Worth It

I saw the note on the patient\’s chart before I opened the door: \”patient is upset that he had to come in.\”

I opened the door and was greeted by a gentleman with his arms crossed tightly across his chest and a stern expression.  I barely recognized him, having only seen him a handful of times over the past few years.  Scrawled on the patient history sheet  in the space for the reason for his visits were the words: \”Because I was forced to come in.\”

By stomach churned.  I opened his chart and looked at his problem list, which included high blood pressure and high cholesterol – both treated with medications.  He was last in my office in November…of 2008.  I blinked, looked up at his scowling face, and frowned back.  \”You haven\’t been in the office for over eighteen months.  It was really time for you to come in,\” I said, trying to remain calm as I spoke.

He sat for a moment, then responded with very little emotion: \”I am doing fine.  You could have just called in an order for labs and called in my prescriptions.  I don\’t know why I had to be seen.\”

\”You have hypertension and high cholesterol.  These are serious medical problems, and if I am going to put my name on a prescription for you, I have to make sure everything is OK,\” I responded, trying to hide my growing anger.  \”I am not a vending machine that you can call to get drugs.\”

\”I\’ll come in if I am sick, but I am not sick right now.\”

\”My job is to make sure you don\’t get sick in the first place!\” I said, my volume rising slightly.  \”I don\’t bring you in because I need the business; I\’ve got plenty of patients to fill my schedule.  These medications are not risk-free.  Besides, how do I know if your blood pressure is OK?\”

\”I check my own blood pressure at home and it has been good.  I can\’t afford to come in to the doctor so much.  I have a high-deductible plan.  I had a stress test and a colonoscopy last year, and that\’s enough spending for me,\” he responded, his pitch and volume rising with mine.

\”I have to say that I find this personally insulting,\”  I threw back.  \”You don\’t think I am worth paying to see.  You just want me to give you your medications, take the risk of adverse reactions, and basically work for free?\”

\”That\’s not what I said!\”

\”It is exactly what you said!\” I said, not hiding my frustration.  \”You want me to prescribe a medication, trust you for your blood pressure, interpret the lab results, and take the legal risk for your prescriptions and not get paid a dime for it!  You are asking me to give you bad care because you don\’t think I am worth paying.  I don\’t do that. I won\’t give you bad care.  If you wan\’t bad care, feel free to find a doctor who will give it to you; if you are going to come to this office I will make you come in on a regular basis.  If you don\’t think I am worth it, then I am sorry.\”

He sat quietly for a moment, and I took a deep breath.  \”Don\’t you have a health savings account?\” I asked, trying to calm my voice again.  \”Most people with high-deductible plans have HSA\’s.\”

\”Yes, we have an HSA, but we are trying to hold on to that money.\”

\”An HSA is an insurance plan!\” I said, not hiding my incredulity.  \”This is what you\’ve been saving that money for!  I want to keep you out of the hospital, keep you from the emergency room, and keep you from spending all your money for a hospital stay.  One overnight stay in the hospital will cost you more than 100 visits to my office.\”

He again sat quietly for a moment, and I directed him up on the exam table.  We talked about his medications and potential side effects.  I pointed out that there are cheaper alternatives for his blood pressure pill that have fewer side effects.  I discussed cardiac screening tests and explained the pros and cons of prostate cancer screening.

I changed his prescription to something cheap enough to recoup the cost of my visit in two months.  As the visit went on, his eye contact grew less and less.  My point was made.  I was giving him something the Internet or a \”doc hotline\” couldn\’t give; I saved him money, educated him, and improved his life.

When I had finished with the visit, I handed him the clipboard.  \”I\’ll see you in six months.\”

He didn\’t respond, but I could see that he got far more out of the visit than he expected.  I am the one doctor out there whose main goal is to keep him away from the hospital and away from having expensive tests.  I often tell my patients that my goal is to get all of my patients very old and to see them as infrequently as possible.

But I am not a vending machine for prescriptions.  I won\’t work for free.  I won\’t take risk without expecting to be paid for it.

I hope he comes back.

