Doctors should return phone calls because it is the right thing to do

Doctors should return phone calls because it is the right thing to do

My veterinarian answers my phone calls.  The other day I called her office to ask for a renewal of the pain medication for my little dog Jack.  He has been blind and deaf for over a year, but now his rear end is going and he is falling a lot and having a hard time getting up. When I asked for the medication, I did so with a certain queasiness that perhaps refilling the prescription was my way of putting off the inevitable.  Suddenly I wanted to talk to the vet.  I told the receptionist that it was not an emergency, but could she please call me back by the end of the day.  She called me back within the hour.

Today I sat with a patient who has recently been through a battery of tests to determine whether his cancer has spread.  He told me how frustrating it has been for him to call his doctors’ offices for the test results, and not receive any calls in return.  This man belongs to an HMO where he can go on line and look at his results himself.  I asked him why he did not do that and he said, “Because I am scared to read the results when I don’t know if I will understand them and there will be no one to talk to.”

Six months ago I received a letter in the mail, from the University that employs me.  The letter said that because I am faculty, I am eligible to have a “concierge doctor” at a sharply discounted price.  For a mere $5,000 a year more than the exorbitant rate I already pay for my Blue Cross PPO, I (and my spouse) will be entitled to a doctor who will see me within 48 hours if I get sick, who will help me “navigate” the system if I get cancer, who will return my phone calls within 24 hours, and who will make sure that if he is on vacation, a covering physician will see me.  My Jewish grandmother rolled over in her grave, sat up and said, “This, I should pay EXTRA for?”

Growing up in a medical family is both a blessing and a curse.  My husband and I are third generation practitioners, if you count my grandfather who was a dentist, and his grandfather who was a veterinarian.  As a consequence, we remember the days when physicians were expected to return patients’ phone calls themselves in a timely manner, guide their patients through difficult decisions and life crises, and see their patients urgently when necessary.  Merriam-Webster defines “concierge” as a person in an apartment building, usually in France, who serves as doorkeeper, landlord’s representative and janitor.  Is this what I want from my doctor?  Is this what I want to be?

My husband and I had the same reaction when we read our proffered “concierge letter.”  We want a doctor who will see us if we are sick, advise us when we have a crisis, and return our phone calls without being paid extra, because it is the right thing to do. This is what we expect.  This is what I provide for my own patients.  This is what all patients deserve.  If my veterinarians can behave like doctors, so can we.

Miranda Fielding is a radiation oncologist who blogs at The Crab Diaries

Image credit: Shutterstock.com

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  • DavidBehar

    Miranda: You should mow my 4 acre lawn for free. Why? Because I said so, it is the right thing to do. Your time may have no value, and your telephone advice may carry no legal liabilities, but please, stop your ipse dixits, and supercilious condescension. Talk baseball, and sex gossip to your lawyer, you are still on the clock, and will get the bill. Our time is more valuable than that of the lawyer.

    Indeed, it is so valuable, it should replace most face to face encounters. The expense of those go far beyond the fee. The patient must lose time from work, drive a beat car, on snow covered roads. The doctor has to spend mass amount on overhead and infrastructure, all with absolutely no medical benefit. I would gladly pay $5 a minute to my doctor to avoid the massive cost of an in person encounter.

    When things are going well, no change need be made. When things are going wrong, only one change should be made, or else we would not know the cause of the benefit or of the adverse event. How long does it take an experienced clinician to pick the action of the encounter? Usually a minute.

    • http://www.facebook.com/todd.solomon1 Todd Solomon

      Well said. Many of my patients actually make something called “office visits” to discuss issues that cannot be simply relayed through my office staff. Others only want free care, such as the ones that call with their “emergency” (that has been going on a for a week) when the office is closed, knowing I will call back and they will save their copay and get free care, while I assume all the liability.

      • Miranda Fielding

        I think the key message here is that if you have an office staff you can rely on (and I am lucky to have a superb nurse) you can certainly avoid some of the time wasting encounters. But not all of us have office staff capable of really recognizing or understanding what is a real problem and what is not .

    • Miranda Fielding

      I’m not sure what you’re saying here (but by the way, I have my own 3 acre plot to mow!) If it is that we should be paid for returning phone calls, while I agree that we should be compensated for our time, I’m not sure that I’d like to see medicine go down the path of “billable minutes”. If it’s that we should do our diagnosing by phone and avoid patient encounters, then I can’t agree. But then I am old school–I still do physical exams on my patients.

  • azmd

    I think it’s likely that being in a relatively well-paid specialty such as radiation oncology makes it hard for you to understand the practice constraints under which the typical PCP practices these days. Of course, seeing patients within 48 hours, answering all telephone calls within 24 hours and being available to help patients navigate a complex medical system is the right way to practice. Unfortunately, your insurance company does not want to pay your PCP to provide those services, and it is not realistic for you to expect for them to be provided for free.

    I suspect that it’s relevant to note here that you are most likely paying your veterinarian cash for her services, which is why she is able to return your calls so promptly. It might also be relevant to wonder why you decided not to practice primary care…

    • http://www.facebook.com/profile.php?id=662132748 Lata Potturi Schaedler

      Very well said. It is hard for me to believe a physician wrote this article. I know how overworked and understaffed our primary care physicians are. How can this practitioner not know?

      • Miranda Fielding

        I’m sorry if you find it hard to believe that I am a physician. I am board certified in both Internal Medicine and in Radiation Oncology and practice in Southern California where the majority of my patient belong to managed care organizations. THe amount of paperwork I have is staggering compared to what I had back in Boston. But still, jeepers, I try to do the right thing, as do most physicians. By the way, KevinMD changed my original title, which had NOTHING to do with phone calls. My title, on my own blog was “I am not a Concierge.”

    • Miranda Fielding

      You are correct in saying that I pay my veterinarian fee for service, but not for phone calls. You are also correct to wonder why I decided not to practice primary care after obtaining my boards in Internal Medicine–it was because I felt that many of my clinic patient in medicine had problems more psychosomatic than real. At least with the cancer patients, they had already been diagnosed with a life threatening illness, which I found more gratifying. Finally, you are correct in saying that I have the leeway to spend more time with my patients than a primary care MD. But I still work long hours, and it seems I cannot leave without answering my phone calls–likely because of the physician father/role model I had growing up. Thanks for your comments. I wish I could fix things for the primary care docs.

      • azmd

        Here’s the most important thing we can do from our relatively privileged spots as physicians with specialties which allow us the luxury of spending time with our patients that the PCPs cannot: we can refrain from dumping on them, and we can advocate for them in the bigger healthcare policy arena.

        I come from four generations of medical professionals, many of whom devoted their careers to public service rather than high-paid specialties. I also find that I cannot leave my office unless I have returned all my calls. But I am well-paid for my efforts and I like to think that I have the grace to recognize that. I try to use my extra time and energy to pitch in and help by participating in organized medicine as an advocate for our profession, and by supporting my colleagues who are facing greater challenges than I have to.

        • Miranda Fielding

          All excellent points. Up until this stage of my career, I have been busy raising three children as well as working full time, which has left me limited time for public service. But it is definitely something to aspire too now that the kids are grown–one of whom is finishing medical school this year. I would also like to point out vis-a vis “dumping on other MD’s” that Kevin Pho changed my title. The original title on my blog had nothing to do with phone calls: It was simply “I am Not the Concierge”. I apologize to all of the primary care MD’s out there if the general perception is that I was dumping on them.

          • medicalstudent

            Unfortunately, Dr. Fielding, your article did come off as you taking a shot at primary care physicians. Thanks for clarifying, though.

          • azmd

            I would encourage you to consider getting involved in organized medicine, particularly if you don’t like the level of service that your insurer-covered PCP is providing. Two of my three children are still at home and I am able to work full time and sit on the boards of two statewide medical associations. As my family likes to say “If you’re not part of the solution, you’re part of the problem.”

          • Miranda Fielding

            Actually my PCP provides a fine level of service for me. It was the University espousing the concierge concept and trying to get its own physicians to ante up the extra 5k that I thought was the wrong message, but many of your comments have made me rethink that, which is a good thing. And my family likes to say the same thing as yours! To which my father likes to add, “if you want something done, ask a busy person to do it.” Again, thanks for your comments.

          • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

            All I can say is, if you pay 5k and your direct care physician cant see you in less than 48hrs and call you more promptly than “24hrs” then I think your university has a crappy deal.

            seriously? 5k ought to get you pretty primo service and prompt attention.

          • Suzi Q 38

            I just would not pay that in addition to my PPO premium costs.

          • mikee60369

            My god. For $5,000 up front per patient, I could have just 50 patients and hardly any overhead. All home visits! Hour long visits! Sounds like this “concierge” plan is a ripoff

          • DavidBehar

            Organized medicine is a bad joke. It is mostly left wing collaborators with the enemies of clinical care. They crush all grass roots real doctor initiatives. They are physical cowards and will not stand up legally to the oppressor besetting clinical care from all sides. The government thugs goes after individual doctors, for example, for discussing off label uses of medications (legal in this country), the stand back and watch. Punk asses. Bitches. Then they condemn direct actions where there is no legal recourse. They are total traitors to clinical care, and morally reprehensible. Look elsewhere for a solution.

          • Suzi Q 38

            Are you really a doctor?
            Maybe you could look into a few ager management classes.

        • ticktickdoc

          azmd…..YOU ROCK!

      • ColdHands

        Wow, really? No wonder it took me 14 years of agony, 7 of which were daily and constant pain, before I was diagnosed with a condition that affects up to 10% of women yet has an average diagnosis time of 9 years… because of course, any woman with belly ache or pelvic pain must be more in need of a shrink than a surgeon, right? Endometriosis may not be life threatening in all cases (though I know of plenty of women with bowel obstruction, kidney damage from ureter blockage, fistulas, and bowel perforation all as a result of this disease) but it is very real, and the quality of life can be something you wouldn’t wish on your worst enemy.

