NEVER ASSUME

You know the old saying, “When you assume something, you often make an ass out of you and me? In my world, assumptions are bad. Ever notice that I discuss my findings and plans with you and then give you a written summary of my findings and plans? 

I can’t afford to assume that you understand me. I can’t afford to assume that you will remember what I said. If I assume that you and I are on the same page and we are not, it can lead to catastrophe. If you do not understand what your doctor is telling you, stop him/her and ask more questions. If you do not say anything, the natural assumption is that you’ve got it! If your doctor does not give you a written summary of the visit, ask for one. The written summary of your office visit is one of the few benefits of the electronic medical record.

Ever notice that I repeat what you say to my nurse and to me? Often, I will read my nurse’s note to you and ask if it is accurate. Do not assume that what you say is what your doc heard. Communications between individuals is often lacking. One of my favorite quotes is, “I know that you believe you understand what you think I said, but I’m not sure you realize that what you heard is not what I meant.”

During your visit with the doctor, both parties should take the time to make sure they are on the same page. One way to assure better communications is to plan for your visit in advance. Write down the questions you need answered and the points you want to make in advance. Once you have your list, prioritize your needs as the doc may not have time to address all of your concerns at one visit.

Do not assume that your doctor has all the answers. Your doctor’s job is not to know everything; his/her job is to know what he/she doesn’t know and how to find the answer. Do not assume that there is always an answer to your problem. There are problems that have no answer. There are problems that have no solution. 

The true art of medicine is in listening, communicating, and finding a way to deal with those problems. In today’s world, everyone is in a hurry. No one is willing to pay for time and no one is willing to wait. The number one complaint about my practice is wait time. I’ve always been perplexed by that complaint because the walk-in system means you will be seen on the day you need to be seen, not on the day an appointment is available. Yes, patients often wait an hour or two in my lobby or exam room. It takes time to listen, more time to communicate, and even more time to make sure that everyone is on the same page.

Help me help you! Prepare for your visit in advance. Stop me if you think I’m not getting your meaning. Stop me if you are not getting my meaning. Make sure you get a written visit summary before leaving. Actually, read that summary and make sure you understand it. Read this blog. It is designed to teach you to help take care of yourself. Send this blog to your friends and relatives. You may save a life.

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WOW, THEY DID IT

During the last few weeks, I’ve been writing about taking control of your health through knowledge, partnering with me to accomplish a healthy lifestyle.  I’ve written about the doctor-patient relationship and characterized that relationship as often being similar to the fireman-arsonist relationship.  Today, I want to share with you the story of two patients who took charge of their lives and changed their lives for the better.  One willingly, the other after I thoroughly pissed him off.  Today was a great day!

My first patient (Number One) of the day had been given a diagnosis of diabetes, hypertension and elevated cholesterol; and he is on multiple medications including insulin.  He followed my instructions and took command of his health rather than letting his health take command of his life.  Forty-two pounds lighter, he is rewarded for his efforts by feeling younger.  He no longer needs insulin and I suspect most of his medication will eventually be stopped.  I applauded his efforts and sent him on his way feeling like I had succeeded as his doctor and mentor.

As a physician, I love to see my patients flourish.  I think of myself as a benevolent teacher and enjoy seeing my students prosper.  While my first patient took my teaching to heart, my second patient did not.  Patient Number Two was markedly overweight, diabetic, hypertensive with high cholesterol and neuralgia (a painful malfunction of the nervous system).  Number two was on three medications for blood pressure, two for diabetes and two for neuralgia.  My efforts to help number two understand the immensity of his problems included:  I tried education and instruction; fear mongering; and guilt.  I TRIED ANYTHING ELSE I COULD THINK OF IN ORDER TO MOTIVATE MY PATIENT TO TAKE CONTROL OF THE ILLNESSES PLAGUING HIM.   It seemed nothing would work.  At last, I let him have it and royally pissed him off.  That worked!