I hope he realizes I am worth it.

33 thoughts on “Worth It”

  1. {{hugs}} You ARE worth it. Even if you didn't change his meds to a cheaper med. And I think it sucks royally that you are made to feel that way.

    There are doctors who aren't, just as there are people in EVERY profession who aren't worth what they are paid.

    But most people work hard and try to do their best. You included. And NO ONE has the right to make us feel differently. Not your patients, not customers in a store, not clients of a whatever, no one!

    He was an ass, plain and simple (can I say ass on here?). I am grateful to ALL of the people I encounter in my daily life who work hard at their jobs to make my life go smoothly. From my mailman to the garbagemen to my kids' teachers to the pharmacists to the grocery clerks to my landlord to my lawyer to… well you get the idea! And I make sure to treat them respectfully and to thank them for working hard.

    You aren't my doctor, but I can tell you thank you for your blog. I find it insightful, often humorous, and often I learn from it. So thank you for writing it and your hard work on it!

    And may you have changed an ass into a human that day…one less ass walking around!

  2. This story just makes me want to cry! You put into words exactly what i go throw and deal with on a daily basis. My patients' visits on average are $35 a visit (and that's for my patients without insurance) — isn't that worth the cost to make sure your kidneys, liver, blood pressure, and your health are worth a visit at least once every 6 months? You did the right thing, Dr. Rob. I think sometimes our patients don't quite know or understand what it means for us physicians to take responsiblity for their health — it's a big deal. But thankfully most do understand once the intricacies of “follow-up,” and why and what it entails is described. It's all about information and patient education, like you demonstrated. Great post.

  3. It's unfortunate that people have grown so accustomed to “free” routine care and primary care. HDHP/HSA plans could be a great boon to consumers who are able to rid themselves of the “it should all be free” mentality.

  4. keithunderdown

    Ok, from that person's point of view I am probably a victim of “socialist medicine”.

    I am a very happy user of the NHS in the UK. I see my doctor every six months or so to confirm my hypertension medication, I'm on statins to keep my blood lipids ok. It must be nearly 30 years since I started on treatment for hypertension I've been treated for prostate cancer with hormones, chemo and radiotherapy. For the last six years I have not even been paying for prescriptions, they are free in my part of the country.

    Everything paid for through taxes! I don't get the American system! Everything structured to increase costs, increase litigation and deprive those most at need of the medical care they need.

    I don't get the American system!

  5. Although I agree with your sentiments, I submit that allowing your anger to get the better of you ran the risk of not producing your desired outcome. Apparently you got through to the guy (who indeed was being an ass), but it was hardly a foregone conclusion.

    Your signal was indeed the body language on entering the room. Starting the visit by letting the patient vent, explain to you why he's so frustrated and acknowledging his feelings instead of coming out swinging would have lessened the risk of him storming out and not listening to you at all. You got away with it this time, but I think you could have had a similar result (perhaps even better) by keeping the focus on him instead of shifting it angrily to yourself.

    For what it's worth, I don't always manage to do this, especially with people who insist on shoeboxes full of useless supplements. One man recently denigrated my education and experience, claiming that he could read the literature and draw conclusions just as well as I; that there was no difference, since I wasn't actually doing the research myself. We got into it pretty good as well.

    Just a thought from someone who's been just as devalued as you. (Agree with the above comments as well.)

  6. Wow, I feel a bit like you got it off of my chest for me. Maybe now I won't need to go through saying it to someone.
    Hope he's back. My guess is that he will be.

  7. Dino – I am very non-confrontational. This was very unusual for me to be so aggressive in how I said this. It was also unusual in how blatant the disregard was, which is probably why I reacted in this instance. It felt very good to say, though (and I did change some details in this account).

    We are people, and we react when insulted. Yes, we serve those who are in need. But I won't be ordered around by someone who doesn't value me.

  8. I give it a 50/50. I see us as the schoolteachers of medicine. We are critical to the whole system, but get undervalued constantly.