      • http://twitter.com/bluesdvm Joyce A. Login

        I am a veterinarian (we ARE doctors, by the way). Our profession struggles constantly with juggling communication skills vs. limited hours/paperwork, and how we can avoid going down the same road as our physician colleagues. There is no 3rd party payment which may make for less paperwork, but it also means there is a lot less money coming in so taking time away from seeing an appointment is no small feat. Even so, it’s not uncommon to get cards, gifts and long thank you letters from clients who are amazed that we will actually take the time to listen, hold their hands, and simply care. It makes for a very rewarding career.

        In full disclosure, I am no longer in private practice, and now, in part, teach communication skills to my colleagues because I have become passionate about the subject. Being able to connect with a client is not only the right thing to do but will also allow for getting better information and greater satisfaction for all involved.

        Seeing so many doctors on here making excuses as to why there is no time to treat patients as human beings who are scared and confused really makes me sad. It’s gives me hope to see that there are still physicians such as Dr. Fielding who ‘get it’.

        • Suzi Q 38

          “Seeing so many doctors on here making excuses as to why there is no time to treat patients as human beings who are scared and confused really makes me sad. It’s gives me hope to see that there are still physicians such as Dr. Fielding who ‘get it’.”

          I was thinking that maybe it was my age. I am 56.

          I am just being a little older and the new specialists that I have to see are just younger. Maybe with being so young, they forgot to be taught in medical school how to keep patients over the long term. They obviously know how to medically treat them, but do they know how to treat them socially as human beings that sometimes need a little extra care that may or may not involve a phone call?

          Things have changed. In decades past, physicians used to have their own practice. Their time was their own.

          Sure their schedule was more like this:

          Early A.M. Hospital patients.

          9:00-12:00 or 12:30 Office patients

          12:30-2:00 Lunch or the hospital again.

          2:15-5:00 office patients.

          Paperwork and calling patients back was in between patients, or after work. Sometimes, Friday afternoons were spent catching up of the paperwork and calls instead of seeing patients.

          Now, with managed care, patients are scheduled every 10 minutes…am I correct??? That is crazy.
          The exception is a new patient consult, which is 60 minutes. Also, my information is put into a computer, which is so efficient for all, but difficult for some doctors. I am not sure that they are given time to do this, in between patients.

          This is why I see some of my doctors staring at the computer screen instead of me. This is even less time for me. I laugh with the doctor and say that there are actually 4 people in the room. The doctor, the nurse, me, and the computer. The only problem is that now I have to compete with the computer for the doctor’s time.

          I realize how tough it is to have to call a patient back when he or she needs the medical decision from the doctor. If it is just a prescription or basic information, the nurse can help in most cases. If it is complex and needs a physician’s expertise, make the call…get it over with.

          • ticktickdoc

            You are absolutely correct about the computer. It takes away time from you the patient. Your family doc just keeps getting dumped on more and more. Truth be told, we family docs DO call patients back every chance available.
            Unfortunately we have a roster of thousands of patients. Think about that. Thousands of people just like you wanting calls and emails. Thousands of patients wanting us to read 100 page articles they found somewhere on the internet. Thousands of patients that show up late or want to discuss 5 problems when they are scheduled for something completely different.
            It’s mathamatically not possible to take care of everthing without either, reducing your salary by working fewer days OR making your own health and your family suffer, or cheating the system which I have heard very few docs to have done.
            Physicians who have to pay off school loans do not have the liberty of working less and subsequently making less money. So…is it REALLY fair that a doc should be expected to make free home phone consultations? Is it fair to stay hours after work to chat with patients (who, let me tell you, once they get a doc on the phone like to open up a whole conversation) while our kids wait at home for mommy or daddy? Is it fair to miss your kid’s school performances because someone needs to hear back about something that does not immediately threaten their life?
            Who else caters to a customer in this fashion? Does a hairstylist call up and talk about how someones hair is doing? Does a policeman call when he is off the clock to talk about a ticket someone got? Does the movie theater call after they are closed to tell someone the plot to a movie?
            Sounds silly and probably poor comparisons I know, but honestly…do the math.
            Docs care about the patients. Yes we feel bad knowing people may be waiting or nervous or may need results to go further with something.
            There is an easy solution. Make an office visit to discuss results. If it’s important, staff will bump you up in line. Make a nurse visit!
            There is a serious problem right now with Physician Burnout. Docs are just plain overworked.
            Too many patients + not enough docs + cuts in payments = bursting point.

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

            Your proposed schedule is similar to the one my family physician still uses. He uses a wave method for appointment timing, allowing 20 minutes per appointment; he knows some will take more time, but others will take less and it all evens out. He also doesn’t schedule patients on Wednesday so that he has time for community service and catching up on paperwork. It might not generate as much money as scheduling patients five days a week for ten minute time-slots, but he doesn’t hate his profession, either.

        • ticktickdoc

          I can’t wait until veterinarians have to use EMR and make sure they press all of the right buttons. Then when they get to deal with government paperwork and fee structures it’ll be even more fun.

        • http://www.facebook.com/alison.m.galvan Alison Manders Galvan

          I can understand why you don’t get it. You’re a veterinarian, not a primary care physician. I’m sure you have your own issues with trying to have compassion for your furry patients yet trying to run a small business. Dr. Fielding is a physican, albeit an employed physician in an academic setting. Not a primary care physician. And she doesn’t get it either. And then she writes articles like this that make the health care situation worse. Your last paragraph makes the situation worse. Everyone is acting as if it’s the lazy, uncaring, primary care physicians, whining about not getting paid, whining about having to call patients. There is nothing further from the truth. Those of us in primary care are hanging on by our fingernails. We are desperate to provide good care but are thwarted at every turn. There is so much red tape and regulations that make it impossible for us to practice good care. “Meaningful use” initiatives require us to treat a computer screen, not a patient. Insurance companies are increasing premiums on our patients, then adding additional out-of-pocket costs like multiple copays, requiring cheap generic drugs to be prior authorized so that patients won’t use insurance benefits. I could go on and on. Wake up! Why do you think that no one is going into primary care? It’s New Year’s Eve, and we are here at the office just to see walk ins (we are not an urgent care, we just didn’t schedule appts today, thought we’d come in and see if anyone needed to be seen.) I just checked the schedule and there are 32 patients on it. It’s 10:58 am, we’ve been here since 8 am, and we’ve seen 18 patients so far. That’s one doc. Those of you who continue to dump on primary care, who continue to label your fellow physicians as greedy and lazy, prohibit us a nation and a medical community from addressing the real problems and then fixing them.

          • Suzi Q 38

            ” Those of us in primary care are hanging on by our fingernails. We are desperate to provide good care but are thwarted at every turn….. I could go on and on. Wake up!”

            I really had no idea that this was happening with my PCP.
            I am saying that I still need a callback when I need one.

            If you decide to go into medicine at all, you must have wanted to at some point. The desire to do so after working so hard to become one must have been strong.
            Kind of like choosing the ultimate mate for marriage, and deciding to stay married.

            I don’t think that you can be absolute and flippant and declare that you can not and will not make those call backs. A few of them are truly important.

            I think that the nurse should be the one to “triage” the calls that have requested call backs.

            Also, some insurance companies have a “nurse on call.”
            The patient that has a minor question about the color of his or her poop can just call. The nurse that answers the phone calls do not have much to do, because no one thinks to call the phone number. Have your receptionist check your patient’s insurance cards. They can all the number for general questions.

            The nurse can probably handle 75% of the calls.
            The very important and urgent ones, need a call back by you.

            If you don’t think so, don’t go into medicine.
            At this time, unless things change (and things are constantly changing) the direction of my medical care is handled by you. I am still depending on you.

            If I shouldn’t be, let me know so that I can hopefully find a different doctor.

          • http://www.facebook.com/alison.m.galvan Alison Manders Galvan

            Suzy, of course every patient should get a call back. I never said they should not. We call back every patient who has a test ordered and give them the results, if normal, or schedule an office visit if the test is abnormal and the doctor needs to discuss treatment. The doctor does not make those calls, he doesn’t have time. The nurses make those calls. The doctor reviews the tests and makes a notation for what the nurse should say. Now if you want the physician to personally call, well, now you’re talking about a concierge model. Dr. Fielding’s article was all about how what is provided by a concierge model should be provided for free, because that is the right thing to do. The example she used was her veterinarian, who personally called her the same day to talk about her sick dog. My husband, our clinic doctor, personally calls only about 5 patients a day. I just asked my two nurses to give me an average of the number of patient calls they made every day. They started looking at their note pads and adding up their calls and the number they came up with between both nurses FOR ONE PRIMARY CARE PHYSICIAN is 40-50 per day. Do the math — if you only spend 5 minutes on the phone that is 4.167 hours! That is because as a busy PCP in private practice today we have over 3000 active patients. Now, if we were in a concierge practice (which to be honest, we would love to do, but our staff relies on us for their jobs and they are like family) we would only have about 500 active patients, maybe less. My husband would only see about 10 patients per day, and he could absolutely personally call each of those patients back. That is what the concierge model gets you — personal attention from the MD himself. Again, Dr. Fielding’s article was that doctors, like her vet, should be providing “concierge” services for free because it is the right thing to do. She is wrong. It is impossible to do.