Patient Number Two proudly came in for a yearly physical today, having lost in excess of 100 pounds.  Medications were no longer necessary.  The diagnosis today was not hypertension, not diabetes, not neuropathy.  Today, the final diagnosis was “HEALTHY”!  

It’s a pity I had to piss him off but it was worth if in the end.

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STORM WARNINGS

While I would like to believe that I am better at predicting storms than the weather- man, unfortunately, I am not.  If you are wondering if I’ve lost it, I haven’t.  Once upon a time, my first patient of the morning left the office by ambulance.  After taking a careful history and performing a thorough exam, my assessment was that he was in imminent danger, much the way the weatherman declares a tornado/storm alert.

Yes, a major storm was in the making, one we docs call sepsis.  Calling in the paramedics is the equivalent of calling up the National Guard.  As always, they responded quickly and efficient, securing my patient against what could have proven to be a major tempest.  The next day, my patient is much better.  The storm has blown over and, thanks to G-d, was nowhere near as devastating as I had predicted.

Unfortunately, there are times when medical storms strike fast and appear from nowhere.  No matter how good my patient and I are at practicing preventative care, there are many occasions when medical twisters touchdown in our lives wreaking havoc.

So, what can we do?  In the case of a severe weather alert, most of us get busy securing our homes, checking on our flashlights, making sure we have gas for our generators and snow blowers and fill our pantry.  We check on our loved ones and neighbors and then hunker down for the night.

In the case of a medical alert called by your doc, respond promptly, heeding his advice.  Don’t argue as it wastes time.  If the doc says, “Call 911,” call 911.  Take proper precautions.  If your doc warns of an approaching storm in the form of a future heart attack/stroke/diabetes, take action by improving your lifestyle, complying with medication and seeing the specialist when recommended.

Yes, my predictions are often wrong.  When I warn of impending doom and it fails to develop either due to your precautions or not, I’m one happy camper.  Now, if I can only figure out how to predict those sudden acts of terror that occur when illness is lurking in the wings but invisible to the modern medical eye.

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MEDICINE BY PROXY

Medicine by proxy is growing rapidly in the United States and I don’t like it!  It’s just not healthy, unless you are the employer/insurance company/ Medicare.

According to Wikipedia, Proxy voting is a form of voting whereby some members of a decision-making body may delegate their voting power to other members of the same body to vote in their absence, and/or to select additional representatives. A person so designated is called a “proxy” and the person designating him or her is called a ‘principal’.’”

In the case of medical care, the “principal” is my patient and the “proxy” (in past times, the physician was the “proxy”) is now the insurer/Medicare.  While proxy voting may work well in the political world, it fails miserably in the medical world.

First, let’s look at how a proxy works in the political arena. “Principals” and “proxies” should have closely aligned goals and aspirations.  If I designate my neighbor as my proxy for a neighborhood association meeting, I know my neighbor will vote both on and in my best interest.  If my neighbor and I disagreed about what was in my best interest, I would never grant him my proxy.

Now, let’s explore a medical proxy.  Patient A buys an insurance policy with Charge’em and Screw’em of America (CSA).  Patient A signs on the dotted line, having no real idea what he is buying and what his rights are.  He also doesn’t know what rights he signed away.  Patient A expects that the medical care provided by his doc will be covered by his new “proxy,” CSA.

CSA’s goal is to make a profit!  Their goal is to cover as little medical care as they can and immediately start exercising their proxy.  How?  Let me explain.  Patient 

A has hypertension that is well controlled on Exforge and high cholesterol, also well controlled by a medication called Crestor.  CSA does not want to pay for either medication as they will cut into the company’s bottom line, so they exercise their proxy by refusing to pay for Patient A’s medication or by requiring a mountain of paperwork from the patient and his doc.  

CSA, the proxy, inserts itself between the patient, the pharmacist and the patient and often is successful in forcing a change in the patient’s care.  Many times, the change is financially costly to the patient (increased number of office visits and additional testing to stabilize the patient on the new med), as well as medically harmful.