  9. Wow. I wish I had your balls.

    This happens more and more, and I usually let the patient vent, ultimately telling them I do need to see them once every 6 months or so and can't take risks prescribing over the phone. On the other spectrum are patients who need to be seen frequently but can't afford the co-pays and I tell them we'll just work 'over the phone', but they need to stay on the meds and not stop the treatment simply because they can't come in.

    Still, I wish I had your balls.

  10. Nicely stated. The key is to have the right balance of enough visits to assure good care without putting undue cost on the patient, adding value to the visits so that patients feel coming has value, seeing enough patients to stay in business, having a style that works for you, and somehow balancing all these needs. I wonder if he''ll come back in 6 months?

  11. ”Don’t you have a health savings account?” I asked, trying to calm my voice again. ”Most people with high-deductible plans have HSA’s.”

    “Yes, we have an HSA, but we are trying to hold on to that money.”

    “An HSA is an insurance plan!” I said, not hiding my incredulity. ”This is what you’ve been saving that money for!

    My grown child, who makes very little money working many, many hours and barely makes enough to cover expenses, has a high deductible, VERY limited , health insurance plan, and simply doesn't have the funds to set up a health savings account. Like this guy, my child avoids going to the doctor, and yes, has pre-existing conditions!

    The insurance company in question sent out a postcard with an 800 number on it, with the “offer” that its clients use this phone service to speak to “fully qualified doctors” ( no informations where these people are and what their qualifications are) for refills and other medical problems and thus save the patients cost of “expensive” office visits.

    The Health Savings Account our family had was funded up to the allowed limit was used up EVERY year by late spring, mostly due to co-pays and medical costs for this child.

    I don't disagree with your post that this man and most of us need to understand, value and accept the necessity of actual, face to face appointments with the doctor.

    The elephant in the living room is the cost of medical care relative to the ability of many patients to pay who don't qualify for public aid.

  12. Yes, you definitely need to assert your individuality. And really, this doesn't do any harm. Your post triggered some thoughts and I've written a few things in my blog about it.

  13. Let me offer a different perspective. Many comments have suggested this patient wanted free care. I read the scenario as the patient is stressed about the cost of care. How do I know? Because I'm now a patient myself. I was diagnosed with a type of inflammatory arthritis a year ago that has thrust me into the health care system in a very, very significant way and on medications I never imaged I'd be on in my early 40s. I now see specialists routinely and have monthly medications with co-pays. So, I get this guy's concerns. Even with my family income, the sting of my monthly medical bills some months is enormous. I can't even imagine the stress other families feel with a less robust insurance plan or a family income less stable.

    The medical system right now, especially in primary care, is, well, lousy. We all feel not so great about the job we do and are constantly on the defensive about the value we bring to the table as primary care physicians. As a pediatrician, I truly understand Dr. Rob's position and have been there countless times over my clinical career.

    At the same time, we forget the stressors today's economy brings for families. To be honest, I didn't really understand those stressors until last summer when I was diagnosed. I sometimes wonder how patients with more serious diagnoses mange or worse arthritis. You have to trust me on this one – it is a challenge to manage the financial burden a truly chronic condition brings in one's life.

    So, please take a step back and don't toss this man under the bus so quickly. I suspect there is much more going on in his life. If he does return to you, Rob, try asking him more about his life. I bet you'll find he softens a bit and you'll be better able to be the true doctor we know you want to be.

  14. I sometimes questioned in my head why I need to come in every three months for my medical issues. Thanks for an eye opening, perspective changing article!

  15. The patient is an amalgam of several I have seen. The one I saw most recently (on whom this is largely based) was in no way poor – in fact it was clear that there was money to spare. If I think that it is economic, I am not this way. The reason this visit got under my skin so much is because I knew otherwise.

  16. Depressing. It is good to be reminded, though, that there are practitioners who don't see themselves as pill pushers, and intend to give patients a good service. Even if your patients don't always understand your motivations, or trust you to take good care of them, please keep doing it! Otherwise I will end up seeing even more of them post-stroke, and *none* of them like the 'you can't eat anything safely any more…you need a PEG' visits.

