Why do you even take a patient on like that when you know full well you won't be able to help them?
Why? Well, its because I have this warped belief that perhaps something I say, or do will help this guy out. Even if I just give him diet advice, or show him some exercises that will do something to alleviate the pain, or even if I say "its time for you to see an orthopoedic surgeon" that the guy will understand that its 'shit or get off the pot' time.
I don't pull any punches in my 'report' to the patient after their initial exam. If someone is overweight, i tell them that their weight NEEDS to be addressed. I have discharged a patient because they did not follow my recommendations on things. That is so UNCOMMON in my profession. That right there is a sad statement. MD's get rid of patients left and right in those cases.
As far as your one guy milking the fuck out of the insurance. Yep, that happens. Those guys are the ones that have fucked things up for people like me. But, something people DON'T think about is this...how much hospitals rape the insurance companies for. Ever see how much an aspirin costs for a hospital stay? Ask for another cookie with a meal there, guess what? They charge for another meal! I have seen it personally.
How about this:
I took a standard two view lumbar series on a patient. Total bill to the insurance : $95. We were done with treatment a couple months later. Almost one year later he was in a car accident. The ER took the SAME study (most will say bullshit, but a 72100 code is the same for me as the ER...its a 2-view limited study of lumbar spine) and billed out...get this : $600. He showed me his ER bill. Who is milking the insurance company there?