So, what’s a guy to do?  You’ve got to have insurance, don’t you?  Of course, you do; but you should know everything about your insurance coverage and your rights under your policy.  You should also recognize that your insurance company does not have your best interest in mind!  You should not allow them to dictate your medical care.

Freedom has a price!  In olden days, people had a Christmas fund where they socked away money for next year’s presents.  It’s time to establish a Health Savings Account where you sock away money for next year’s medical expenses.  Going to the dinner and the movies next weekend?  Maybe a quiet meal at home and a Red Box movie would be just as fun and the money you save can be put away for future health needs.

If you are going to choose a healthcare proxy, chose your doc, not CSA!  If there is a safe and less expensive alternative, trust that he’ll find it!   Most of us are acutely aware of our patient’s financial problems and the cost of healthcare.  I didn’t go to medical school to bankrupt my patients!

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MEAN PATIENTS

MEAN PATIENTS GET WORSE CARE

You know who you are, or do you?  I was fairly lucky.  Over the years, I had relatively few mean patients. On the other hand, my staff had a fair number of mean patients.

Why the discrepancy? While it was easy to be mean to my staff, it was relatively hard to be mean to me.  I never understood the logic behind pissing off my staff.  My staff controlled the flow through the office.  If you wanted to see me, you had to go through them.  Yelling at them, insulting them and being overly demanding not only ruined their day, but ruined my day as well.  Trust me, you want to see a healthy and happy physician.

I was trained in conflict management and never hesitated in pointing out inappropriate behavior.  Disarming an angry patient was usually easy, but it was always time consuming.  Wasting clinical time was always a pity.  It’s no wonder that mean patients get worse care as half of the visit is spent resolving whatever is making you mean.

Click on the hyperlink to see a Zdogg video on this topic.  I particularly like Zdogg’s advice on how to interact with your doc.  Your doc’s office staff is there to help you.  Be kind to them.  Remember, if you don’t like how they do things, discuss your issues with the office manager or the doc.  In my office, Renee, the insurance companies and I set the policies and my staff followed them. 

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1984

Renee and I opened Lake Zurich Family Treatment in 1984.  We were broke and the banks did not want to lend us any money as NO ONE HAD HEARD OR, OR COULD IMAGINE A WALK-IN FAMILY PHYSICIANS OFFICE.

Our attorney and financial advisors were sure that we would have a negative cash flow for 2-3 years.  Despite such dismal projections, I signed the lease and construction began.  My earliest patients met me while we were still under construction.  I worked at Northwest Community’s ER during the day and installed ceiling tiles and laid flooring at night.  

It was summer and the TCBY was open.  People would stroll into the office and ask me if I knew anything about the new doc hose practice was opening soon.  I told them that I personally knew Dr Segal and he was a great doc. I also told them that he was pretty good at installing flooring and ceilings.

The landlord met with me and informed me that someone was working in the building at night and the union was threatening to shut down the site.  He was surprised to find that the “someone” was me.  When he told the union crew that the night worker was the doc and that the doc was broke, they stopped working on the rest of the shopping center and finished my office.

In those days, being a doc garnered a lot of respect.  Being a doc who would get his hands dirty garnered even more respect.  When times were bad, I could always look at the exam room floor and smile, knowing what I was capable of creating.

One of the individuals who strolled in late at night when I was working as a laborer was Tom, the local independent pharmacist.  Tom welcomed me to the community and taught me how important it was to have a family pharmacist on a patient’s healthcare team.  Tom would call me if my patient failed to pick up his/her prescription or if someone had a problem with their meds.  He would also help those who could not afford their meds.

When Osco opened, Vicki (a pharmacist) assumed the same role, becoming a vital part of many patients’ healthcare team.  Over time, things changed.  The Oscos of the world, insurance carriers and pharmacy benefits managers (PBMs) put Tom out of business.  The major pharmacies started rotating multiple pharmacist through their stores and the family pharmacist became extinct.  With few exceptions (the pharmacist at Marianos in LZ), a major part of a person’s healthcare team disappeared.