  17. We can't surmise a person's financial burden by what we think they have in the bank. All we can do is offer support. My family is by no means on the poverty line yet my medical bills have tossed us an unexpected curve ball that we couldn't have planned for, even after doing all the right things.

    Let me tell you from personal experience, the HSA quickly dries up when real medical bills come into play.

    None of us know the real situation the burden of our prescriptions put on our patients. You don't know otherwise unless you ask…and truly listen.

  18. Keith, assuming your first remark was directed at my post, I would think nothing of the sort. I'm a very happy occasional beneficiary of OHIP in Canada, and see relatively few problems with it.

    The US system, as you and Dr. Rob have pointed out, is a much different, much more complex beast. I wouldn't offer HSA/HDHPs as a solution to health care shortcomings in the UK or Canada, but I think that if implemented properly they could do a whole world of good in the US.

  19. Good grief! I must really be naive but I can't believe people don't think you, or any doctor, is worth it, or see you as order takers! And as far as frequency, I've gone from yearly visits to twice yearly visits with my family doctor since I was diagnosed (and successfully treated) for early stage breast cancer. I'm glad he wants to keep his eye on me. It makes me feel cared for, not resentful.

    And I'm also very glad you didn't put up with that guy's crap.

  20. You are DEFINITELY worth it! I feel for these patients who are getting the short end of the stick on medical insurance & are forced to make decisions like this man thought he had to make–he was so wrong in his thinking but I can understand why he felt the way he did. I wish every person could be as blessed as this man to have a primary such as you!

  21. As a grad student who pays way too much money on a high-deductible insurance plan (and who knows nothing about a health savings account), I have to say I can relate to your patient. 2 years ago, I had a routine checkup which led the doctor to order a scan of my kidney. Two CT scans and one MRI later (plus missed time from work), plus expensive visits to for the doctor just to tell me that the tests were inconclusive, my insurance didn't even cover the bills, because it was all linked to my pre-existing (in high school!) condition. No one gave me any inkling of a warning of what all the tests would cost me, nor did they tell me that the scans might not give any answers, or that insurance might not cover a cent of it . Two years later, I'm still struggling to pay for it all. I tried to take out an additional loan to cover it all, but was turned down.

    I've stopped going to the doctor for anything since–not because I don't find it worthwhile, but because I simply feel violated by the whole system and can't take any more chances. If the doctors could say “this is how much your visit will cost” then I would at least be able to save up for a doctors' visit, but it's the surprise expenses–which no one asks your approval for but just tells you you need, and charges you in the end–that I absolutely cannot bear.

    It's impossible to know just where your patient was coming from, and he may have needed a wakeup call to realize the importance of investing in his health. But I hope you can also relate to the position he's in and understand the source of his anger without taking it personally. We are all human, just doing the best we can.

  22. I will not hold this against the patient – I agree that I don't really know where he's coming from. But as a doctor I am dealing with my own emotions in the exam room. There are two humans in the exam room, not a doctor and a human. I was insulted and devalued. The person didn't try to explain, they just wanted to take advantage of me (or at least that is what they seemed to be doing). Patients need to present this kind of thing in a way that is not a personal insult to the doctor. I hadn't scheduled the stress test or the colonoscopy – they did that on their own. I don't think the stress test was worthwhile, so it was their decision that cost them 10x what my visit would cost.

    I understand their emotion, but he was 100% wrong. He should not expect me to call in meds. Yes, it is hard to have to spend $80 to see me. But a PCP visit when you have two diseases that could kill you and are taking two medications that could kill you….. That is an unreasonable expectation, and that expectation was given in a way that was not sensitive to me as a person.

  23. I see the negative outcomes of this all the time in the back of an ambulance. Patients who don't take advantage of primary care and then incur thousands or tens of thousands of dollars in medical bills because they ignored that little something that had been bothering them for years.

