I Work for a Living

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\”Patient was very angry about this.  Are you going to break protocol?\”

The nurse\’s flag came across my desktop this morning on a patient who was last seen 13 months ago.  He has hypertension and our protocol is to see all hypertensive patients every 6 months, 12 months if stable.  When patients call and are due for an appointment, then nurses will call in one month with no refills and require an office visit to be scheduled.  If they still don\’t schedule one, they get only one week at a time until they come in.

\”No.  I am not breaking protocol,\” I responded.

I may get an angry patient coming in to the office this week, but I don\’t really care.  I am prescribing a medication that has some risk and the person has a disease that needs to be monitored.  What bothers me, however, is the anger this patient expressed to my nurse.  The implication is that I am manufacturing business by bringing in people in unnecessarily.  The implication is that I should prescribe his medications like a Pez dispenser without being paid for my service.

I work for a living.  I use my education and experience to make sure my patients stay as healthy as possible.  I take a risk with every prescription I give.  I cost less than a monthly cable bill.  I am not greedy; I\’ve got lots to do.  I just want to do my job and be paid for it.

The best-case scenario is that he will come in with perfect blood pressure and no complaints.  The problem with this is that he will then feel justified in his consternation at being \”forced\” to come in.  He will think to him self: \”I was right.  I told you so!\”

I don\’t care.

Then my first patient this morning was a woman who I saw for a routine visit last year.  She has high cholesterol and hypertension, and was \”feeling fine\” when I saw her last year.  On my routine examination I noticed an irregular heart beat.  The EKG showed atrial fibrillation (a potentially dangerous heart arrhythmia) and I sent her to the cardiologist.  She was electrically cardioverted back to normal rhythm – we call that a Georgia Power consult – and is back in normal rhythm.  \”I didn\’t realize that I didn\’t feel as good as I could.  Thanks.\” she told me today.

Case closed.  Be mad as you want, but I won\’t let your unreasonable expectations make me become your vending machine while being on the legal hook for anything bad that happens.

When I listened to the heart of the woman in the office today, the heart beat regularly.  We both smiled.

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30 thoughts on “I Work for a Living”

  1. Patients need to have an appreciation for preventative care and monitoring, but (as your grumpy patient showed us) price sensitivity can cloud judgment. What is a way to circumvent this headbutting of interests? Do you feel fee capitation would help — bundling payments for monitoring a hypertensive patients — or would it just unnecessarily burden the practice with the responsibility of underwriting?

  2. Patients need to have an appreciation for preventative care and monitoring, but (as your grumpy patient showed us) price sensitivity can cloud judgment. What is a way to circumvent this headbutting of interests? Do you feel fee capitation would help — bundling payments for monitoring a hypertensive patients — or would it just unnecessarily burden the practice with the responsibility of underwriting?

  3. I am not sure. I have heard others suggest this mindset is due to the $10 copays of the 90’s. People got in their heads that a PCP is worth $10, not thinking that they will drop $200 on a plumber visit without surprise. I am not sure that there is a solution as long as I am billing my patients for my service. This guy represented a minority of patients (it was unusual enough to goad me into writing), but enough patients think this way that I am regularly reminded that some people don’t value what I do. It’s life, really. I don’t have to like it, though.

  4. I am not sure. I have heard others suggest this mindset is due to the $10 copays of the 90’s. People got in their heads that a PCP is worth $10, not thinking that they will drop $200 on a plumber visit without surprise. I am not sure that there is a solution as long as I am billing my patients for my service. This guy represented a minority of patients (it was unusual enough to goad me into writing), but enough patients think this way that I am regularly reminded that some people don’t value what I do. It’s life, really. I don’t have to like it, though.

  5. A possibility to consider — from the patient’s point of view:
    He seems to understand that he needs to keep his hypertension under control because he’s willing to adhere to your recommendation that he take the prescription. He gets the importance of that.

    But I think he doesn’t have a complete education. He doesn’t understand the danger of not getting regular check ups for his hypertension.

    He needs to know that just because he’s taking the meds doesn’t mean his hypertension will remain under control. He needs to know that he won’t have any symptoms that it isn’t under control until he collapses from a heart attack or a stroke. Just as you have explained the benefits of keeping his hypertension under control with his prescription drug, you need to explain to him what will happen if he isn’t monitored.

    Often patients are unrealistic because they don’t understand the ramifications of their own choices. And who is going to teach them?

    As you said, Dr. Rob, you use your education and experience to help your patients. But nobody ever teaches a patient to be a patient. And until something like this comes up, nobody ever requires a patient to take responsibility.

  6. A possibility to consider — from the patient’s point of view:
    He seems to understand that he needs to keep his hypertension under control because he’s willing to adhere to your recommendation that he take the prescription. He gets the importance of that.

    But I think he doesn’t have a complete education. He doesn’t understand the danger of not getting regular check ups for his hypertension.