WHAT A PITY!!!

Once again, ZdoggMD has done a brilliant piece on the modern-day pharmacy.  Please click on the hyperlink and listen to what he has to say.

In the next few days I’ll write an article on “Pay For Performance” and the shift from medicine being a calling to medicine becoming big business.  Stay tuned.

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TO MEDICATE OR EDUCATE

To educate or to medicate, that is the question!  Education takes time and time is something most physicians are short on.   Education takes a commitment from both physician and patient.  The physician must commit to keeping up on the most modern treatment options and providing the patient with fair balance.  The patient must commit to acting on what he/she learns in a positive manner.  Let me give you an example.

Patient A has diabetes in its earliest stage.  His physician gives him a choice of either starting on medication or changing his lifestyle.  His physician gives him an overview of diabetes and the diabetic lifestyle along with a referral to a nutritionist as well as reputable internet sites to help him on his journey.  Patient A chooses to take the education route and does a great job!  I called Patient A tonight to congratulate him.  His most recent blood panel was one of the best I have ever seen.

Unfortunately, Patients B-Z also chose the education route but failed to follow through.  After a while, physicians get tired of wasting their breath tying to educate patients.  For every Patient A, there are 25 patients who fail to take their lessons to heart.  There are 25 patients who don’t have time to do their homework.  Twenty-five who promise to do better in the future.  “Doc, give me 3 more months and I’ll show you I can do it.”

Unfortunately, medicating a patient is easier than educating a patient.  It takes less time.  It is more likely to work, rewarding the patient and his physician with a modicum of success.  It is less likely to end in disaster and is more defensible in court.  So why not medicate everyone?

It’s a slippery slope.  Your doc starts you on medication and asks you to start working on changing your lifestyle.  Your blood sugar improves a little.  You want to celebrate with a banana split.  Why not?   You can take a little more of your medication.  Five years later, you are on lots of medications.  Rather than lose 20 pounds, you’ve gained thirty.  The dire effects of the diabetes and medication have snowballed.  You would change your lifestyle and start exercising but your back is bad and the incision in your chest from bypass surgery hurts like hell!

To educate or to medicate, is there really any question which one you should choose?  Help your doc by following his instructions, taking your medication as directed and following up when requested.  Make educating easy and successful.

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EMRs ARE NOT ALL BAD

While I used to spend much of every day cursing my computerized medical record (EMR) for its constant breakdowns and shortcomings, there are a few good things about it.  One indispensable computer task was when it reminded me to call a patient and prompt him to get his follow up chest x-ray.

Your new MD is responsible for several thousand patients’ healthcare.  Each patient generates tons of paper (computer data points).  The part of medicine patients never see is the paperwork.  In the case of Mr. X, he was ill in April and I ordered a chest x-ray.  The results of that chest x-ray came back a day later and were scanned into his chart by a clerk.  The clerk then sent the scanned results to my desktop for my review.

In the computerized world of medicine, orders have to be reconciled and processed, passing through multiple hands.  Once on my desktop, I reviewed the results and, because they were marginally abnormal, contacted my patient with instructions to repeat the x-ray in 3 months.  A new order for a repeat chest x-ray was then sent to the hospital and an electronic reminder was set to alarm today.

The beautiful part of the EMR kicks in and your MD is notified.  An alert notice lit up on my desktop, my patient was called and will do his part.  Hopefully, the x-ray will be normal and this story will have a happy ending.

I’ve always told my patients that if they can make something good come out of something bad, then the bad was not so bad after all.  The computer’s ability to send reminders may be its only true value.  Funny, the bad still seems just as bad.  I guess I was wrong!

The moral of today’s story is not that EMRs are bad.  Today’s point is that there is a mountain of paperwork/computer input associated with every visit.  Your doc needs your help!  How can you help?  Be a responsible patient.  If you have a smart phone, set your own alarms to remind yourself when important follow up appointments need to be made and keep them.  Learn to use your patient portal and keep track of your results and your doc’s comments.  Most of all, forgive your doc for typing away at the keyboard during your next visit.  He/she does not like it any more than you do.

