by Danielle Ofri, MD, PhD
If asked what a doctor does, most people would probably come up with the standard description of diagnosing and treating disease, usually while wearing an ill-fitting white coat. Before I entered practice, even during my medical training that probably would have been my answer too.
But my years in the trenches of real medicine have altered that definition greatly. I do spend time doing the things I learned in medical school like diagnosing disease and writing prescriptions, but that turns out to be only a part of the job, often a very small part.
Much of the time I find myself acting as sounding board. Recently I saw one my regular patients, a woman whose main medical issue is hypertension. But for most of our visit she spoke, often tearfully, of the strain of raising grandchildren since her daughter died of HIV. We never really got to her hypertension, and I certainly didn’t have any easy answers for her difficult life situation, but this seemed to be the only time and place that she could devote to her own issues.
A good portion of my time is spent being a teacher. So much of medicine involves education-talking about what a disease means, which medication side effects are important to watch for, how to plan a healthy diet, which screening tests are important, what a particular diagnostic test entails, what the various lab results mean, and so on.
Then there are the many niggling clerical tasks-filling out forms, calling insurance companies, obtaining prior authorizations-the annoyances that add an unpleasant grumble to the day.
But when I think about what might be the overriding job description, the one that not only incorporates the above but also extends to the more existential aspects of medicine, I see the doctor as a translator.
For most people, medicine is a foreign country, with its own language, customs, and mores. My patients are immigrants to this country, and many feel very disoriented. My job, as their physician, is to translate this alien world for them, to help them acclimatize and hopefully thrive.
Jhumpa Lahiri used a beautiful phrase for the titular story of her marvelous first book: “The Interpreter of Maladies.” Doctors, of course, fit this bill-we are constantly interpreting our patients’ maladies-but we are also interpreting the greater culture of medicine.
Being a translator can often be burdensome. It is not enough, as a doctor, to assemble the clinical details, deduce a diagnosis, compose a treatment plan. You also have to be sure the patient understands it all-and that can be an infinitely harder and longer process.
But there are also many joys to being a translator. I once had a new patient who suffered from both osteoporosis and osteoarthritis. Her previous doctor had worked out a meticulous treatment plan, including hand-written charts of how and when to take each pill. Yet, the patient was entirely confused about her medications.
After a complicated conversation with many false starts, I finally realized that the patient thought that osteoporosis and osteoarthritis were one and the same thing. The pills for each condition were dumped into a communal pill bottle and taken in a random manner.
My “diagnosis” was that this patient did not have a full understanding of the language of medicine and that these terms had never been fully translated for her. We spent a long time going over the difference between osteoporosis and osteoarthritis. It wasn’t easy, but by the end of our visit she had a basic comprehension that these were two different diseases and the medicines were treating entirely different things.
This patient had many more serious medical conditions to contend with, but she seemed delighted at this small victory, that she finally understood these diseases, that she finally “owned” this aspect of her health.
There was, of course, no place on the insurance form for this sort of effort. The insurance company would never pay my hospital for the painstaking “translation” work that is so critical to good health. But that’s the reality. Luckily there is the patient’s happiness and hopefully improved health that is the real payback.
Danielle Ofri is writer and practicing internist at New York City’s Bellevue Hospital who blogs at Medicine In Translation. She is the editor-in-chief of the Bellevue Literary Review. Her newest book is Medicine in Translation: Journeys with my Patients.
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{ 7 comments… read them below or add one }
I agree. My primary practice is ICU and Hospital medicine. There is just so much more to it than seeing patients, writing orders, managing vents etc. Talking to the patients and their families takes a significant portion of my day. Some family conferences take more than an hour. For the families to be able to make decisions regarding their critically ill loved ones, you have to provide a lot of education. Sometimes, you have to do it again and again.
At the end of your day, when you sit down to do your billing, you realize that much of the work you did today cannot be billed for. And it’s Ok, since that what it takes.
The CPT codes allow you to upcode according to time when you spend most of the time counseling. So there is a place on the insurance form for the effort as it can be reflected in the CPT charge without meeting the history, physical, and complexity criteria.
Yes, you are right. There is a code for a prolonged care. The problem is that it has to be provided at the bedside so family meeting in a conference room would not qualify. And, I believe Medicare (most of our patiens) still would not pay for it. Having said this, I am not a coder and I might be wrong about some of it.
In reality though, I don’t really care if I am going to be paid for it or not, It just something that needs to be done.
“Much of the work you did today cannot be billed for.” Hence the primary care shortage.
If memory serves me the “Interpreter of Maladies” in the story was not an MD but a taxi driver the woman on the trip told the story of her affluent self-centered life.
Ralph:
If you don’t care if you get paid for it, then who does? If patients and third party payors aren’t going to attach more monetary value to your time than you do.
The attitude of feeling superior and generous about ones self-sacrifice is fairly strong in primary care and is a false generosity. It’s end result is to obstruct the fulfillment of the needs of patients. It is because this generation of primary care doctors have failed to demand that an appropriate value be put on their labor that they next generation of patients may not access to primary care physicians at all.
I agree whole-heartedly with commitment to patient need and to the ethical requirement of not abandoning ones patients or of not reducing service based on discovering that the one will not reimbursed. But one must not denigrate the value of the work and must defend that value in every way possible (usually by collecting for it!) as a obligation to the well-being of the profession for the benefit of the patients it serves.
There absolutely are codes to cover prolonged, face to face physician services. You need a good coder but more than anything you need good documentation.
It does take some extra paperwork (i.e. notes documenting the encounter), but it pays to be a compassionate physician. The compensation is not simply monetary. It is good for the patient and it is good for a doctor to be empathetic and responsive. I don’t think I would be too presumptuous to say that is what most people had in mind when they went to medical school.
It is a good thing to be good TO people not just good FOR people. It is even better to get paid for it.