          • Suzi Q 38

            I am getting more understanding of what it is like for you and your office. Thank you.
            I rarely have had a doctor call me, but if and when it is important, he does call.
            He called me about a month ago.
            I did not ask him to, I sent an email to his nurse and asked a question through his nurse. I now realize that maybe I could have asked to see him at an office visit.
            The problem is that another office visit would have taken another 2 months to get in for a specialist.
            My PCP is a lot better if I need to see him.
            I can sometimes get in the same day if it is important or a mini-emergency. I just have to go at about 4:00 P.M. and hope for the best.
            Maybe if you have too many patients and can’t care for them all, there should be a limit on what you take in.
            I am probably oversimplifying it all.
            I guess I am saying that I am coming around on this, “kicking and screaming”, LOL.
            My deal will be that I highly prefer a doctor that works with his staff to give me a call-back when it is important.
            Not to ask him about his vacation or to chit chat about the weather.
            If he can’t or doesn’t have that kind of a practice, I feel I am even more at risk.
            I have to go elsewhere to find a different situation.

            I may have to pay a little more, even though I never heard about concierge medicine until now.

          • http://www.facebook.com/alison.m.galvan Alison Manders Galvan

            You said “Maybe if you have too many patients and can’t care for them all, there should be a limit on what you take in.” Well, that is exactly what we have done. At first, we signed off of the insurance companies that caused the most burocratic headaches or that gave us too much trouble paying (Aetna, Humana, Tenet and Coventry). Still got too busy. Then about 5 years ago we stopped seeing new Medicare patients (we still participated in Medicare but only saw current patients who turned 65). Still too busy, too many patients, Medicare reimbursements have been cut again, and the requirements placed on us by the government (eprescribe, meaningful use,PQRI) with the threat that if we don’t comply we will face FURTHER cuts as well as audits on our charts. So now we have as of January 1 opted out of Medicare entirely. That means that we are no longer Medicare providers, and Medicare patients who want to see us must pay cash. Frankly, I’m shocked that of our 250 Medicare patients app. 50% are electing to stay in our practice and pay cash for our services.

            So, yes, we are limiting the patients we accept. We are also looking for a Nurse practitioner or PA, but they are also hard to come by. It seems they too would rather go into specialties. We have avoided this in the past because our patients have expressed that they want to see a DOCTOR. But we (by that I mean patients and doctors) don’t have a choice. So, you got any other suggestions?
            The way our healthcare is being delivered is a mess. You, as a patient, are not happy. You think we physicians should be doing more. We in primary care are not happy. We keep trying to tell you that we can’t do more. So when Dr. Fielding, a fellow physician, writes an article such as this, further dumping on her primary care colleagues, it gets my dander up.
            Oh, and WarmSocks, our office is now closed. I am sitting here, alone, all the staff has gone for the day — including husband and daughter. So no cracks about my not being efficient.

          • Suzi Q 38

            Dr. Galvan,

            Part of the reason we are so demanding is that we know that things have changed.

            We don’t know all the “behind the scenes” B.S. that the insurance companies and Medicare has bestowed upon you.

            I know that I am a very ill patient. I never used to be.

            Deciding whether or not my symptoms are full-blown M.S., or the transition into paralysis because of the spinal stenosis is not easy to acknowledge or accept.

            If my symptoms are taking a turn for the worse, I will call your office if you are my doctor. I will expect someone, anyone, to call me back. I will even accept the phone call from your daughter, that helps out during holiday break. Of course, I prefer a person with medical experience. But if it is: “Dr. G says you should do this and this…then pick up your prescription at the pharmacy….or You’d better come in tomorrow….or Dr. wants to meet you at the hospital in an hour….or when in doubt, go to the E.R., we just don’t have the time to see you.”

            I don’t think the author was singling out just the PCP’s.

            I think she was making a point in general for all doctors.
            Of course, I am the patient. I like the doctor that takes the time to call me back. If not, at least have the nurse call.

            In retrospect, it could be one of my specialists that she is talking about as well as PCP’s.

            Like most things, it is difficult to generalize, because I have learned that you all have different types of practices.

            When you went on in detail about the ways that you did try to control the number of people that you serve in your practice, I realized that the people in your city just like you and love how you care for them.

            “If it’s not broke, don’t fix it.”

            I hope that things get better for all.
            Because of you, I will be kinder and less demanding of my PCP. I realize that even though I am one of the PPO patients, he has so many other medicare and other insurance patients. Who knows if he gets enough to pay the bills.

            In the end, I still want a call back, or I will be at my doctor’s office until I get an answer, insurance card ready if need be.

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

            Why, if you have 32 patients waiting, are you taking the time to read and write long comments on a blog? That makes it look like you have time management problems, which doesn’t make people very sympathetic to claims of not having enough time to do your job right. If you want people to believe that you don’t have enough time, don’t publish on the internet that you have time during the work day to do things not directly related to patient care.

          • southerndoc1

            Warmsocks:
            Hateful post.
            I assume you’d object to Dr. G pissing, farting, eating, etc.?
            I would guess the she, like many of us, posts while on hold with an insurer trying (for the patient’s benefit) to get a prescription approved.

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

            Not intended to be hateful. She didn’t say that she took a quick break to attend to basic needs. She said that it was the middle of her workday and there were patients waiting. Surfing the ‘net while there are patients waiting is not going to be viewed as good time management.

            If you (or she) are phoning patient A’s insurer for a pre-auth during patient B’s appointment time, that’s wrong. If that’s something that is a common practice of many physicians, then there are many physicians who might benefit from a time-management consultation or seminar. That’s not hateful, it’s realistic.

            I admit that I don’t know how my PCP handles pre-auths. My rheumy’s office has a very efficient system, and the paperwork is handled by the MA. What is different about what goes on in primary care that pre-auths require lengthy phone calls by the doctor instead of paper shuffling by support staff? I’m not being hateful; I’d really like to know.

            Pre-auths really aren’t the point, though. The blogpost asserts that it’s reasonable and right to return phone calls. Comments in response show many PCPs taking offense at what seems to be a post stating the obvious. Businesses need to return phone calls or people will go elsewhere. Patients probably don’t care if it’s the doctor or a nurse to return the call; we care that the call is returned.

          • southerndoc1

            Stand by my post.
            The idea that a doc is not allowed to take two minutes between patients to write a quick post as a way to relax/blow off steam/ refresh the grey matter is hateful and intolerant.

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

            Not so. The idea that a doc would spend two minutes of a patient’s appointment time to surf the ‘net is the kind of thing that makes patients feel their time isn’t respected.
            I don’t have a problem with people taking breaks. I have a problem with people choosing to ignore obligations. If there is a patient waiting, then the patient should be seen at the appointment time.

            When people are at work, they are expected to engage in activities that generate income for the company. Many companies block/limit internet access and monitor computer usage to help keep people on task.

            People who flip hamburgers at McD’s take breaks. Those who make it to the executive level in any company rarely have time to take breaks. It’s normal. However, good time management would suggest scheduling a break if you know that you’ll want one.

          • southerndoc1

            Wow. You are a piece of work.
            Dr. G opens her office on New Year’s Eve (when probably nearly every other office in town is closed) to see walk-ins and call-ins, and sees 18 patients by 11 AM. But you, using your psychic powers, know that she needs to learn time management, and that it’s a fact that she’s goofing off when patients need to be seen. Did it ever cross your self-righteous little mind that she may be ahead of schedule? that she may be taking a planned break? that she may be waiting for test results on the patients who are in the office?
            Unbelievable.
            (Note: if there are 32 patients and you’ve seen 18, there are not 32 remaining to be seen. Basic math)

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

            With the statement “I just checked the schedule and there are 32 patients on it,” I lost track that she’d said they were walk-ins. Somehow I don’t equate walk-ins with a schedule.
            So, if she’s chosen to see patients without appointments and they’re there on a first-come, first-served basis, that’s one thing; if she wants to keep walk-ins waiting, they don’t have a basis for complaint. If patients phone to see if there are any same-day appointments available, then that is considered an appointment to be kept at the appointed time. Huge difference.
            I was sincere in my question about how pre-auths are done in the primary care setting.

          • southerndoc1

            “how pre-auths are done in the primary care setting”
            Good question. Of course, every office is different, but everyone aims to get as much of this handled by the person lowest on the totem pole. One problem is that the number of pre-auths is going through the roof: we’re doing 75% more than one year ago. Currently, the largest employer in our area have an 8 page form to be completed for every ED prescription. And we’re having to do pre-auths for generics now. So, what happens, is that after the last patient in the morning or afternoon, EVERYONE in the office is tying up EVERY line in the office trying to get through to insurers/pharmacy plans. If I need an urgent consult or diagnostic test, I frequently have to get on the phone for a peer-to-peer review, which means I talk to them when they call, or the patient suffers. I can’t schedule those so that they’re not during other patients’ appointments. And of course, everything is 10x worse during the new year, with new insurance, etc. It’s taking our nurses an average of 30 minutes on hold per call just to get hold of a human being this week.
            Up until a couple of years ago, we used to call every sick patient and every patient with a new prescription for a 48 hour follow-up. Not any more: all that time and more goes to pre-auths. Docs are acutely aware of what a problem this is. We just wish patients were a little bit more understanding of what goes on behind the scenes.
            End of rant.

          • http://www.facebook.com/alison.m.galvan Alison Manders Galvan

            We now have two full-time nurses for one primary care doctor. One nurse is putting patients in the exam room, and the other is answering phone messages, doing pre-auths for tests and drugs, scanning in consultant notes that have come in via snail mail, handling Rx refill requests, sending labs results over to the doc from our lab interface, calling patients back with test results, and doing EKGs or drawing blood in the afternoon (phlebotomist is here mornings only). The doc does not do preauths, but will occasionally get on the phone for a peer to peer is needed. In fact, sometimes I get on the phone, because they asked for Dr. Galvan and I am Dr. Galvan. ;)

          • http://www.facebook.com/alison.m.galvan Alison Manders Galvan

            Southerndoc, we finally had to implement an office policy that we don’t pre-auth generics. I can’t afford to hire another staff member, and it would take that to find time to do those pre-auths. Walmart has the $4 generics and we suggest to our patients that they use them.

