Patient complaints do not fit the primary care office visit

Primary care physicians often have to see patients with a litany of issues.  Often within a span of a 15-minute office visit.

This places the doctor in the middle of a tension — spend more time with the patient to address all of the concerns, but risk the wrath of patients scheduled afterwards, who are then forced to wait.

And, in some cases, it’s simply impossible to adequately address every patient question during a given visit.

It’s a situation that internist Danielle Ofri wrote recently about in the New York Times.

In her essay, she describes a patient, who she initially classified as the “worried well”:

… a thin, 50-year-old educated woman with a long litany of nonspecific, unrelated complaints and tight worry lines carved into her face. She unfolded a sheet of paper on that Thursday morning in my office with a brisk snap, and my heart sank as I saw 30 lines of hand-printed concerns.

Ms. W. told me that she had recently started smoking again, after her elderly mother became ill, and she was up to a pack a day now. She had headaches, eye pain, pounding in her ears, shortness of breath and dizziness. Her throat felt dry when she swallowed, and she had needling sensations in her chest and tightness in her gut. She couldn’t fall asleep at night. And she really, really wanted a cigarette, she told me, nervously eying the door.

This is the kind of patient who makes me feel as though I’m drowning.

Dr. Ofri did as many doctors do, she listened appropriately, went over the patient’s history and physical, reviewed prior tests, and concluded that many of her symptoms were due to anxiety.

Except, in this case, they weren’t. The patient eventually had a pulmonary embolus, and hospitalized.

In Dr. Ofri’s poignant words,

the truth was, any of her symptoms might have masked a life-threatening illness. Headaches could have been a cerebral aneurysm. Needling sensations in the chest could have been angina. Pounding in her ears could have been a brain tumor. But I had to rely on my clinical judgement that it was extremely unlikely for her to have all of these serious conditions simultaneously, so I chalked it all up to stress. And I was wrong.

She did the right thing, apologized to the patient and told her what happened. But therein lies the conundrum that doctors face.

Should every patient’s symptom be tested for the unlikely risk of something dangerous? In the current practice environment, where doctors have decreasing amounts of time to see patients, and mistakes are dealt with in an adversarial malpractice system, the incentives all point to the affirmative. The subjectiveness of clinical decision making is poorly tolerated in the United States.

I like Dr. Ofri’s suggestion of prioritizing complaints, and explaining to patients that only so much can be done within the constraints of a 15-minute office visit. In fact, that’s exactly what I do.

But I’d be willing to bet that she’d be more prone to order that D-dimer or CT-pulmonary angiogram the next time she’s faced with a similar patient.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

Comments are moderated before they are published. Please read the comment policy.

  • http://www.managemypractice.com Mary Pat Whaley

    Staff who schedule appointments also need to be trained to discern patients with multiple complaints needing more time by asking “Do you have other issues you’d like the doctor to discuss with you at this visit? If so, I need to give you a longer appointment.” Patients can be hesitant to reveal everything on their list (especially if anything on the list is embarrassing), but everyone wins if the patient can be scheduled for a longer appointment. This doesn’t work for acute visits, but as mentioned, the most pressing issues can be addressed now and a follow-up appointment made for the balance. A one-size appointment does not fit all established patients.

  • http://dlmcblog.com meghmala

    It is a common problem in our country.We don’t know where we can get good medical treatment.

  • M Camp

    I agree w/ Mary’s comment -at least that would help the situation bc patients are not one size fits all. When making the appointment, the patient could be asked if it’s a “wellness visit” (ex. getting a yearly physical) vs wanting to see the doc regarding a particular acute ailment vs wanting to see the doc about multiple ailments.

    Also, maybe the patients could have a checklist of sorts so the doc could prioritize and be sure he’s seeing the big picture. I’m not talking about the ton of paperwork patients are asked to complete upon each visit-just something to help both the patient & the doc.

  • AA

    Dr Pho said,

    “The subjectiveness of clinical decision making is poorly tolerated in the United States.”

    With all due respect, you are missing the point.

    Patients would have alot more respect for doctors if they admitted they didn’t know the diagnosis. Instead of dealing with their own inadequacies as a clinician, they essentially blame the patient by saying it is all in their head.

    You go on to say,

    “”Dr. Ofri did as many doctors do, she listened appropriately, went over the patient’s history and physical, reviewed prior tests, and concluded that many of her symptoms were due to anxiety.””

    Hmm, I am puzzled by this remark since Dr. Ofri said, This is the kind of patient who makes me feel as though I’m drowning.

    It seems like already she was tuning out her patient.