  24. Dr. Rob,

    Every time I read your blog, I find myself wishing I had a PCP like you. What's really weird for me lately on the patient side of things is that I'm feeling like the specialist docs I've come to know over the last year or so actually care more about my health and sanity than my PCP–who I've known for about half my life by now–does. It's rather strange, in an unsettling sort of “this is topsy-turvy” kind of way…I mean, I've heard more from the interventional radiologist who did a procedure on me last fall since that time than I'd heard from my PCP's office in the last 10 years…same goes for my equally new gynecologist. Somehow as a patient that doesn't sit right. I don't know what that says about either of us, but it can't be anything good. I think the biggest differences I notice between my PCP's office and my GYN's (and they're both equally busy, so that's no excuse) is that the latter doesn't have a whole slew of midlevel providers to take over some important aspects of patient care, and although like any physician his time is precious, he actually uses some of it to have meaningful dialogue with his patients. I think that's an art that's been squashed by the insane bureaucracy that's become health care, but it's a vital part of the process, alongside the science and fancy technology (yes, I've seen my share of that as a patient, too). A little time and the willingness to listen, with a bit of compassion thrown in for good measure, do wonders for fostering the relationship between a physician and their patients. Perhaps I just solved my own dilemma by ruminating a bit in these comments… Keep up the good fight, Dr. Rob, you're truly a gem in the giant morass of insanity that's health care.

  25. Good for you! And good for him! Powerful post and you could be our family doc anytime ..although ..be forewarned ..I ask a LOT of questions… but I'll always have a warm smile for you. 🙂 Drats ..I guess this post indicates you won't treat me via medblogdom. You're safe from the endless questions then. 😉

    I am amazed sometimes at the thought processes of some patients… that they perceive the med folk as someone ripping them off and wasting THEIR time when they NEED the help. But.. they don't understand ..but ..still .. ?

  26. I hope *he* realizes he's worth it too.
    It's amazing how many don't understand the idea of self-care.

  27. Great post. I have these discussions periodically as well. Patients
    don't have enough knowledge to understand the nuances on when they
    should spend money to be even healthier and when they can safely skip.
    Note my latest post on Life Line Screening – Worth the Money? http://davisliumd.blogspot.com/2010/05/life-lin


    Davis Liu, MD
    Author of Stay Healthy, Live Longer, Spend Wisely: Making Intelligent
    Choices in America's Healthcare System
    Website: http://www.davisliumd.com
    Blog: http://www.davisliumd.blogspot.com
    Twitter: davisliumd

  28. I used to have to go to my PCP once a month (in addition to all my specialists). I was stretched out to 6 weeks, then 2 months and now 3. However, my PCP is threatening to pull that back a bit if I don't stop 'trying to cope' when I get ill.

    I can see the need to bring in patients, particularly those with chronic conditions because we get so used to fighting those issues sometimes it seems like just another 'flare' or 'issue' and we don't want to 'bother the doctor'.

    When I was stretched out past the 6 week mark, I started to grin and bear it till my next appointment. I probably did that at the 4 week mark too, but it's more obvious with the farther apart visits. I've also gotten into the bad habit of skipping my monthly labs for high risk meds.
    Waiting for my next appt to do them …
    How much of it is not wanting to go in and how much of it is patient fatigue of being chronically ill and wanting to pretend I'm 'normal' is hard to say.

  29. I saw a guy last week who has bad chronic disease. I really didn't have much to do with him, but he REALLY was happy I saw him because it kept me in the loop. He wants me to know what's going on and wants the comfort of seeing him. I thought about this post when I saw him and realized that some people just need to see me for non-medical reasons.

  30. Wow! I go away on vacation and return to find that you've stirred up another hornet's nest.

    Dr. Rob, I really appreciate posts like this that explain why doctors do some of the things they do. It's hard enough to make the time to see my doctor when I feel crummy, but to do it when things seem okay feels like poor time-management on my part. It's not just the money. I hate having to take half a day out of my schedule to have a short chat with my doctor when I feel okay, and I would gladly pay a fee to get refills without having to take the time to go see a doctor. It's been very helpful to know (from your other posts on this same topic) that my doctors need to see me before renewing those prescriptions, even if I think I'm doing okay. Thanks for another great post!

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