          • http://www.facebook.com/alison.m.galvan Alison Manders Galvan

            We didn’t book appointments ahead of time for Christmas Eve or New Years Eve, intending to just show up and see if anyone called in. However, over the weekend (remember, both days were a Monday) we had several patients who were added to the schedule by our nurse who was on-call, starting at 8 am. When we opened the doors at 7:30 the phone was ringing off the hook. We just kept filling up the appointment slots. So they were not walk ins per se. I suppose you could consider them same day appts. Unfortunately, my husband did not have time to blog while he was seeing those 32 patients. He also did not have time to eat lunch (we went to lunch after we finished, at about 2:30. It was yummy. Had a martini too.) Why do people always automatically assume the worse about physicians these days?

          • http://www.facebook.com/alison.m.galvan Alison Manders Galvan

            You assumed that I was the doc seeing the patients. Reminds me of what we said as kids — when you “assume” you make an “ass” of “u” and “me”. Ha!

          • Suzi Q 38

            Dr. G., “Play nice in the sandbox.” LOL.
            I hope that warmsocks is not serious.

          • http://www.facebook.com/alison.m.galvan Alison Manders Galvan

            I suppose the boss (my husband) could be really pissed if knew I was posting on blogs. It isn’t very time efficient, I admit. But he learned a long time ago not to piss me off! Honestly, he doesn’t have time to monitor blogs and such, so he leaves the piolitically active stuff to me.

          • Suzi Q 38

            I doubt it. My husband is the same way. He knows not to tick me off. He also knows that at times, I am addicted to certain topics.

          • Suzi Q 38

            So what? She (Dr. A. M. Galvan) doesn’t have to explain herself to her husband or anyone else, including you.
            Why are you here? Why am I?
            Are you the “break police??”
            My husband doesn’t even ask me as many questions as you do….LOL.
            Let’s play nicer in the internet “sandbox.”

            I am on “sofa rest.” The doctor told me to rest for a week and see if my symptoms improve or get worse.
            I am supposed to make a daily diary with 3 entries a day.

            I am interested in what she has to say, because I may have been unfair to my PCP and a few other doctors.

            I can be very direct and a bit intimidating, I have been told.
            I don’t know why. I am not a nurse or a doctor.

            I just pay a lot for my PPO insurance and felt that in paying extra for PPO I should be able to get decent medical care, with a call-back if need be.

            I guess I have to be more flexible and a little more creative on my end.

          • mikee60369

            I’d suggest that your doctors just have you come in for an appointment when you need an “auth.” So that way their time would be reiumbursed.

          • http://www.facebook.com/alison.m.galvan Alison Manders Galvan

            I am Dr. Galvan. I am a board certified Pathologist. I quit practicing pathology part-time in 1997 to become the office manager for my husband, a general internist, who always wanted to have his own solo primary care practice (can you tell how young and naive we were 15 years ago?) We are partners in this practice (in fact if you look at the corporate docs he is president and I am vice president). He does the billing, I run the administration/billing/HR. So when I post you will often hear me refer to the practice as “we”, and by that I include my husband, our two full-time nurses (takes 2 nurses to run this busy practice), our billing person, front desk receptionist, xray tech, and plebotomist. As well as my college daughter who comes in on breaks to shred. Although I am not actually in the exam room with my husband, I consider myself as integral a part of our practice as he is. I am quite passionate about the plight of primary care, as you can tell. Hence my proclivity to write long comments on blogs.

          • DENAL

            If the work is hard quality will suffer

        • mikee60369

          Dr. Login
          I truly, truly hope that you are able to maintain your lack of 3rd party payment. Trust me when I tell you: it’s not worth it. Having a direct relationship with your patients is the most honest and straightforward way to operate.

      • Steve S.

        ” I felt that many of my clinic patient in medicine had problems more psychosomatic than real” – bingo, you just unwittingly hit on one of the main reason primary docs don’t personally answer calls from patients. In your specialty, you deal with a very different subset of patients with a very specific illness and treatment.

        Most FPs manage a panel of from 1,000 to 3,000 patients (or more). There’s a subset of those who would LOVE to chat with me for 15 to 20 minutes about their leg cramps or carpal tunnel syndrome, or the color of their BM’s. 10 to 20 calls to the office a day is not unusual, some potentially serious, most not. For me to call them, figure at least 4 to 8 minutes apiece if you include documenting it in the EMR. Easily 1 to 3 hours of unpaid work daily, on top of a full office schedule plus the routine charting, paperwork, med refills etc.

        Sorry, occasionally I’ll call personally if there’s something serious. Most of the time expect a call back from my nurse with instructions or info. That’s just the way it has to be if you ever expect me to see my kids.

        • Suzi Q 38

          Thank you for you for explaining.
          I am a parent, so of course I want you to see your kids.
          For my PCP, I don’t expect a call back unless I view it is truly serious. I can see when I walk into his waiting room that there are 20 patients sitting and standing there, sometimes more. If there are more, they are waiting outside, as there is a bench.
          For me, my health crisis escalated in part due to a doctor decided NOT to call me back. Now that I read all of your posts, I truly think that he erroneously thought that I my a hypochondriac and that my very rely symptoms were psychosomatic. Besides all of that, he was a specialist.
          My symptoms started after the hysterectomy he gave me, so although I viewed it as linked to the hysterectomy, he did not want it to be.
          I kept reminding him of it, probably for 3 office visits, before I demanded a referral to a neurologist. He kept putting my referral off, and never entered my complaints in the computer.
          Even the referral was delayed, as he did not put the paperwork through. I had to remind his nurse TWICE, and I finally called the neurolist’s nurse and had her call the other nurse. I was getting my referral, and that was that.
          I had not only called him, but I wrote him a 5 page letter, that is how serious I thought the problems were.
          The nurse forwarded the emailed letter to him, and he ignored it.

          The neuro had probably talked to the specialist and decided that I was just a hypochondriac.

          Those two don’t think that anymore. They are now concerned that I will have to make a big deal of this.

          Any other patient would and should. They royally screwed up.

          I only got one hint as to what was to come. I had to see a gastroenterologist. My bowels had been giving me problems since my hysterectomy. He never thought that I was a hypochondriac, so I enjoyed our visits.

          He asked me to repeat my newer symptoms, which had increased since Late Spring or early summer.
          “Tell me again…” he said. No one had ever asked me to do that.
          He looked a little scared when I did. He said that I needed to tell my neurologist that the problem was in my upper spine, not just my lumbar.

          My point is that a phone call 3 weeks before the vacation ( or correct treatment much earlier) would have helped me a great deal.

          I could have had much needed diagnostic MRI’s that would have showed the blockage immediately. I could have been told that I should not go on my trip, or if I did, DO NOT sign up for the difficult excursions. Also, do not be immature and go down the huge twisty water slide (which I did). Be very careful not to fall or get into an accident as the spinal cord already had signal changes.
          How about this: “Here is a prescription for pain meds, just in case.”

          If need be, I could have cancelled my trip and rescheduled it, as the long plane ride alone may have been too risky.
          Now my condition has worsened, and my symptoms are not only here to stay, but they have caused severe weakness in my legs and arms that are not reversible.
          I need that surgery, but it was just stop the progression, not repair that damage that has already occurred.

          All because a couple of specialists determined erroneously early on in my treatment that I was a hypochondriac, taking about psychosomatic ailments.

          Please let me know if you really think that about me.
          I will be offended, but not angry.
          I will take my complaints about a very real medical problem to the correct doctor that has brains and forethought and is not so stressed that believes me.

          If you truly do not believe the patient, say so.
          If I thought that this was a possibility, I would have left sooner.
          Thank you for your post, it gives me an idea of what happened to my doctors.
          Here I thought that I was getting the some of the best, as I was at a teaching hospital, and they were specialists with excellent credentials and prior fellowships.

          I have learned that while credentials are good, it really doesn’t matter. If the doctor thinks that you are a hypochondriac, it can be a year or never before you get the proper care.

    • Homeless

      When you take way urgent care, the communication, and the coordination of care, what value does primary care have?

      I can get care at the retail clinic staffed by nurse practitioners for a fraction of the cost within a few hours. They’ll return phone calls.

      • http://www.facebook.com/people/Jason-Simpson/100001631757606 Jason Simpson

        They do? Thats news to me, I’ve been to plenty of them and they’ve never returned a call or called me to let me know about test results. And that is in 3 different major US cities spread around teh country.

        • Suzi Q 38

          I don’t expect a call about test results. The doctor usually goes over the results when I see him or her for my follow-up care. If I want the results sooner, I just call the nurse for a copy of my lab results. I have them mail or FAX it to me.
          If I need the results for a specialist, I just keep a copy and give it to him or to her.
          I only expect a call back for something more serious.

          • azmd

            Here’s the problem with that expectation: “a call back for something more serious” seems to imply that a meaningful conversation is going to take place. That conversation is probably not a two minute call to give you the results of a lab test, as you mention. It is more likely to be a 10-15 minute call in which the doc provides you with counseling and education. That will be a call for which the physician will not be reimbursed, as he or she is not allowed to charge your insurance for phone contact. Nor, as you mention in one of your other posts, is the reimbursement that a primary care doc gets for office visits with you generous enough to provide a margin of excess payment that could indirectly cover such a call. Why not call and make an appointment to go in and see the doctor if a conversation of substance is required?

            I think it is hard for patients and their families to understand what the big deal is with a 10-15 minute call. It seems like a small amount of time, and it is. But when you multiply it by a dozen other patients per day, also expecting the same type of phone call, you are adding two hours of unpaid work to the doctor’s day. People don’t realize this, or if they do, they don’t appear to care.