  • pcp

    Mary and M Camp don’t understand how primary care docs are paid. We are paid more to see two patients with uncomplicated sore throats, than one patient with complicated problems. If I spend an hour with a patient, I am not paid enough to cover my overhead. I don’t know of any office that will give a patient a longer appointment at their request. It’s a lousy sytem, but doctors are powerless to change it.

    AA: a subjective feeling of drowning on Dr Ofri’s part (a common response, no matter what your job is) in no way implies that she “tuned out” the patient.

  • Finn

    @pcp, aren’t there different codes for different types of visits, such as annual physical vs acute-care visit vs monitoring chronic conditions? I don’t think anyone expects their PCP to provide an hour-long visit while only being compensated for the first 15 minutes of it.

    • pcp

      Yes, but the numbers don’t work out. Two level IIIs, in my neck of the woods, pays much better than one level IV. Code a level V more than once in a blue moon, and you’re setting yourself up for regular audits. The payment for physicals has been so reduced that no new problems can be addressed during that visit.

      And yes, many people do expect an hour of the doc’s time when they are only scheduled for 15 minutes.

  • Taylor

    It is a wonder anyone goes to medical school or wants to be a doctor anymore. Reading these articles makes me really feel for my doctors. The insurance companies, bureacracy, and everything it takes to get paid sounds like a real nightmare. There has to be an easier way for the doctors to provide a service and then get paid (a fair amount) for the service!

    • jsmith

      There is an easier way, several of them actually. And med students are taking them. Dermatology, radiology, anesthesiology, radiation oncology….

  • http://www.healthecommunications.wordpress.com Steve Wilkins

    From a patient perspective, I can accept the fact that sometimes there is too many issues to adequately address in a single visit. Tell the patient that up front makes sense. Negotiating an agenda up front also makes sense.

    What I don’t understand is why didn’t Dr. Ofiri just take care of what she could in one visit and then schedule a follow up appointment for the unresolved issues?

  • http://hcrenewal.blogspot.com Roy M. Poses MD

    Doctors are paid for office visits according to the type of visit (level 2, 3, 4, or 5), not according to the amount of time spent or effort made. The “codes” for types of visit are limited, so that for practical purposes, there are only a few codes that can be used for an office visit to a general internist, family practitioner, or other primary care doctor (level 3 or 4 as noted above). For the most part, health insurance does not pay at all for efforts made on behalf of a patient that do not involve face to face contact (e.g., telephone conversations, looking up information in books, articles or on the internet, filling out forms, etc)

    So if a doctor spends a lot of time with a patient with complex problems, and then looks up information and talks to consultants, he or she is paid very little more than for a routine office visit for a cold. An employed physician who ends up spending too much time on individual patients could become very unpopular, and a practice containing many such physicians would likely go bankrupt.

    On the other hand, there are thousands of codes for procedures, constantly updated and revised, and generally much more lucrative. In addition, when procedures are done in hospitals or clinics, these facilities can bill separately from the physicians’ bills.

    So the system is heavily biased towards paying physicians for doing things, and not for talking, examining, counseling or thinking.

    Of course, if primary care physicians were paid for talking, examining, counseling, and thinking, they might make more discerning diagnoses using fewer expensive tests and consultations, handle more problems themselves instead of reverting to consultants, and better explain to patients why they may not need the latest, most expensive drugs that are not necessarily better for them.

    That would be better for patients, but it would cut into the income of some highly paid specialists, the companies that make the expensive drugs and the devices used for the high-technology tests and procedures, the hospitals at which the expensive tests and procedures are done, and especially the marketers and executives of those companies and organizations. Thus it goes against the financial interests of a lot of wealthy individuals and organizations to let primary care doctors do their jobs better.

    So you will hear all sorts of complaints about any effort to reform the system to make primary care work better for patients, and all sorts of veiled denigration of primary care doctors.

    By the way, many other developed countries have systems in which primary care works much better, patients do just as well in most respects, but costs are lower. However, people who point that out may get their patriotism questioned.

    By the way, much of the blame for this mess should accrue to how Medicare handed over control of its “Resource Based Relative Value Scale” payment system to a secretive committee run mainly by doctors who do procedures for why primary care is in such dire shape. See our latest post about it on Health Care Renewal and follow the links:
    http://hcrenewal.blogspot.com/2010/10/ruc-it-up-how-us-government-fixes.html

    Ask the people who defend the status quo by cloaking themselves in supposed free market ideology to address that example of regulatory capture/ corporatism and watch the sparks fly.