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HELP SAVE A DINOSAUR

I’m bored!  I hate being retired.  Many of you have called to let me know how frustrating it is to find a new doc.  Apparently, many of the practices in our area are closed to new patients.  There is a growing shortage of generalist, family physicians and internist in our country. My sudden retirement has made that shortage readily apparent in the northwest suburbs of Chicago.  

Today, while cleaning up some old files, I came across this article.  Family practices across the US are disappearing.  Reimbursements are dismal and expenses continue to rise.  While I miss seeing my patients, I am happy to be rid of the hassles and disappointment associated with billing and collections.  Doctors are not paid for their services.  Doctors are reimbursed by an insurer at an ever-decreasing rate at some time in the future.

Your physician is not raking in the money!  In all probability he/she is struggling to keep his/her practice a float.  I know that sounds ludicrous, but I assure you it’s true!  The private practice of medicine is financially non-viable.

In a world where 20% tips are often added to your restaurant tab, where you tip the garbage man at Christmas, your hair dresser and just about every one else who provides you with a service, you don’t tip the one person who works to keep you healthy and treats you when you are sick.  I’m going to catch a lot of shit for printing this but perhaps you should consider tipping your doc.  The odds are he won’t take it, but I bet he goes home feeling truly appreciated.

Remember Dr. P.  Dr. P. and I practiced in a time when patients paid in cash, brought presents to the office (usually food) and appreciated our care.  Of course, as we actually got paid for our services, rates were much lower.  Sports physicals were $5 a child when I first started in practice.  A visit for a sore throat was less than today’s copay.

Then, everything went haywire and the insurers dismantled and destroyed a beautiful thing.  Unfortunately, the article I wrote in 2013 is even more pertinent today.  You can help.  How? Read on.

July, 2013

“Doc, it’s only $10. I can’t believe you’re throwing me out of the practice for a measly $10. You, docs, are all the same. It’s all about the money!” Unfortunately, the money is important. It costs money to keep a practice running. It costs money just to collect the money owed to the practice. Sometimes, it’s not only $10; tonight’s was only $100! My question is always the same: if it is only $10, $20, or even only $100, why not pay it when the bill comes?

The answer is often the same, “My spouse pays the bills. This letter terminating our relationship is the first I’ve received. If I had known I owed you money, I would have paid.”

So, let’s look at some simple facts. Your physician’s office is one of the few places where you can receive advice, services, and materials without payment at the time of receiving them. Can you imagine leaving Jewel without paying for your groceries or picking up your car from the mechanic without settling the bill? Of course not!

Once your physician cares for you or your family, his billing department (yes, department, it takes many employees to process and bill for his services) sends your bill to your insurance companies. Your physician then waits for his reimbursement and for your insurer to decide what portion of the charges you are responsible for.

Once your responsibilities are determined, a billing clerk sends you bill number one. I’m sad to say only thirty percent of patients pay bill number one. The other seventy percent receive bill number two. When bill number two is going out, my staff makes a call.

“Mr. ‘X’, this is a courtesy call to let you know that you have a balance of $xxx. Would you like to pay by credit card now? No? You will receive another statement in the mail shortly and we would appreciate your sending payment. We will be glad to work with you.” Very often, messages must be left asking our patients to return our calls and they never do make these return calls.

When the bill still hasn’t been paid by the time the third bill cycle comes around, the billing clerk makes another phone call similar to the one before trying to make payment arrangements that are comfortable for the patient. We know these are hard times for many people and we want to know what is comfortable for you. All we ask is that you make a commitment to pay your balance and then honor this commitment each month. We ask for you to communicate with our billing staff, not ignore them. The balance will not go away. They will help you!

