Author: wellthy

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. 

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.

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.

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.

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.  

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.

Is medicine a profession or is it a business?  To us old timers, medicine is first and foremost a profession; a calling.  As such, the business of medicine has always come second.  Unfortunately, neglecting the business side of medicine has led to my profession’s downfall.

Fast forward to current times.  Medicine has become big business.  Companies such as Walgreens have led the charge.  Obamacare has led to the creation of Accredited Care Organizations owned by corporate entities and poised to suck every available penny out of my once proud profession.  Physicians, Nurse Practitioners and Physician Assistants have become corporate America’s service technicians and patients have become cost centers to be controlled and serviced in mass.

What’s behind the changes in medicine?  Profits!  America’s leading healthcare companies have figured out the business end of medicine and are going at the business full gun.  Pharmacies are now doing acute and chronic care in their Quickie Clinics.  Does anyone see a problem here?  I certainly do!

In past articles, I have written about the ethics of selling cigarettes in a facility that administers care and medication to sick smokers.  Corporate America has taken greed to a whole new level.  Apparently, it is OK to help someone develop chronic obstructive lung disease and then treat him for his chronic illness for the remainder of his life.  

The treatment of chronic diseases entails more than just writing a prescription. It entails helping the patient develop healthy lifestyles.  Will the store front practitioner who is treating a patient for diabetes walk her through the store and show her everything she shouldn’t buy or will the sale on large bags of Reese’s Pieces catch the patient’s eye and will he/she end up with several bags of the sugary delight in their cart?   Will the three 12 packs of Coke for $9 sale be the diabetic shopper’s reward for purchasing his/her healthcare at such a convenient location?

Will the store front practitioner walk the hypertensive safely out of the store avoiding the racks of salt-laden chips and pretzels?  I think not!  Instead, the store designers will continue to set up food gauntlets designed to lead the customer to the most profitable products and fill the corporation’s coffers.

The business of medicine is the end of medicine as us old timers know it.  Ethics and morals will change and it will become completely ethical to sell an obese individual a diet pill, a six pack of Millers, chips, pretzels and candy.   If you can sell cancer sticks in a place of health, hell, you can do anything!

First, let me tell you that, if I could do it all over again, I would still be a doctor.  I would still move to Lake Zurich and would still have had an walk-in, open door policy.  Yes there are things I would change, but the basics would be the same.

Second, I have led a gifted life.  In telling you the truth about being a doctor, I am not looking for sympathy but instead, I am looking to bring you and your future doctors into a closer patient-doctor relationship, one that might be strong enough to actually change the future of medicine in the US.

THE FUTURE OF MEDICINE IS DISMAL!  Medicare for all is not the solution.  Medicare for all is the end of humane medical care!  Just look north to Canada to get an idea of what’s coming.

Now, back to my story.  It starts when I was seven years old and had a sore throat and fever.  Dr. P. came to my house to care for me.  I remember Dr. P’s visit as every time he made a house call, I got a shot in the buns.  Dr. P. was a general practitioner.  There were no family docs in 1958.

Dr. P. was a respected member of the community.  Many placed him on a pedestal.  Afterall, he delivered your babies, cared for your family, took out your gallbladder and did birth to death care for your extended family.  Most importantly to you, he helped create the doc that took care of you for the last 34 years.

Dr P’s office was like mine, first come first served.  Dr. P’s wife worked in the office, as did mine.  Dr. P made you wait your turn, as did mine.  I never heard anyone complain about the wait.  Unfortunately, that’s where the similarities ended.

By the time I hung out my shingle, the world had begun to change. The respected position that Dr P’s cronies occupied had already begun to crumble.  My colleagues and I mortgaged our futures to pay for medical school.  We gave up our 20s to gain the education and credentials needed to answer their calling, and it only got worse. We found that in order to pay our overhead and make a living wage, we had to work 80 hour weeks.

Today’s graduate has $400,000 or more in debt.  The dream of owning their own practice is gone!  Today’s physician is an employee whose rules are set by the corporation that employs him.  Medicine is now a big business and those of us with a calling, drown trying to fight the current that pushes us further and further into the computer monitor that sits between the patient and his/her doc.

I’ve gotten off track.  Every time I told Dr. P. that I was going to be a doc like him and join his practice, he told me that the practice of medicine was changing, and I should find something better to do with my life.  I ignored him.  I’m glad I did.

By the time I graduated, health issues had forcibly retired Dr. P. Again, I followed in his footsteps.  I opened my own office.  My wife ran it and, in the end, struggled to keep us financially afloat.  And, in the end, health issues retired me.  Strangely enough, Dr. P. has Parkinson’s as do I.