    • ninguem

      Roy M. Poses MD – “So if a doctor spends a lot of time with a patient with complex problems, and then looks up information and talks to consultants, he or she is paid very little more than for a routine office visit for a cold…..”

      Agree completely of course. Which is why the nurse-practitioner clinic in the pharmacy wants those routine visits.

  • http://www.BocaConciergeDoc.com Steven Reznick MD

    It is very hard to understand from the story what actually transpired , other than a complicated patient with multiple nonspecific complaints went to see her doctor because she did not feel well. It is clear that both employers and insurers and government bureaucrats in an effort to keep the cost of health care down have created a high volume system which minimizes the time a doctor has to take a thorough history and do an appropriate exam. It is always best when a doctor has the opportunity to get to know his patient and can visually see that they are ill. Disease states like pulmonary emboli are very hard to diagnose if the symptoms and history are nonspecific. Information such as the patients color, skin temperature and color, pulse rate, blood pressure , temperature and respiratory rate all help. Visually observing if she is using the accessory muscles of respiration helps. An inexpensive battery powered finger oximeter can be used to tell if the patient is hypoxic or not ( by measuring her oxygen saturation.).
    In todays medical climate a clinician has to recognize if a patient is ” sick” and requires further evaluation and testing. It helps to know the patient and know what she looks like when she is well. With patients changing doctor from year to year because their insurer changes insurance plans from year to year, this is sometimes a tall order .
    In today’s society there is little or no value placed on paying to have an experienced, competent and compassionate physician care for you . The latest smartphone and iPAD have more value and heaven help if the doctor visit involves a copay requiring $25 -$50 out of pocket at the time of the visit. There is a story told of a wealthy man choking to death on a piece of food. An experienced doctor rushes over and performs the Heimlich manuever and saves his life. When the grateful patient regains his composure and breath he asks the doctor how much he owes him. The doctor replies ” one tenth of what you would have paid me when the food was caught in your windpipe.”
    The public wants physicians to be perfect even though they dont know the patient, dont have adequate time to evaluate them, must always be on time or be considered rude or insensitive, and in most primary care offices can not afford to hire the best support staff who can actually triage medical problems correctly.

    • http://Www.twitter.com/alicearobertson Alice

      Steve says: The doctor replies ” one tenth of what you would have paid me when the food was caught in your windpipe.” [end quote]

      Well….there is a similar story about a prostitute! Ha! Ya’ know they have paying customers who I surmise are eager to pay more than a co-pay….no refunds….limited time….and again I surmise they work hard under duress of arrest. Maybe they are onto something…..particularly the high class call girls (who are often highly educated like doctors)….and repeat customers who, obviously, like their great customer service! Hmmm..:). Just teasing you to make a point about keepin” the customers….um…patients happy in a high volume world. Yeah…the doctor didn’t have time to help me with my sleep deprivation induced mania. I am the consequence of inaction….sigh…..

      The real point of my post is….I forgot….ha…no, seriously….(and this part is not to Steve…it’s an open rant) doctors make some valid, educational points when it is done with humility and a willingness to learn. The tide has changed…patients are empowered…more knowledgeable…your jobs are much harder….on a few levels almost impossible (you are not psychics). But sometimes your “entitlement” mindset matches those who will lead the march against you and make your jobs even harder.

  • http://www.managemypractice.com Mary Pat Whaley

    @pcp

    I do realize that you are paid more for two separate lower level visits than one higher level visit, but that’s not the entire equation. The Medicare national allowable for two 99213 visits is about $134.00, whereas one 99214 is about $100.00.

    The expense for two visits versus one might very well absorb that $34.00 difference based on your overhead.

    Patients also resist numerous shorter appointments as they feel they are getting less for their co-pay, and want the most bang for their buck.

    This is not an easy issue to resolve. It does go back to the question of is a physician reimbursed appropriately for the value s/he brings?

    I write an article about the “cost” of an office visit on my blog in an article called “There is no such thing as a 10-minute office visit” http://www.managemypractice.com/there-is-no-such-thing-as-a-10-minute-office-visit/

    Mary Pat Whaley, FACMPE

    • pcp

      “Patients also resist numerous shorter appointments”

      Very true, but until the system changes (I’m not holding my breath!) they’ll be forced to accept them.

      Your post on the “10 minute visit” was great.

    • ninguem

      Not in my office. The overhead is fixed, rent, utilities, hourly labor, etc. It’s the same if I see two patients or twenty.

      The increased overhead for two mid-level office visits is a trivial amount of consumables, table paper, EKG paper, etc. I suppose increased wear and tear on carpets and plumbing.