    He needs to know that just because he’s taking the meds doesn’t mean his hypertension will remain under control. He needs to know that he won’t have any symptoms that it isn’t under control until he collapses from a heart attack or a stroke. Just as you have explained the benefits of keeping his hypertension under control with his prescription drug, you need to explain to him what will happen if he isn’t monitored.

    Often patients are unrealistic because they don’t understand the ramifications of their own choices. And who is going to teach them?

    As you said, Dr. Rob, you use your education and experience to help your patients. But nobody ever teaches a patient to be a patient. And until something like this comes up, nobody ever requires a patient to take responsibility.

  7. Isn’t that what both you and I are trying to do? I try to do it in my blogging and in the exam room. You certainly advocate educated and empowered patients. This guy is in the minority (thankfully), but is representative to me of a mindset that thinks medicine is simple and straightforward. I really believe he thinks he understands is blood pressure better than he really does.

  8. Isn’t that what both you and I are trying to do? I try to do it in my blogging and in the exam room. You certainly advocate educated and empowered patients. This guy is in the minority (thankfully), but is representative to me of a mindset that thinks medicine is simple and straightforward. I really believe he thinks he understands is blood pressure better than he really does.

  9. I feel you, man. I run into this all the time. It’s a catch-22. I can do the wrong thing for the patient and get on their good side, or I can do the right thing and be accused of being a money-grubbing creep.
    And how, exactly, did we allow ourselves to be made to feel guilty for plying our trade? I guess we’re supposed to give our services away for free. People need groceries, too, and I don’t hear anybody clamoring for the government to “negotiate” their fees for lettuce and tomatoes at the point of a gun like they do with us. Well. At least not yet.

    Once our profession is decimated in the interest of ensuring health care as a “right”, somebody else is bound to be next.

    Sorry. I guess I’m just a bit bitter. Still $200K in debt and Ted Kennedy is promising to destroy my family’s future by the end of July. May the mob get what they want…and may they get what they are willing to pay for.

    Demoralized,
    MOCKBADOC.

  10. I feel you, man. I run into this all the time. It’s a catch-22. I can do the wrong thing for the patient and get on their good side, or I can do the right thing and be accused of being a money-grubbing creep.
    And how, exactly, did we allow ourselves to be made to feel guilty for plying our trade? I guess we’re supposed to give our services away for free. People need groceries, too, and I don’t hear anybody clamoring for the government to “negotiate” their fees for lettuce and tomatoes at the point of a gun like they do with us. Well. At least not yet.

    Once our profession is decimated in the interest of ensuring health care as a “right”, somebody else is bound to be next.

    Sorry. I guess I’m just a bit bitter. Still $200K in debt and Ted Kennedy is promising to destroy my family’s future by the end of July. May the mob get what they want…and may they get what they are willing to pay for.

    Demoralized,
    MOCKBADOC.

  11. As a nurse I am guilty of trying to get refills for maintenance medication without a visit. I am really busy and feel that as a nurse I know what I need. Thank you for reminding me that it is more than just the obvious. You are taking a risk too and you also need to feed your family. Thank you for helping me see outside of my own needs, wants, desires. Great post.

  12. As a nurse I am guilty of trying to get refills for maintenance medication without a visit. I am really busy and feel that as a nurse I know what I need. Thank you for reminding me that it is more than just the obvious. You are taking a risk too and you also need to feed your family. Thank you for helping me see outside of my own needs, wants, desires. Great post.

  13. Can I just put the other point that most of you PHP types seem to be ignoring. “I work for a living” can mean that, whether because you won’t get paid for medical visits, or just because of the nature of your job, you can’t always afford (time, never mind money) to attend a doctor’s appointment. As a case in point, I was recently asked to make an 30min appointment, being asked at close of play Thursday, I was on vacation away from home for 2 weeks, then when I got back I had to be in the office all day the next 2 because my boss was on vacation! To be at the doctor’s for a 30 min appointment (assumes surgery is on time) means taking about 90 minutes out of my day including travel!

  14. Can I just put the other point that most of you PHP types seem to be ignoring. “I work for a living” can mean that, whether because you won’t get paid for medical visits, or just because of the nature of your job, you can’t always afford (time, never mind money) to attend a doctor’s appointment. As a case in point, I was recently asked to make an 30min appointment, being asked at close of play Thursday, I was on vacation away from home for 2 weeks, then when I got back I had to be in the office all day the next 2 because my boss was on vacation! To be at the doctor’s for a 30 min appointment (assumes surgery is on time) means taking about 90 minutes out of my day including travel!

  15. In order for primary care physicians to make a living, they have to see their patients during occasional office visits. Doctors aren’t payed by insurance companies to talk on the phone, consult via email, or to write refills for prescriptions.
    The problem lies in the reimbursement system. Only paying physicians for office visits blocks innovation in patient-physician communication. Why did you have to travel to see your physician? Because, in the interest of delivering excellent patient-centered care, doctors have no other viable financial alternative to conducting office visits.