            I encounter this all the time in my own work, which involves calling patient’s families to obtain collateral history, or explain legal aspects of the patient’s treatment. The call is already going to take me 10-15 minutes, which is factored into my workload, However, the vast majority of the time, I find that family members view this call as an opportunity to vent, I end up providing them with supportive therapy, and the call stretches to 30-45 minutes. I do it because I feel bad for them, because I recognize that there are few resources out there for them to turn to, and because I am aware of how terrible it is to have a family member who is chronically mentally ill. But two or three such calls in a day can make the difference between my being able to pick up one of my children on time versus them standing alone in the dark waiting for me at the end of an evening activity. It is very clear to me that the vast majority of patients’ families have absolutely no awareness of possible time limitations that I might have, and no interest in knowing about such limitations. And so I delegate many of these calls to my social worker, which many families also seem to resent.

            I am not sure what the answer is here. Perhaps physicians should just be like monks, with no family or personal life, and no expectations of doing anything with their time other than devoting it to providing the things that their patients need and want. But I don’t think that would be very healthy. A physician’s job involves giving of yourself. And in order to do that well, you need to take care of yourself as well as your patients. For primary care doctors, it seems like the system has been rigged to squeeze as much as possible out of the doctor. And we are seeing predictable results.

          • Suzi Q 38

            Your points, as always, make sense.
            I have been given more education of what to expect from my PCP.
            My doctor problem was actually with a specialist.
            I don’t know if that makes a difference.
            I am not sure what their work loads are like, but I can only think that he did not view my condition as very serious.
            Mistake on his part.

          • http://www.facebook.com/alison.m.galvan Alison Manders Galvan

            In our primary care practice, we only give lab/test results over the phone that are normal or mildly abnormal. If there are multiple abnormalities in labs, or a major abnormality on a radiology study, then the nurses call the patient to come in for an office visit. Yep, some patients complain, accuse us of being greedy (you just want my copay!), and now our standard answer is that is how we run our practice, and our feelings won’t be hurt if they would like to find another doctor who is able to practice medicine over the phone.

          • azmd

            Good for you for having good boundary awareness and setting limits on what you can reasonably provide for your patients. One of the things that troubles me in medicine is that it is so much part of our culture to deny our own needs and focus solely on the needs of our patients. In the residency training program where I teach, this characteristic is still being promoted as part of our trainees’ “professionalism,” in spite of an obvious long term link between this sort of attitude and later problems with burnout.

            Also, I think times have changed and we are much more likely these days to be dealing with patients who are a little fuzzy on the difference between what they want and what they need. Paternalistically taking on the responsibility for fulfilling every want that someone might have, at the expense say, of making enough money to cover your office overhead, is just silly and self-defeating.

            The other ramification of our inability to set limits of what we are able to provide for our patients is that that inability is being very cynically exploited by healthcare systems. They know that we feel an obligation to do everything we can for our patients because that’s how we are socialized as doctors. So they know we will do it even in the face of not being paid for the time we spend providing the care.

          • http://twitter.com/Liberty_Doc Patrick Hisel

            Because who is really being greedy here is the one wanting something for free.

          • http://twitter.com/Liberty_Doc Patrick Hisel

            Well Said.

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

        That’s the crux of it, isn’t it? Is there value in primary care? I believe there is. Patients miss out by not developing a relationship with one physician to provide the majority of their care. Primary care is designed to provide patients with a single physician who knows us and can tell — without having to wade through years of someone else’s paperwork — when something has changed. If you see the same doctor all the time, the doctor will know whether you’re someone who overreacts and shows up every time you catch a cold, or if you only show up for medical issues truly in need of a physician. That makes it more likely that your symptoms will be taken seriously when you’re ill, and can shorten the time it will take to be diagnosed if there ever is a serious problem.

        Primary care specializes in seeing the whole person. People are not only hearts or feet or skin or eyes or immune systems. People are complex individuals with interconnected systems that affect one another, and it is important to have a physician knowledgeable enough to step back and look at the big picture. Primary care provides that, and our country will be poorer if we don’t make primary medicine an attractive specialty for physicians.

        • Suzi Q 38

          I agree. I have had the same PCP for at least 10 years.
          He knew I had numbness in both hands and feet, but he thought it was a touch of my pre-diabetic a1c of 6.1.
          He never dreamed that it all was linked to the “inner thigh weakness” that I had been experiencing for about 6 months or so, after my hysterectomy.
          He never made the connection.
          I had sympathy for him, because I realized that it would be hard to treat the whole body, rather than the neurologist, gastroenterologist, or gyn/oncologist working independently in their fields.
          I am fairly sure that the specialists sent him a copy of their reports, but I am not sure that he had the time to take out of any given busy day to read them. This is so that he could “connect the dots” of a huge neurological problem brewing.

          I wonder if it would have been better for me to check in with a nurse navigator when I first checked into the teaching hospital doctors. I found out about this service way too late. When I was so angry that I was ready to leave anyway. I realized the value of having her help out.
          She checked in with the various departments to make sure my appointments were in order, she also checked in with a few of my specialists.
          I am not sure the insurance paid for her at all.
          I think her salary is covered by the hospital.

          One time, I was visiting my specialist, and she found me in the waiting room and checked in with me.

          I appreciated that.

        • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

          Warm Socks, first off I like your username. Second, in relation to what you mentioned about the interconnected systems that affect one another is very interesting. The reason is because one of the last times I saw my Primary Care Physician I asked him a particular question about those with multiple health problems. He said that the problems interact with each other. I found that interesting because I never herad that before, and I want to ask him about that whenever I see him next time. Thank you for sharing this. I do have a question though. How is this country going to be poorer if we don’t make Primary Care Medicine an attractive specialty? The reason I ask this is because of what I have seen throughout healthcare, and also by some I have talked to one on one. There are those that would prefer to have other specialists, or other types of doctors like accupuncturists be Primary Care Physicians. This one lady that I talked to about the Primary Care issue said that in some States accupuncturists can be Primary Care Physicians. She made the comment that she wished she could live in one of those States. Another lady I know has a Primary Care Physician as far as on the records with her insurance (she has an HMO), but she uses one of her specialists as a Primary Care Physician instead. The reason? She’s more comfortable with him because he has an idea of the bigger picture of her problem.

  • Suzi Q 38

    As a patient, I rarely call a doctor unless it is truly an emergency.
    If I have a question, I send an email to his or her nurse, or I call the nurse.
    Sometimes, the doctor calls me back to tell me that I can not take HRT because I am prone to cancers, or urges me to have surgery on my cervical spine as soon as possible, before I lose more mobility.
    Once I was distraught because the doctor had told me that I may have M.S.
    He wouldn’t know for sure until the results from the LP and the brain scan came through. He promised to call me and let me know within 3-4 days. Of course, the call never came as promised. I was fretful and worried the entire time. I could barely get through each day.
    After almost a week, I finally called the doctor’s nurse and explained the situation, saying that I needed to know what the results were.
    Of course, she said that she would call me back. She never did.

    I finally got their attention when I drove down to their office at the teaching hospital and went in unannounced. It was not that doctor’s day to work there, and so I tried to explain the situation to the nurse that was there.
    I asked to speak with my doctor’s nurse, but the nurse that was working was not only curt, but rude. She asked me in the middle of the waiting room
    “What do you need from the doctor??” I was equally rude and said, “I want to know if I have M.S. or NOT, DO YOU MIND???”

    They got me in an exam room really fast and got ahold of the nurse I wanted to speak with. I told her off for not getting back to me.
    She apologized profusely, but it was too late.
    I realized then and there I needed a nurse navigator from administration.
    She handled everything very smoothly for me from that day on.

    It is a shame I had to tell my story to administration in order to get what I perceived as something that should have been done as promised….not just from the doctor, but the nurse as well.

    When the nurse finally told me that my tests were negative, I thought:
    “Why make me wait? You knew this information days ago. How about putting yourself in my shoes for a day and think about how you can assage my fears with some much needed good news???”

    I think that the author’s advice and concerns are “right on.”
    There are always compromises that can be made. Not every call requires an answer from the physician. IF it is important enough, so be it.

    Good communication between patients and doctors is rarely a bad thing.
    Bad communication or lack there of can lead to misunderstandings of complacency and apathy regarding any patient’s care.
    This can, at times lead to anger and resentment. In times like these, I feel like heading over to the patient advocacy department to ask them to please explain why my physician could not call me as promised in my situation.

    If I wanted to know if I had M.S. and my doctor or his nurse did not think my phone call was important enough to provide a phone call, he or she is not the type of doctor that I want for me, my friends, or my family.

    Once I got my information, I gracefully left and got a second opinion from the chair of the neurology department of a rather large teaching hospital.

    He is a very busy doctor, and they triple book him everyday that he works.
    This physician was far more approachable, even though he was considered an expert in his field. He had built that department since the early 80′s. At the end of our visit, he handed my husband and I his business card. He told me that if I had any questions or concerns, I was to send him an email. His fellow physician said that I could do the same with him. He said that he might not be able to call me back, but he would answer my question by email.

    I liked that.

    Sometimes, if doctors can not understand that this is the only body and life that I have and it is very important to me, I am probably with the wrong doctor.

    Luckily, I have PPO insurance that we pay dearly for.
    I view good health insurance as more important than a car payment.
    I will drive a “beater” in order to have good health insurance.

    If I select you as my doctor, it must be mutually agreeable that you treat me as you would want to be treated.