      I’d say the vast majority of the time, I’ll take two 99123 visits over one 99214.

  • Muddy Waters

    With more awareness such as these posts, maybe patients will start to realize the complexity of being a doctor. Often, a “lamen” fails to realize the breadth of medical knowledge and the impossibility of entertaining every possible diagnoses for a given complaint. Yet, they expect perfection from their physician, and they don’t expect to pay very much for the service because healthcare is often deemed a “right.” I wonder if the above patient tried to sue the doctor for missing a pulmonary embolus. I like the concept of “informed refusal,” where a doctor can quickly outline the most fatal possibilities of a given complaint and then offer the patient the right to pay for the testing. If the patient is willing to accept the risk of non-treatment as opposed to forking the liability on the physician, then both the cost and bureaucracy of healthcare are diminished. I doubt that patients would be willing to accept this, and thus the deterioration of healthcare continues.

  • Dr D

    It’s even harder when you have a patient who has had multiple small complaints for many visits which were in the past nothing, , and then finally comes in for something serious. I have trained my staff to “grab the list”, so I have a few seconds to look at it before going in. But with families being spread out-I become the physician, the social worker, care coordinator. As the hats shift, the view of the patient changes.
    Patients’ tolerance for symptoms vary-there are patients I just make come in, no matter what, because if they call in they probably need to be in the ER, but won’t go, and there are patients who have an anxiety attack over a mosquito bite.When the latter comes in, again, (with sufficient work-up) the first 5 times , it becomes harder to hear symptoms that are serious without the framework of the first 5 visits. (I’m assuming here that a very full workup was done for those complaints, not blown off)
    Bring in those lists.Don’t put that chest pain on the bottom.(besides not being safe, it’s a bit cruel to your doctor) Have the secretary xerox the list so you both have a copy, so a quick realignment can occur.If you feel really ill-like the pulmonary embolism, you probably belong in the ER-where you can’t hiccup without getting a CT angiogram and/or an EKG.

    • http://warmsocks.wordpress.com/ WarmSocks

      Grab the list? Good idea. A few times, my doctor tried to read my list upside down, then he started asking for my written list of questions. Now I print two copies and hand one to the nurse when she takes me to the exam room. It works very well. I don’t have to explain everything three times, and the doctor knows from the very beginning exactly why I’m there.

  • http://www.davisliumd.blogspot.com Davis Liu, MD

    It’s unclear that having more time or limiting a patient’s complaints to the top three problems would have made any difference. While Dr. Ofri might feel better, it is clear that the cognitive error was not considering the pulmonary embolus as part of the differential. As they say in med school, unless you are actively thinking about it you won’t see it, even if it is starting you right in the face. Pulmonary embolus are hard to diagnose. Even with an additional 45 minutes with all of the data and without the correct mindset, from the article it isn’t clear the right diagnoses would have been reached.

    Davis Liu, MD
    Author of Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America’s Healthcare System
    (available in hardcover, Kindle, and iPad / iBooks)
    Website: http://www.davisliumd.com
    Blog: http://www.davisliumd.blogspot.com
    Twitter: davisliumd

  • http://www.healthecommunications.wordpress.com Steve Wilkins

    Regarding giving your doctor a list…

    There was (and still may be) a malady described in DeGowin & DeGowin’s medical textbook called the “maladie du petite papier.” At one time traditional medicine held that patients who related their complaints to physicians from a written list were “mentally ill.”
    I kid you not.

    I am not really sure how much things have changed. If you want a citation let me know.

    • http://warmsocks.wordpress.com/ WarmSocks

      maladie du petite papier
      Oh, my! I just did a quick search and found some articles using the term, but they all say that’s a thing of the past and patients should make a list before seeing their doctor. Not true?

      • ninguem

        How about five pages of complaints, both sides?

        • http://warmsocks.wordpress.com/ WarmSocks

          :O

  • http://www.healthecommunications.wordpress.com Steve Wilkins

    I think lists make a great deal of sense from the patient’s perspective. But I suspect that there are more than a few physician who cringe each time a patient brings out “the list.” After all a list implies “competing priorities” in an already time constrained appointment.

    If anything has changed…it’s that patients with list aren’t viewed as crazy so much as annoying??

    Any physicians want to take a crack at addressing patients with lists?

    • http://www.twitter.com/alicearobertson Alice

      Why are doctors so resistant to e-mail? My doctors at the Cleveland Clniic answer e-mails, and two encourage it. It saves office time, and they aren’t pressured. Is it because they don’t want it in writing? There is a disclaimer on the e-mails. One specialist claims I am the only patient who e-mails and misses the feedback and input. They can see more clearly into a patient’s heart if they take the few moments it takes to read. Most doctors are good typers, so they can type up a response quickly.