After the billing department has had to send out three billing statements and make multiple phone calls, this patient has added to your physician’s overhead and the bill is still there. Finally, after months of continuing to “care” for you while you continue not to pay your balance, we turn your account over to the first level of collection. At this stage, we still will see you as a patient while you are receiving letters from the collection company; and we are hoping that you will pay your bill and all will return to normal.

There are many opportunities, even at this point, to settle the account and make payment arrangements. It just takes communication and desire. However, if you do nothing and this first part of the collection process runs its course, the final step occurs. The patient is sent a certified, return receipt letter, along with an identical first-class letter, informing him that he has been discharged from the practice. 

It is, at this point, that the patient who has “never received any bills” shows up. The patient is irate! It’s only $100. “Doc, you need to take a lesson in caring! It’s all about the money, isn’t it?” Funny, the termination letter was sent to the same address as every other statement, collection letter, and bill; and it was received!

Meanwhile, 100 patients who refuse to pay the seemingly trivial amount of $10 they owe cost the practice $1000. You do the math. It adds up to a lot of money. It may sound strange to you but $10 is a significant amount of money to your family doc. Your family doc doesn’t have any high-priced procedures to pay the bills with. Your family doc needs the copay and needs you to take care of the bill that you generated when he took care of you. Also, keep in mind, that the $10 you don’t pay doesn’t take into account how much it costs us to re-bill you two and three times.

I am going to repeat this. We know times are hard. Talk to my staff. They will work with you. If you get a statement and you think there is an error, call immediately. Maybe there is an error. Help my staff fix it. Don’t wait until it is too late to refile or fix a claim. If the statement is correct but you can’t pay the balance, be honest and set up a payment plan. Just make the promise and carry through monthly. By being honest with your doc, you can help lower his overhead and preserve your relationship. By avoiding the subject and not responding to your debt, you leave the impression that you do not value your doctor’s care and his staff. 

Remember Maki’s favorite line, “Help me help you.” Help us help you by paying your first bill or letting the billing staff know what’s going on. Do not rely on your spouse to pay the bill: it’s your debt, your relationship with the doc, and your responsibility.

One last piece of advice. When you’ve ignored the bill or waited too long to address it, don’t be threatening, belligerent, or insulting. Take responsibility, pay the bill, and write an apology. Maybe you can salvage the relationship; maybe you can’t. A simple “I’m sorry, times have been tough” goes a long way.

So, why am I writing this series of articles.  Medicine should have never become a business.  It has been and always should be the calling that brought me to Lake Zurich.  Those dinosaur-like physicians who struggle to stay in independent practice need help.  They can’t tell you that they need help.  Our profession is a proud one despite everything that has happened to us and very few of us will tell you the truth.

I can.  I’m retired and old enough to speak my mind.  

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WHAT’S HAPPENING TO YOUR DOCTOR

I’ve been working on a series of articles designed to help you understand what’s happening in your doctor’s life.  I think understanding your doctor will go a long way to helping repair our broken system.

Let me explain.  I have been powerless in my attempts to change what’s happened to my beloved calling.  I have watched the demise of the Marcus Welby style medicine I grew up with and seen it replaced by a cold and data driven corporate model.

There are many physicians who feel the way I did in the latter years of my practice.  Each answered their calling and started their medical careers with the best of intentions.  Each struggle to keep their private practice up and running.  In the end, all will fail and ultimately sell out to corporate America.

We, the doctors who have answered our calling have become like the dinosaur; extinct.  Some retire, some die and unfortunately, some commit suicide.  All, unfortunately, are misunderstood by their patients.  All end up feeling powerless.

This morning I awoke to find the following video on my desktop.  ZdoggMD is brilliant and is on the right path in trying to bring doctors and patients together in an attempt to create a new approach to medical care as am I.

If we are ever going to change our system, we are going to have to work together, patient and doctor.  The first step is to help you, the patient, understand how we got here and who your doctor really is.

Click on the highlighted ZdoggMD and watch this short video.  Please watch the second video as well. Tomorrow, my series will continue.

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