    You are not a shark lawyer that loves to start the time clock and charge billable minutes for each phone call. I once called our lawyer for a couple of questions regarding gaining possession of my father in law from a step mother. My lawyer charged me $50.00 and did not notify me when I called! I would not call her again. When she did call ME, I asked her if she was charging me for the call. If the answer was yes, I told her that she had to talk really fast of I would have to hang up, LOL. I told her not to call me if she had to charge me. She got the message and never charged me for a phone call again.

    A doctor is not a lawyer. A lawyer is not a doctor. A doctor is not a gardener. A gardener cares for plants. A doctor cares for humans.
    A doctor is human, and not just on the outside.

    To me a doctor is held to a higher standard than that.
    If you don’t think so, maybe this is why the respect for doctors is declining a bit.

    • Miranda Fielding

      I think you bring up several very important points–the most important one being that if you have (or might have) a life threatening illness such as MS, there is NO excuse for having to wait one minute beyond when your doctor or nurse knew that your tests were negative. I make a point to never give bad news over the phone, but if it’s good news, we try to call the patient right away. Perhaps this is one reason I feel that phone calls should be answered–ALL of my patients have cancer and therefore a disease which is potentially life threatening. The other important point is that it doesnt have to be a doctor who returns the calls–it can be a nurse, or a medical assistant, or even a secretary as long as these people are well trained in what to say and how to say it. It’s all about teamwork and even though a patient is not a “customer”, it’s about customer service. Thank you for your comments.

      • Suzi Q 38

        “If you have (or might have) a life threatening illness such as MS, there is NO excuse for having to wait one minute beyond when your doctor or nurse knew that your tests were negative.”

        That is what I thought.
        I am fine with the nurse, medical assistant, or even nurse navigator giving me the news. It doesn’t have to be the doctor.

        I erroneously thought it was bad news because it had to work so hard to get any answers.

        I shouldn’t have to work THAT hard.

        Some patients would not have done what I did.
        Others are more involved with the direction that their medical care takes. I am the latter.

      • medicalstudent

        I can understand being frustrated at the doctor’s office not returning your calls quickly or answering your questions adequately. However, unless you’re at end-stage MS, it’s not life-threatening. MS progresses over decades and patients with MS, in the US, tend to have life-expectancies almost close to normal (off the top of my head, I think they lose about 5-7 years off their life expectancy compared to unaffected individuals).

        So, if you’re going to make an argument, make it on the basis of having the office return calls and provide patients with information as soon as possible (after the results come back). Not on the untrue “fact” that MS is a life-threatening disease (except for the end-stages, of course). In general, it takes decades for MS to kill you.

        To clarify, I fully agree with you and Suzi Q that test results should be notified to the patient ASAP. I’m just pointing out that your “MS is life-threatening” argument is weak and there are better arguments to be made as to why patients should be aware of their test results as soon as they’re available.

        • Suzi Q 38

          I don’t think that her argument that a possible diagnosis of M.S. (life threatening or not) is weak.
          Weak to who? To you, who sees it daily…monthly???
          To you who doesn’t have it?

          To me, it would have been a very tough diagnosis to accept. Since I am 56 and tested negative on most of the tests, if I had M.S., it could have been the primary progressive….In most probability fast moving. Unlike the type that occurs with younger patients and comes and goes slowly over 3-4 decades, mine may have progressed and was perceived as progressing quite quickly. I may have had to be bedridden by year 5 or 8, who can predict?

          Not life threatening?? Surely you naively jest.
          How about quality of life threatening?? Ask Annette Funicello, who is lying in a bed and “speaks” with her eyes. Ask her family who has to care for her each and everyday.

          You are right, I should (I use this word everyday and will continue to do so when appropriate..physician PC or not) have been notified, at least by a valued co-worker or employee of the doctor of my negative result.

          “K” is the name of a huge, popular HMO in California.
          In decades past, “K” had a horrible reputation with
          long waits for doctors, no call-backs to patients, and rare referrals to specialists. We used to joke that if you had to endure “K” HMO, you could be dead before you got to the specialist that needed to treat you.

          I am pleased to say that for whatever reason, my friends and family’s perception of this HMO has improved.
          They say that their doctors have good bedside manner, are very skilled at what they do, and actually repsond to any questions via email within 24 hours.
          This is purely an anecdotal observation…so please, no requests to document my words with solid, double-blind, crossover studies.

          Me?? I would still rather pay extra for BC PPO as long as Obama and advisors let me.
          If my doctor does not want me and my PPO business, I will regretfully have to seek a better patient/doctor situation elsewhere. Plain and simple.
          If you work for yourself, and have your own business, one or ten patients leaving may or may not be a problem.
          If you live and work in a small town, word travels fast, and it could be a larger problem than you think.

          If you work for a teaching hospital that carefully chooses doctors based on credentials and quality of work, it may be a problem. Why? For whatever reason, they need business too. If I am unhappy, they will know it.
          How? They send us evaluations to fill out every few months.

          In my case, they were wondering why I wasn’t having my $100,000.00 (my exaggeration, sorry) laminectomy at their hospital.

          Believe me, it involved gross lack of communication, no call back, and my neurological condition which was neuro related and not MS, rapidly deteriorated and I could barely walk at the time. I was told that since I did not get the necessary treatment when I called, my deterioration may be permanent, even after my cervical surgery.

          All because of a doctor that wanted to say, “I don’t need to call you back. I am way too busy.” Instead of saying that, he ignored important phone calls that could have helped him get to the crux of my health problem.

          Anyway, he did finally call me back, but only after the neurosurgeon called him to tell me what a jerk and how stupid he had been. He told the doctor that my condition,
          (which had slowly deteriorated over several months), may be permanent…that he had BETTER call me before I refuse the surgery at their facility and walk over to a shark lawyer’s office instead.

          Guess what? When the doctor finally called, his bedside manner was as sweet as a first year med student, treating his or her first patient. He apologized profusely, and asked me not to report him. What did I have?
          Several emails to his nurse, asking for help. Documentation of the fact that according to his nurse, he received all of my emails.

          Sometimes you talk about patients that sue for nothing.
          I am trying hard NOT to sue. I am praying that I get better, so I don’t have to and that I can have a happy ending to this bad medical treatment.

          You can be the smartest doctor or gifted surgeon in your hospital, your city…but if you don’t want to have to return any phone calls, or email requests for help, find employees that will help you and cover for you.

          If you don’t think that you should (I use the word freely, kind of like “amaaaaazing”) have to call patients back, you are truly in the wrong profession.

          Please find a different one, because not doing so unlike other professions, can have disastrous implications for actual people. This is a huge responsibility.

    • DavidBehar

      If you reported me to the administration, I would invite you to go to a doctor in whom you had more confidence. It is not because administration scares me. It is because you would have consument worthless time answering your bogus complaint. There is too much Nordstrom style customer service and catering in medicine, empowerment of disruptive patients. They consume the time needed for other, equally sick patients.

      It is even worse when it is not the patient making inappropriate demands, but family members with personal agendas not known to the doctor. Such low lifes demand futile care, and intimidate doctors with lawyers threatening litigation. They must be crushed using legislation ending all standing, once the patient has expressed a preference about futile care. Ban them. Have them arrested if they show up. If they have legal guardianship, take them to court to strip them of their powers. Doctors may stand in for their patients, and these obnoxious families must be deterred.

      • Suzi Q 38

        “If you reported me to the administration, I would invite you to go to a doctor in whom you had more confidence.”

        Great idea. This would be mutually acceptable to all.
        i would rather take my chance on a different doctor with a better attitude and conscience about what is considered good patient care.
        If my condition worsened permanently because you chose not to call me back, I think at the very least your administrators needed to know what kind of doctor they had working for them.

        If your hospital has the policy of calling patients back when it is important, then they possibly would not agree with your view on not returning patient’s phone calls when they are experiencing chest pains mistaken for heartburn or leg paralysis mistaken for arthritis.

      • Suzi Q 38

        “There is too much Nordstrom style customer service and catering in medicine, empowerment of disruptive patients. They consume the time needed for other, equally sick patients.”
        Sometimes, I actually agree with your statement. When I get those evaluations in the mail, I try to give the doctor the highest points possible because I know that administration wants to make sure that the doctors are doing a good job.
        Conversely, if there are areas for improvement, such as a call back when it is important, the doctor may need to make adjustments in the way that he treats his patients.

      • Suzi Q 38

        “Such low lifes demand futile care, and intimidate doctors with lawyers threatening litigation.”

        Lawyers are interesting people.
        I know so many lawyers, that if I needed one, I would just have to go outside and yell for one of the neighbors’ adult children to assist me, LOL. I know lawyers from high school and college.
        I know lawyers that are parents of my children’s friends. My husband knows a few lawyers at his work…let’s see. Two of my daughter’s sorority sisters at Berkeley are lawyers. My best friend’s husband and his brother are lawyers. I can go on and on. Ho hum.
        I understand your negativity towards them and those that hire them, but it is nice to have one when and if you ever get unjustly fired or sued.

        I don’t have to threaten with litigation, unless the doctor is grossly negligent and therefore not very bright (maybe he was last in his class and just was not good at medicine) or refusing to do his job. If so, he wouldn’t be hired at the fancy teaching hospital. I would not want to call in a lawyer to compel him to do his job, because it is simply easier to report him myself.

        Unlike other patients, I know that the minute I call in a lawyer to do my talking, the treatment for me or my family member stops. I have my lawyer, the hospital calls theirs. We are not allowed to speak to one another without our lawyers. Why???? The lawyers want the conflict to continue.
        In fact, they want it to escalate. Why??? Billable minutes and hours. The longer the conflict, the more they get paid on both sides.