      A doctor here said they were going to charge $25 per e-mail, but would waive it if you came in for an office visit. I found that ridiculous. E-mail saves phone tag and is much more efficient.

      E-mail helps both the patient and doctor to form a relationship of trust. I wish I could share some my doctor’s e-mails. They are empathetic, encouraging, and enlightening. Sometimes it is easier to write than to speak your heart.

      I wrote to our doctor before surgery (warning do not read Atul Gawande’s book on doctor mistakes before surgery. His words were like cyber-xanax:))

  • http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD

    Lists are only a problem because of the expectation they create. Doctors cringe because the patients expects each item on the list to be discussed and reviewed – and doctors just don’t have that kind of time (typically). On the other hand, show your lawyer (who gets paid for his time) that list and he will pour over it in great detail. I’m sure lawyers love clients with lists.

    Alice – doctors like to get paid for their work – and since emails and phone calls often don’t lead to reimbursement (and indeed, often lead to less income, as the patient will often then not come in for an actual visit) they don’t like these things either. Academic docs, Kaiser docs, and a few innovative docs who shun insurance and bill for their time have no problem with email and phone calls.

    • http://www.twitter.com/alicearobertson Alice

      Alice – doctors like to get paid for their work [end quote]

      Well……….I would like to get paid for all the entertainment I provide! :) Oh…….I’ll get serious….your answer is understandable. I am one of the few people who thinks doctor’s salaries are fine…when it’s honest and the patients are treated well (thinking of one doctor I don’t like much… who wasn’t worth the time it took to drive to see him for his costly misdiagnosis…but he is the exception….don’t worry I have ordered a Voodoo doll from Amazon…really cute….you just send the victim’s pic and order a set of needles………haha).

      Quite frankly, if they charged a reasonable fee I would pay for email (or an annual fee for the unlimited plan…..oh my mind dances at that thought)……..that’s how highly I rank it. It’s far better than a list (with a list you would need a blank piece of paper to gather the answers…..or you would need to turn on the video recorder of your phone and relisten when you get home). They say patients only remember 30% of less of the answers from an office visit. So, you may get the answers to your list….but you may also forget a whole lot. An email is far better……..and you are right my doctors are salaried……but do the e-mail at home on their own time…..or when a patient cancels and they have a whole 15 minutes to burn. They are really patient centered……and kind hearted.

      And……I really must brag…..my salaried doctor gives me an HOUR of his own time. I can book the last appointment and he offers to clear his calendar. The other doctor offers to come in early. No extra money in these visits or their e-mails………be still my beating heart!:)

  • http://ethicalnag.org Carolyn Thomas

    My daughter, who’s been a patient of our family doctor since the day she was born 31 years ago, was recently phoned by the doctor’s office to remind her it’s time to book her annual routine physical exam.

    “Oh, by the way,” says the doctor’s receptionist, “We’re doing things a bit differently with annual check-ups from now on: we now book TWO different appointments, one day to check ‘everything above the waist’ and one day for ‘everything below the waist’!”

    This new protocol is quite clearly a cash grab, with little or no consideration for the inconvenience to the patient who must now book time off work on two separate days for the appointment plus the half-hour drive (each way) to get to the doctor’s office.

    Please tell me this isn’t a growing trend in the world of family practice!?

    • http://warmsocks.wordpress.com/ WarmSocks

      First I’ve heard of such a thing. Is that a cash-only practice? I suspect insurance companies would object to two physical exams. Or perhaps they can cite the new health-insurance-reform law as justification.

      Few people need a physical every year. Maybe your daughter could do a waist-up exam one year, and a waist-down exam the next.

  • Clifton K. Meador, MD

    I spent most of my professional life with such complex patients. See “Symptoms of Unknown Origin” by Clifton K. Meador, MD, Vanderbilt University Press.2005.

  • Harry

    I have always been the type of physician who will spend more time with patients, handle several medical issues during the same visit, and document appropriately to justify level 4 visits. My patients really seem to value the additional time i spend with them, as well as the specific disease processes, evaluation, and treatment recommendations i suggest.

    With rising overhead though and an ever-decreasing income, i have tried to find ways of approaching my practice differently. I don’t want to feel like my only option to increase revenue is by working harder, seeing more patients, and working longer hours.

    When i consider the number of issues that i frequently encounter (and almost feel obligated to handle) during one of those level 4 visits, along with the amount of time required to appropriately navigate through such visits, i began to realize (as stated above by others) that it seems to make more financial sense for me to limit the number of problems that i address at a given visit and bill primarily level 3′s.