Is your doctor rich?  Everyone assumes he/she is.  Everyone (including his/her staff) assumes that docs rake in the cash.  Unfortunately, it’s not true.  Yes, physicians make a good income, but they work long hours (I often worked an 80-hour week), spend a great deal of time away from the family while on call, and have massive debt to service.  Oh yeah, they still have to deal with life and death situations on a daily basis as well.

Well, I got off track again.  I’ll resume tomorrow.  I hope you will stick with me as I think giving you an understanding of who your doc is will help you work with your doc to improve everyone’s lives.

I’ve written about it before and I’ll probably write about it again — it’s an emergency until proven otherwise. Chest pain is an emergency until it is resolved and proven to not be of cardiac origin. Abdominal pain is an emergency until it is properly diagnosed and treated. The worst headache you have ever had is an emergency until your brain scan is reported as normal.

Yes, I admit it. I overreact to a lot of things. I am a pessimist by train, always guarding against the unseen enemy. I have to be! If I agree with your husband and treat his chest pain as indigestion, I may treat you for depression after the funeral. If I agree with your insistence that your abdominal pain is just the stomach flu, I may have to teach you to change your colostomy bag. If I underestimate your headache and give you the pain pill you are asking for, I may visit you in the nursing home the rest of your life.

Agreeing with you makes you happy the majority of the time. By the same token, disagreeing with you ticks you off when the tests all come back normal and you have to pay for the workup. You get a big, “I told you so!

It’s an emergency until proven otherwise, and, when the heart attack is real, I’m a brilliant diagnostician, an excellent doc. I saved your life. When it’s indigestion, I’m that quack who overreacts to everything. So, who am I?  Am I a brilliant diagnostician or a quack?

The answer to that is easy. I am your doc, working hard to keep you safe and well.  Like every other doc, I use my experience, knowledge, and evidence to create a differential diagnosis that is appropriate for your symptoms and then I act to protect and heal you as best I can. I don’t have to be brilliant. I just have to care for and about you. While I may be wrong about what ails you or, in retrospect, misspent your money, I am not a quack.

So, the next time I ask you go to the ER, please go! The next time I order an MRI, please get it! The next time I ask you to come to be examined, please don’t argue! I can’t examine you over the phone. There are things that can be done in the ER that I cannot do in the office. An MRI can find things that a physical exam cannot uncover.

One last thing. If it makes you feel good to say, “I told you so”, then say it. If not, then I would be grateful for, “Thanks, doc, for looking out for me.”

Our greatest glory is not in never falling, but in getting up every time we do. 

Confucius
Chinese philosopher & reformer (551 BC – 479 BC)

A very wise man, named Gary, posted this quote on his facebook page; and I fell in love with it.  There are multiple ways to fall.  My patients fall literally, bruising, breaking, and lacerating their bodies. Then there is falling in a figurative sense.  My patients fall from grace by cheating, lying, or worse.  They fall out of love.  They fall off the wagon, off their diet.  They fall for the wrong person.  Falling is a human trait.  Falling leads to suffering and misery.  Getting up from a fall leads to recovery.

Confucius was right. What separates humans is not the act of falling, but the act of getting up, dusting yourself off and repairing the damage that leads to glory.  Over the last 30 years, I have seen many of my patients fall and injure themselves.  I have witnessed every type of a fall and some truly miraculous recoveries.  After reading Gary’s post, I realized the people I admire the most are people who keep getting up no matter how they fall or how often they fall.

Gary’s post was very timely.  As many of my readers know, I have started taking my own advice, eating properly, exercising and generally appreciating life. I want to warn you:  The older you are the harder it is to get up after falling.

I fell off my diet and exercise routine over the last few months.  Between the surgery, the Parkinson’s, and the depression accompanying the loss of my profession, I was attacked by the “too die for” foods of my past and I succumbed.  I was having trouble returning to my healthy lifestyle until I read Gary’s post.  “Our greatest glory is not in never falling, but in getting up every time we do.”  I’m up on my feet and back on the right path.

The next time you fall, get up as fast as you can.  If you can’t get up on your own, call for help from a friend or family member.  If you hurt yourself, get help.  When you can’t admit you fell due to personal pride or shame, recognize we all fall at one time or another and the true glory is in getting up!  

Confucius should have added an addendum.  Once you are back on your feet, learn from your fall.  Knowledge will protect you from the pitfalls of life.  If you can’t stop falling, you may need a cane, walker, psychologist, or priest.  Whatever the cause, get help!

Be happy, be healthy!