        Imagine a huge mistake on the doctor’s part because he or she stood his or her ground and refused to call the patient.
        The patient worsens, and there are serious complications.
        The patient complains, or gets a lawyer.
        The hospital decides that they need a lawyer to defend themselves, even if the doctor is wrong. Thousands of dollars are spent and it never goes to trial. Why? The hospital settles because it knows the doctor, after a careful review, should have called the patient. It is just too expensive to take a chance at a lengthy trial.
        I guess the hospital would keep the doctor, but they would not want to do so if there were more conflicts, with different patients. It just would not be economically prudent to do so, as much as they admired him for his academic medical achievements. He or she would be considered too much of a “risk” to employ at their hospital.

        When chosen carefully, phone calls may reduce patient misunderstandings and promote patient satisfaction.
        Communication is not a bad thing. In my opinion, it can keep lawyers away.

      • Suzi Q 38

        “They must be crushed using legislation ending all standing, once the patient has expressed a preference about futile care. Ban them. Have them arrested if they show up. If they have legal guardianship, take them to court to strip them of their powers. Doctors may stand in for their patients, and these obnoxious families must be deterred.”

        What is futile care???When nothing can be done for the patient and the patient is going to expire soon??
        As my best friend, who died at the age of 37 of lung cancer, and they sent her home to die?
        I was so upset about that that I called the hospital and demanded care. Luckily, a really nice nurse spoke to me, and told me that they had done all that they could do.
        I was sad, but I did not threaten them with a lawyer for goodness sakes. I was just devastated and fearful about what to do with her.
        She told me that she wanted to go to Disneyland the next day, so off we went, wheelchair and all. She was afraid of falling asleep during lunch at the Blue Bayou because she thought she might not wake up.
        We went on almost every ride that day….I will never forget it.

        Anyway, patients and their families argue about such things because they are scared. Anger comes from fear. When you see anger with your patients and their families, know that it is the fear of the situation that fuels the anger.
        Don’t take it personally.

        Most lawsuits are withdrawn because they simply have NO merit.

        • RJones

          I have just one word: HOSPICE.
          Wonderful.

          • Suzi Q 38

            True.
            Her mother had not come to terms with that.
            She was much more in favor of driving to Mexico as soon as possible, for “experimental” treatment.
            I was just there.
            WE instead went to Disneyland, then planned and a slumber party.
            All of us lady friends took care of her, as she could still sit up.
            Once we finished the party, we all went home, and her mother took over.
            She called us from Mexico.
            She got a few days of treatment there, and then she died.
            Her mother had to pay the Mexican government to get her body back to us for a funeral and burial.

            Hospice sounds like an easy fix, but we had not faced reality yet at the time.

      • Suzi Q 38

        David behar,
        Thank you for your posts.
        It has been truly cathartic and personally enlightening answering your views.
        Unfortunately, I have to go to sleep now.
        Good night.

      • Alison Galvan MD

        David, we went to our med school alumnae association ball a few weeks ago, and spoke with Dr. Isadore Cohn, retired former chief of Surgery at Charity hospital, a crusty old-timer who struck fear in the hearts of many a med student. He said, “Can you believe that now they take surveys and ask patients if the LIKED their hospital stay? You’re not supposed to like the hospital! It’s supposed to be a horrible place that you can’t wait to get out of! That’s what’s wrong with medicine today!” Made us both laugh!

    • ticktickdoc

      Suzi. As frustrating as that experience was, you cannot assume the physician was not dealing with other, possibly more stressful situations.
      Yes physicians should have your best interests in mind. They are not however SUPERMAN. What if his child was on his/her deathbed? What if the physician were injured? What if there were OTHER patients with problems MUCH WORSE than yours that he/she had to attend to.
      You felt anxious. You were frightened. That’s understandable. That does not make you the center of the universe.
      Is a judge going to go to court at 3am to decide if someone is guilty or not? Is a car mechanic going to come to your house if your car is broken down to help you out?
      Physicians, believe it or not have other patients, and they also have lives of their own to live. Your diagnoses would not change if you found out 3 minutes, an hour, or a week earlier.

      • Suzi Q 38

        Yes, you do have other patients, and they understandably do have their own lives.

        You are right about that.
        You must love what you do or you wouldn’t sign up for doing something so difficult.
        Your examples are fine, but they do not involve someone’s life as we speak. Maybe indirectly, perhaps, but probably not.
        The judge….maybe if someone killed a juror or the wrong person was put in jail and was killed in the process….not likely, but possible. The car mechanic??? I have AAA.
        I really didn’t expect my doctor to make a house call for me.
        A phone call would or email from his nurse would have been acceptable.

        In my case, the doctor took 4 weeks to call me back.
        He only called me back because his colleague, my prospective neurosurgeon, told him what was my problem. That I needed to please agree to a surgery before I lost function in my legs for good.
        He called me better late than never to ameliorate our situation so that I would agree not to report it and schedule my surgery at their hospital.
        I would have liked to think that he was worried about me, but I think that he was more worried about himself.

  • medicalstudent

    Dr. Felding,

    I think you’re missing a very important piece of the puzzle: you’re a radiation oncologist! Your day is completely different from the day of a PCP. I’ve spent a lot of time with radonc (since it’s a field I used to be heavily interested in), both research-wise and clinical rotations, and I can tell you that the IM and FM services were far, far, far busier than radonc ever was. I was stunned when my radonc attendings would spend 1.5hrs with each of their patients — they saw maybe 4-5 new patients per day and 1 or 2 consults. On the other hand, my FM and IM attendings would be seeing patients every 15-20 min and still be constantly behind. The day would always finish late, behind schedule. Compared to that, my radonc rotation was a “vacation” of 8-5 stable, controlled hours. This was true for attendings as well and residents only rarely stayed late. “Call” was from home — each resident had the pager for a week; I don’t think I’ve ever seen a radonc resident/attending come in during call duty (radonc emergencies are, luckily, relatively rare). The same cannot be said for the months I was on IM and FM.

    You’re a radiation oncologist. You have, arguably, one of the highest incomes of all specialties in medicine. It’s also pretty unlikely that you have busier days than a PCP does. So, something that works for you, in your office, is probably not going to work for a PCP who’s constantly running around seeing a large volume of patients. It’s easy for you to “do the right thing” when you already get paid a high salary (which you completely deserve, as does any other physician, regardless of specialty) and have a much less busier schedule than PCPs do. You can easily compensate for unpaid extra work. Not many PCPs can do that, even if they wanted to. Spend some time in a PCP’s shoes and you may change your tune. Because, right now, your article comes off as condescending and like it was written by someone who doesn’t fully understand how other fields work.

    Best wishes.

  • southerndoc1

    Take home messages:
    Docs, especially PCPs, see red when they see the word “should.”
    Docs, especially PCPs, see red when they’re compared to vets or anyone else who sets and collects appropriate fees for their work.
    Docs, especially PCPs, much of the time can’t “behave like doctors” because of the system we’ve created. (I.e., time that docs and staff used to spend calling patients is now gobbled up by pre-auths and peer-to-peer reviews)
    That aside, I’m amazed by a University that tries to sell lousy “concierge” services to its employees to make a buck. I hope you gave them a piece of your mind, Dr. Fielding.

  • Alison Galvan MD

    If I have to read one more comment by a specialist about what Primary Care “should” be doing I will scream! You did a residency in Internal Medicine but chose to go into RadOnc, and now you feel that you have the right to comment. The ONLY thing you have a right to comment on is RadOnc. So go ahead and write articles about how to practice RadOnc, to your heart’s content. You are making the system worse by writing this type of article, not better. Why do you think Concierge medicine even started? I know, you probably think that “greedy” primary care docs just want to get rich. Could it be that primay care would LOVE to be able to phone all of their patients in a timely fashion, to have the time to have that personal relationship with each patient? An article this summer in Medical Economics magazine suggested that Primary Care, if they want to stay in business, should schedule 10 patients an hour. That’s a patient encounter EVERY 6 MINUTES! And how should we accomplish this? By “cutting out the chit chat.” I would not want to be associated with any specialist who would sell her fellow physicians down the river. In fact, I think it would be a splendid idea to send a copy of this article all the FPs and IMs in your community. Your referral base needs to know how little you think of them.

    • Suzi Q 38

      I am not sure she discussed primary care doctors specifically, but doctors in general. Sending a copy of the article to FP’s and IM’s???
      Lower yourself to a threat in response to an honest opinion?
      How immature.

    • Miranda Fielding

      Wow! That was about as hostile a letter as I’ve ever had. FYI: I’ve practiced in the same city for 20 years, and think VERY HIGHLY of my referring doctors as they obviously do of me. I’ve been in three different practices during that time–two different private practices, and most recently for the last 5 years in an academic practice. My referring doctors AND my patients have followed me around for 20 years. I have patients from Boston who still contact me for follow up more than 20 years later and I am very proud of that fact. I completely disagree that primary care MDs should see a patient every 6 minutes. I am sorry for you if anyone is making you do that. My referring MD’s tell me that the thing they like about me the most is that I call them personally when there is a problem, I take their phone calls, and I do the same thing for their patients. Shame on you for your hate filled letter. Again, the original title of my post was “I am Not the Concierge”. It had nothing to do with phone calls. My referring doctors are quite happy. If you are not, I suggest you retrain in a different specialty.