    In my region, most commercials pay approx $65-75 for a level 3 and approx $95-105 for a level 4. if you break those numbers down by the number of problems typically encountered for a level 4 visit, that translates to me being paid $65-75 for the 1st problem and $15 for the 2nd and 3rd problems. Any additional problems are done essentially without payment! I am not aware of many other businesses/industries that function in this manner. My mechanic certainly doesn’t give me any discounts for doing more services to my car, yet this is exactly what physicians are doing everyday. By dealing with more issues at each visit, I am spending more time with each patient, seeing fewer patients per day, and essenitally allowing the insurance companies to further discount my services beyond the contracted rates. I am selling myself short. By limiting patients to 1 problem per visit (which admittedly may not be an easy sell), I can assure myself of $65-75 per problem. And realize, too, that there are many instances where a single problem visit can generate a level 4 code.

    In this way, i feel I will be able to more adequately address a given medical issue more thoroughly, and actually generate more revenue. Don’t get me wrong, it’s not just about the money, but i also cannot lose sight of the fact that i am running a very expensive business and will be of no value to any of my patients if i ignore the financial aspects of what i do for a living. After all, this is not a hobby. This is my job, my way of meeting financial obligations and providing for my family. Until things change, I will constantly be looking for ways to maneuver within the system that the insurance companies have constructed.

  • http://ethicalnag.org Carolyn Thomas

    “…My mechanic certainly doesn’t give me any discounts for doing more services to my car…”

    Interesting analogy. But my mechanic also charges by the procedure – $XX for a tire rotation whether that work takes him 15 minutes or one hour – until the work is addressed to my satisfaction, which means he attempts to solve each car problem as effeciently as possible. Anybody who’s done home renovations knows that the carpenter offers one estimate for the complete job (including labour) and sometimes it takes longer and sometimes it takes not quite as long as estimated.

    For every patient who brings a list, you likely have patients who come in (as I do regularly) simply to renew prescriptions – a 2-minute visit, if that. I’m not hearing anybody complain about charging full price for these mini-appointments.

    As a patient, I’ve been to doctors who stood up (STOOD!) for the entire quickie consultation, hand on the doorknob, meter running, ready to flee the exam room as quickly as humanly possible after sizing up and solving my “problem” so he can rush off to the next patient next door.

    Is this what it’s coming to? Drive-thru medical practice?

    • Harry

      Maybe we’re on to something here. If we mirror medical practices after a very successful fast food business franchise, maybe physicians too can become more profitable. Maybe even a drive-thru window so I can just take your order and a quick peak at you. Patients will love it because they won’t even have to get out of their cars for the visit.

      All sarcasm aside though, people hopefully realize that we’re not dealing with “drive-thru” concerns. I approach each patient with the utmost responsibility that they’ve entrusted me with. Also realize though, that there are tremendous sacrifices that physicians have made along the way to becoming who we are; sacrificing some of the healthiest years educating ourselves/learning the profession, incurring extensive amounts of student loan debt rivaling that of new home mortgages, delaying marriage and/or perhaps starting a family……these are just some of the intangible sacrifices that i feel are often times forgotten by society. All people make sacrifices along the way, but i just don’t want people to be misled that doctors are just greedy and their one and only concern is money.

      We do, however, deserve to be fairly compensated, keeping in mind how expensive it is to operate a medical practice, and the personal debt loads that we carry. Society has to value what physicians offer them. We all assign different values to those things in life that we feel are important to us and I am certainly no different. However, it never fails to amaze me how difficult it can be to collect a $20 copay from patients, when most of us don’t think twice about stroking out $100/mo for a cell phone, $25-50/mo for internet, $50-100/mo for cable/satellite tv, etc. And, again, it’s frustrating that most people pay monthly premiums for health insurance, but then don’t understand the specific coverages they’re paying for and that, at times, despite having insurance, they may be required to pay additional healthcare-related expenses to their doctor or hospital. We are all caught up in the same third-party payer system, patients (consumers) and physicians alike.