  16. In order for primary care physicians to make a living, they have to see their patients during occasional office visits. Doctors aren’t payed by insurance companies to talk on the phone, consult via email, or to write refills for prescriptions.
    The problem lies in the reimbursement system. Only paying physicians for office visits blocks innovation in patient-physician communication. Why did you have to travel to see your physician? Because, in the interest of delivering excellent patient-centered care, doctors have no other viable financial alternative to conducting office visits.

  17. That’s a fair point, but doesn’t actually address mine even if I lived in the USA. I live in Scotland, where the basis of PHP remuneration is a capitation fee (or fixed salary for small rural practices like the one I’m in).
    My point was that sometimes patients have to do stuff at times which don’t fit a schedule which is drawn up on the basis of “we need you to do this now”. I wasn’t complaining that I had to travel to the surgery; I was complaining that I was told “you need to do this now” at a time of year when I honestly couldn’t spare the time I needed to do it for the next month.

  18. That’s a fair point, but doesn’t actually address mine even if I lived in the USA. I live in Scotland, where the basis of PHP remuneration is a capitation fee (or fixed salary for small rural practices like the one I’m in).
    My point was that sometimes patients have to do stuff at times which don’t fit a schedule which is drawn up on the basis of “we need you to do this now”. I wasn’t complaining that I had to travel to the surgery; I was complaining that I was told “you need to do this now” at a time of year when I honestly couldn’t spare the time I needed to do it for the next month.

  19. Aha, it does seem that I missed the point. Thanks for clearing that up.
    And I agree. It takes two to tango and physicians need to be mindful of the fact that patients have schedules, lives, and commitments too. In many cases, the “do this now” / “my way or the highway” mentality isn’t conducive to high quality patient care.

  20. Aha, it does seem that I missed the point. Thanks for clearing that up.
    And I agree. It takes two to tango and physicians need to be mindful of the fact that patients have schedules, lives, and commitments too. In many cases, the “do this now” / “my way or the highway” mentality isn’t conducive to high quality patient care.

  21. I read your blog all the time. First time I’m leaving a comment.
    Just so you know, my doctor prescribed me Lipitor at least 5 years ago. She insists I come in to have my liver checked. She says she actually needs to see me and touch my body in order to check it efficiently.

    She has only checked it twice, one of those times being because I asked her, “Didn’t you say I needed to come it so you could check my liver?” This makes me think she only wants to drum up some money.

  22. I read your blog all the time. First time I’m leaving a comment.
    Just so you know, my doctor prescribed me Lipitor at least 5 years ago. She insists I come in to have my liver checked. She says she actually needs to see me and touch my body in order to check it efficiently.

    She has only checked it twice, one of those times being because I asked her, “Didn’t you say I needed to come it so you could check my liver?” This makes me think she only wants to drum up some money.

  23. You should be cynical about this. I am not sure why she would refill your medication for five years without caring if it was a. doing good, and b. doing harm. At the very least, I check a lipid profile and liver tests once a year – most of the time I do it every 6 months. Why? Because it is what is best for the patient.

  24. You should be cynical about this. I am not sure why she would refill your medication for five years without caring if it was a. doing good, and b. doing harm. At the very least, I check a lipid profile and liver tests once a year – most of the time I do it every 6 months. Why? Because it is what is best for the patient.

  25. Genevieve Fire

    I think I’m at the opposite end of the spectrum as far as protocols for follow-up care are concerned. After having a pulmonary vein isolation ablation last August for long-term A-Fib and A-Flutter, I still do not know when or if I need to see the diagnosing cardiologist on any regular basis. I’ve only seen him 3 times since the original diagnosis and not once has he indicated a follow-up plan (including after being put on arrhythmia medication and warfarin). The last time I saw this doctor was 7 months after the procedure, at my initiation, due to shortness of breath and persistent chest pain. At the end of that appointment, as usual, there was no discussion of follow-up. I guess by that time I should have known to be pro-active about this, but hope springs eternal… As an engineering consultant and very adherent patient, I wonder if this the way a HMO/clinic doctor saves time and money. Your thoughts?

  26. Genevieve Fire

    I think I’m at the opposite end of the spectrum as far as protocols for follow-up care are concerned. After having a pulmonary vein isolation ablation last August for long-term A-Fib and A-Flutter, I still do not know when or if I need to see the diagnosing cardiologist on any regular basis. I’ve only seen him 3 times since the original diagnosis and not once has he indicated a follow-up plan (including after being put on arrhythmia medication and warfarin). The last time I saw this doctor was 7 months after the procedure, at my initiation, due to shortness of breath and persistent chest pain. At the end of that appointment, as usual, there was no discussion of follow-up. I guess by that time I should have known to be pro-active about this, but hope springs eternal… As an engineering consultant and very adherent patient, I wonder if this the way a HMO/clinic doctor saves time and money. Your thoughts?

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