prove that these patients were
not
in pain. The hospital staff lived with the constant fear that a patient would complain to the state about being denied treatment, which could trigger an investigation and result in the hospital getting cited and potentially facing cuts to its Medicare/Medicaid funding. With dwindling resources forcing hospitals throughout the country to close their emergency rooms or shut down altogether, the threat felt very real. It was easier just to write the prescription.
    Our pharmacy network lent a hand in helping to keep track of how many times a particular medication had been prescribed to an individual patient. Repeated narcotic prescriptions always raise a red flag, particularly if they come from different doctors. I received calls on numerous occasions from pharmacists alerting me that someone who had left the emergency department with a prescription written by me had recently been prescribed sixtytablets of the same medication by a doctor at another medical facility.
    Then the pharmacist would ask: “Dr. Davis, do you still want me to fill the script?”
    My response was always the same: “No, and I will notify my department so they’re on the lookout.”
    There were times I tried to claim small moral victories, quietly reducing the dosage of the pain medication the staff administered to a patient I suspected of abuse, or refusing to send the patient home with a prescription for Percocet or OxyContin. Other times, I refused to give the third dose of Dilaudid, insisting instead that if the patient was still in pain, he needed to be admitted into the hospital. My refusal to follow the unwritten rules occasionally resulted in blowups. A patient would protest loudly, curse me out, and sometimes even trail me around the department, threatening to call the state to complain about poor treatment and a lack of respect.
    That was sort of how I wound up one sunny spring day in 2002 sitting in the emergency medical director’s office. The discussion was to be my quarterly Patient Satisfaction Review, a survey that had become the latest trend in hospitals’ frantic quest to generate business in an era of budget cuts and reduced services. How satisfied a hospital’s patients were played a large part in its reputation. My scores, normally above average, had fallen a bit, I suspected because of