      As far as the mechanic/construction analogy, i agree there is some truth to that. However, if you’ve ever dealt with them for extensive work, you will quickly learn that the difference between ‘standard’ work that’s “included in the estimate” and additional work, for which they’ll be glad to do for an additional charge. This is why it can be so difficult for some people to understand. Unlike our mechanics and construction workers, physicians often times are providing intangible services. We’re not putting on a new set of tires for your car or putting on an addition to your home. Yet, we still have to have some way of quantifying our work. So, even though to a patient, we may just be having a simple conversation in the exam room, physicians are actually working on different levels with different patients, concerning different problems at different levels of evaluation/treatment/control, etc. In other words, not every patient is alike. Some require more work than others, yet as physicians, there is no additional payment for the extra work we provide. Strictly in the eyes of the insurance companies, i get paid the same amount of money regardless of the quality of the care I provide. It’s strictly a volume-driven payment system. The more patients we see, the more money we’re paid. As I’ve previously stated, the more time that doctors spend with their patients, developing relationships and a good understanding of each patient’s medical conditions and tailoring a specific treatment plan that’s best for each of them…..the less patients we see in a day and the less money we actually make. And regardless of how many patients a day I’m seeing, the majority of my overhead expenses are fixed. Hence the original analogy of “fast food medicine”, in an effort to maintain an adequate cashflow to meet operating expenses and earn a decent living. There are a lot of physicians who have wealth, but i would argue that there are just as many who are struggling to survive. Unfortunately, society has a perception etched in stone that doctors are all millionaires and i don’t see how that will ever change.

      And when i tell my patients that i would gladly switch bank accounts and loan payments with them in a heartbeat, as expected, they simply laugh!

  • http:/www.myheartsisters.org Carolyn Thomas

    Hi Harry,
    You make some well-balanced and thoughtful points about the workplace demands common to many docs. Thank you for those. Like a lot of patients, I’m very aware of what it has taken my own doctors in terms of their education, personal debt, and family sacrifice to get to where they are today. (Speaking of which, I’m positively horrified when I hear about patients who expect and then GET their doctor’s cell phone numbers and email addresses for after-hours contact, as if the docs don’t even have a right to be off-duty and at home with their own family and friends!)

    At the risk of getting off-topic here, a young family practice resident who was doing a hospital rotation on our hospice palliative care unit recently was complaining to me over coffee one morning about his big student loan. I called him over to the window and pointed out the doctors’ parking lot below – a sea of Beamers, Benz, Jags, and other luxury cars you simply will not see in general staff or public parking.

    And that very unscientific observation appears to summarize the overriding difference for me. Big education expenses, sure. Big overhead, sure. Big ability to recoup training and overhead investments, YES, in a fashion that few of us non-physicians could even dream about.

    As high as the overhead admittedly is for docs, let’s face it, nobody is ever going to hold a fundraising telethon for physicians. Docs “struggling to survive”? Really?

    In fact, medical practice overhead, as high as it must seem when you’re personally paying the bills, is mere peanuts compared to that of the average automotive garage owner or even that of my oceanographer ex-hubby (each of his lab’s new gas chromatography-mass spectrometry machines costs almost $100,000, for example – and he needs a bunch of them!)

    Again, we’re veering dangerously off-topic here from Dr. Kevin’s excellent original post, but it appears that we’re basically either looking at reducing the TIME per patient visit in your offices, or reducing the KIND of patients, or increasing the number of well-informed and personally responsible patients who actually NEED to see you.

    • Harry

      Carolyn

      Thank you for your viewpoints and understanding of a difficult situation that some physicians continue to battle on a regular basis.

    • pcp

      I can almost guarantee that the family docs are not driving those Jags. An excellent study has just come out showing that FPs graduating with 150K in debt and leading very modest life styles are further in debt at the end of their first five years in practice.

      And are you saying that your husband personally writes a check for each $100,00 spectrometer that his lab buys? If not, not a valid analogy.

      • http://www.myheartsisters.org Carolyn Thomas

        Yes, pcp, he does: hubby owns the lab. Just as my mechanic owns his automotive repair shop, and just as a family doc owns his/her practice.

        • Harry

          And i would venture a guess and say that both your husband and your mechanic operate in a free market, where they’re able to set their payments to both cover the cost of goods/services sold and to generate a profit. And that when their costs rise, they are able to simply pass at least a portion of those along to their customers, in order to meet their rising overhead and maintain acceptable profit margins. Herein lies a major difference between the business of healthcare and most other industries. Unlike docs, their businesses aren’t being price-fixed by some other profit-driven third party. Sounds all too simple, really. Maybe the next time i have my brakes changed, I’ll offer my mechanic $65 as payment in full, even though he charges me $200 for the work, just to see what kind of response I’ll get………

          • http://www.myheartsisters.org Carolyn Thomas

            “..both your husband and your mechanic operate in a free market, where they’re able to set their payments to both cover the cost of goods/services sold and to generate a profit…”

            Yes and no. They each operate in a HIGHLY competitive arena where, for example, if consumers can get their tires rotated or their batteries replaced cheaper elsewhere, my mechanic has just lost business. No loyalty among car repair customers!

  • http://www.healthecommunications.wordpress.com Steve Wilkins

    Great comments!

    Carolyn’s closing statement struck me. She correctly identifies the following options: “we are either looking at reducing the TIME per patient visit in your offices, changing the KIND of patients, or increasing the number of well-informed and personally responsible patients who actually NEED to see you.”

    Doctors…if someone paid you to develop a plan to do what Carolyn suggested, e.g. proactively manage your existing panel of patients, you know, triage who you see, how often you see them, etc. what would be the key elements of your plan?

    How would this be different from the current model in which any of your patients can call up and demand a chunk of your time whether they need it or not.

    I am not thinking about rationing care. Rather, I am thing about doctor’s better managing scare resources.

    I look forward to your ideas

    • http://warmsocks.wordpress.com/ WarmSocks

      I was talking to someone recently who lamented this very thing happening. The doctor she’d seen for a few years was out on vacation, and she got in a car accident, so saw his partner for treatment. It turned out that she liked the partner better and the next time she needed an appointment, she asked the receptionist for an appointment to see the partner. Two days later she received a certified letter with a copy of her medical records and a letter informing her that she’d been fired as a patient. Talking with others, I’ve discovered that practice does that to everyone who asks to switch doctors.

      There’s another doctor in town who sends out an application to anyone who calls asking if he’s taking new patients. The doctor there reviews applications and determines whether or not he wants to take on that person as a patient.

      • AA

        WarmSocks, that blows my mind being fired in that manner.

        I wonder how the doctor decides whom to take as a new patient? That could be a good or bad thing depending on what type of questions he asks.

        What I find ironic is when I was looking for a primary care doctor a few years ago, I asked if I could meet with one for 15 minutes so I could ask questions to see if we were compatible. I was willing to pay for the time.

        Nope, I had to pay the full price of an examination. Needless to say, I moved on.

        No matter what, the next time I want to gorge on junk food, I will have to remember your post as motivation to not do that so I can stay healthy. Very important since I have horrible health insurance coverage.

        • http://warmsocks.wordpress.com/ WarmSocks

          I was curious what that one doctor’s acceptance criteria was, but not so much that I wanted to call and ask.

          When we lived in Seattle, the doctors offered a short “meet the doc” appointment at the end of the day to see if you were compatible. There was no charge, but no medical questions asked, either. Then again, there’s a medical school in Seattle and an abundance of doctors so they’re competing for business. When we moved, everyone I phoned to set up such an appointment thought I was crazy. Yes, I had to pay to meet a few people, but not a full physical exam fee. It was worth it.

          As long as my PCP stays in business, I have no intention of switching. Someday he’ll retire, though, and I’ll have to come up with my own criteria and interview a few doctors before I decide who to entrust with my care. That’s not something I look forward to.

  • M Camp

    To the docs out there: Can you help us…help you…to help us? I get it that your time is money, you have a life outside of your practice, you have tons of debt when you get out of school, you cringe at patients bearing lists (not all of you, but many), you think patients’ expectations may be too high for what you can deliver in a single visit (& still make a profit) and that the new government regs & insurance companies are just adding to this stress. I’m a daughter of a DO & know a bit about docs frustrations and that they rarely get any “time off” & they don’t get reimbursed as they should from the insurance companies but I’m also a patient and know the frustrations I have.

    How can we work better together?

    @Warm Socks: Docs “firing” patients because they want to switch? I guess that could be another post all together…

  • http://boxcuttersinc.wordpress.com Michael Wong

    One idea I’ve used to help out busy docs — where appropriate, pair doctors with a community or support group, whose role is to assist patients with some of these tasks.

  • http://Www.twitter.com/alicearobertson Alice

    Doctors firing patients… I know this happens….I imagine they were red flagging patients…but I was told that once a doctor starts treatment they cannot dump you during that time. My doctor said he can suggest that you may be happier with another doctor, but he would not fire a patient.

  • sh

    Glad I quit primary care, don;t regret it one bit….

  • Dr D

    It depends on the state, but your doctor can’t fire you in a crisis or active problem(-high blood pressure in good control is not an active problem.,. They can fire you otherwise-just as you can fire them. You should be given names for resources to fins another physician
    I have only fired 3 patients in 15 years-but the patients really worked at it-falsely getting refills of a narcotic, or something similar. But if you aren’t happy, you should find another MD. Just like any other relationship, it should click. If you don’t trust them when you are well-what about when you are sick?

Most Popular