      • http://www.facebook.com/alison.m.galvan Alison Manders Galvan

        Perhaps your referring physicians would not think so highly of you if they read this article. Especially those physicians that have chosen to become Concierge physicians. You insinuate in your article that they should provide concierge services for free (“For a mere $5,000 a year more than the exorbitant rate I already pay for my Blue Cross PPO, I (and my spouse) will be entitled to a doctor who will see me within 48 hours if I get sick, who will help me “navigate” the system if I get cancer, who will return my phone calls within 24 hours, and who will make sure that if he is on vacation, a covering physician will see me. My Jewish grandmother rolled over in her grave, sat up and said, “This, I should pay EXTRA for?”). You so smuggly pass judgement on your fellow physicians, from your comfortable post as an employed physician at an academic institution. Should we turn our noses up at you for choosing to become an employed physician in an academic setting? Retrain in a different specialty? Are you kidding? There already is a HUGE shortage of primary care physicians in this country — how could you in good conscience suggest such a thing? Are you so sure that your referring PCPs are happy? That’s funny, because I don’t know of any primary care docs who are happy. And there sure aren’t any new physicians coming out of residency and going into primary care. My response offended you? Well, your article offended me. And please quit blaming Kevin for changing the title of your article. That’s wearing thin. I’m not offended by the title, I’m offended by the content.

        • Miranda Fielding

          Well, stirring up a little discussion is never a bad thing. Sorry I offended you. But I will go on practicing the way I have for 30+ years. It works for me, both in the private practice settings I’ve been in, and in my current academic job. I wish you success and job satisfaction in yours.

      • RJones

        When you are as argumentative as the person you are dressing down, you lose credibility.

    • ticktickdoc

      Alison Galvan MD……RIGHT ON! I’d like to see the author work 7 half days a week in a clinic here seeing 12 patients per half day and then having teaching and research AND allowing medical students to participate in the office visits. Then to clear the desktop of emails and orders AND field the phone notes. There needs to be humanity put back in to a physicians life.
      My children have a right to eat dinner with their parents. I have a right to some free time before I go to bed. Why do people like the author believe we are available 24/7?
      Physicians will preach and preach how important sleep is, how important it is to rid the body of stress and participate in hobbies and enjoy family life and get exercise…etc. Why does this same medical advice not hold true for physicans themselves? We are expected to sacrifice our time to make sure each and every single person gets what they want. Ridiculous.
      If there was not medical insurance with just about every thing covered, then 90% of visits and calls, I believe, would vanish. People wouldn’t be so willing to spend their own money on every little whim and fancy query that comes there way.
      And comparing FP’s to a veterinarian is just silly. There’s no way the two lifestyles during the working day are similar.
      I highly doubt a depressed dog schedules a 15 minute sore back visit and then starts crying and NEEDS you to keep talking for an hour while the other cats and parakeets wait.
      I love specialists that dump on FP’s and claim they know how hard it is. “Schedule a followup visit with your FP and have them control the meds I want you on”.

  • http://www.facebook.com/shirie.leng Shirie Leng

    Azmd is right. You want to do everything you can but if you don’t get paid appropriately you can’t pay your staff, the rent, the electric bill. No one’s trying to get rich here, trying to make a living. And Dr. Fielding says she didn’t go into internal medicine because the diseases weren’t “real”. Honey, depression, domestic violence, hunger, poverty, these are all diseases that are as real as it gets. Drs don’t get paid for treating them, that’s all.

    • Miranda Fielding

      Excuse me, but I DID go into internal medicine. And I didnt say that the diseases weren’t real; I said that in MY internal medicine clinic as a resident, there were a lot of psychosomatic complaints. My experience only. ANd I am not to blame for the disparity in reimbursement between my field and yours, am I? That’s what you are really upset about and I completely agree with you. And by the way, my daughter is currently interviewing for residencies in Internal Medicine, with my encouragement.

  • doc99

    PCP’s should be paid for their time, not CPT codes. That would be a game-changer.

  • Miranda Fielding

    You know, I actually agree with you that the motivation of most of the concierge doctors that I know are actually motivated by wanting to provide better care, not to make more money. But the sad thing for me is that it will widen the gap between the “haves” and the “Have Nots”. In my > 30 years in practice, I”ve taken care of rich people and poor people, and for the most part the poor people were universally more rewarding to care for. In my current practice, I take PPOs, Medicare, Medi-CAL and “no pays”–meaning that the University is committed to a certain level of charity care. Now you’ve made me wonder whether if I had stayed in Internal Medicine, given how much time I DO want to spend with patients, whether I myself would have been practicing concierge medicine by now. Thanks for your thought provoking comment.

    • kjindal

      a few questions for you (seriously, I don’t mean to offend):
      1-does your accepting medi-cal and “no-pays” affect your bottom line directly?
      2-does the University receive subsidies from the state (or federal gov’t) in exchange for the charity care they (and you) provide?
      3- do you have to pay your excellent nursing staff out of your gross revenues?
      4- do you mow your own 3-acre lawn?

      thanks for inciting a spirited discussion!

      • Miranda Fielding

        I will try to answer.

        1. Accepting Medicare and Medical improves my bottom line. Our biggest managed care contracts pay significantly less than either. Really. I am SO not kidding.

        2. Yes, the University receives subsidies from the state for charity care. But the costs far outweigh those benefits. If you read my blog you know that there is a significant problem with illegal immigration in my state. Still, I am proud to provide charity care.

        3. How many and what level of experience nurses I employ is determined by the departmental budget, which is determined by net departmental revenue.

        4. I am grandfathered in in Internal Medicine, but my husband is board certified in Pulmonary, Critical Care and Infectious disease and my daughter is a medical student going into IM so the dinner table conversations have kept me current. If I had to recertify, I would because I am proud of having that background. I am also grandfathered in Radiation Oncology. I cant help it. I’m old.

        5. I am afraid of the lawn mower and I have a son still living at home so no, I dont really do mow the lawn. I do however muck the horse stalls and clean up after as many as 5 deerhounds (now down to three) and grooming them, which is a LOT of dog.

        6. You’re welcome!

  • medicalstudent

    I’ve rotated at academic centers and I’ve also rotated at a more private practice type of place, where there were no residents and it was just me and the attendings. During my radonc rotations, I was responsible for contouring normal structures. I fully understand the complexities of H&N cases — med students routinely work with their attendings in contouring cases (usually, we contour normal structures, as I previously mentioned, but we would occasionally help contour the tumor as well). Even with all this, a day in radonc was far less busy than a day in the FM or IM service.

    Now, I’m not saying you have an easy life or an easy day. Don’t put words in my mouth. What I am saying, however, is that, relative to a primary care physician, the day of an avg. radiation oncologist is likely to be much less busy. While I can only vouch for the personal experiences I’ve had at the institutions I’ve rotated through, other colleagues and those on the interview trail have confirmed similar findings in the places they’ve rotated through. Hell, the stability and lifestyle that radonc offers is one of the reasons why it’s such a competitive field. No one can deny that. So, something that works for you will likely not work for a PCP.

    • Miranda Fielding

      Once again, I would direct you to my piece “Cancer is not a Lifestyle”. But then again, you seem to already know everything. Good luck on the interview trail–perhaps we’ll meet. And get back to me about how stress free it is once you’ve actually been responsible for curing cancer for thirty years or so.

      • http://www.facebook.com/people/Jason-Simpson/100001631757606 Jason Simpson

        Fielding’s work could easily be replicated by a computer. Rad oncs will quickly be going out of business along with the radiologists as computers take over the low hanging fruit of imaging and work that can easily be done by computer

        • Miranda Fielding

          Jason, please do your homework before making such an uneducated statement. I am not a radiologist. I do not read X-rays. In fact, when I do a treatment planning CT scan I do not charge for the scan itself because I do not offer an interpretation. We take our scans and do treatment planning but this is only a very small part of what I do. I really dont think that a computer in India can sit with a patient and explain the natural history of that patient’s cancer, the role of radiation in treating it, the alternatives to radiation, and the risks, benefits, side effects, and especially the late effects of treatment.

          That being said, however, I do think that radiation, despite all its advances, will hopefully become obsolete one day. It wont be because some guy in India can grab the low hanging fruit (as you so ignorantly call the treatment of cancer) but because better, targeted therapies will take its place. And when that happens I will happily retire.

        • ticktickdoc

          I never thought of that. Interesting.

        • ticktickdoc

          Jason. Very interesting. I hadn’t thought of that.

  • Alison Galvan MD

    Perhaps a better and more constructive discussion would be how to fix our healthcare system so that our primary care physicians would not have to resort to a concierge model in order to take adequate care of patients. We are struggling to remain an independent small physician primary care office. We have watched our colleagues sell their practices off to the large hospitals and become employed physicians. They all agree that the loss of autonomy is difficult at best. Certainly not in the best interest of the patient. I won’t ever say never — we have looked at both the concierge model and employed MD model. But for now, we hang on by our fingertips for our patients and for our staff, who desperately need the jobs we offer. Hats off to you, Dr. Jones, for looking for a way to provide quality care for your patients, and enduring the criticisms from your fellow physicians.

  • azmd

    Just so you know, a 30 second Google search using terms gleaned from biographical terms from your blog reveals your real name and academic position. I won’t post it here, but if you are making such candid replies because you are under the impression that your anonymity is protected, you may want to rethink a little bit how you express yourself on the Internet.

    • Suzi Q 38

      Good advice in general, AZMD, but again, such negativity and harsh threats for the author giving her opinion as a clinician for over 30 years. What, a physician can’t “call out” other physicians on the politeness of calling their patients back when it is deemed important??? Not to mention the liability of NOT calling the patient back.
      There is no way that I will pay $5K extra for that service.
      I will instead find another doctor that does take my care seriously and calls or has someone else call me back when it is important.
      My surgeon has never called me back personally. I just call his nurse. She doesn’t get back right away, but at least she calls within 2 days, unless I am highly acute. Also, if I were that acute, I would go straight to the hospital or at least camp out at the office.

      Another option is for me to make another appointment to see the doctor and talk about my heath challenges.
      The problem is that my doctors are usually booked up for 2 months. I can not wait that long for an answer, so this is why I would call.

      • azmd

        Hi, Suzi Q–I am truly sorry you have had bad experiences with doctors. I can sympathize, as one of my children has some chronic medical issues and over the years I have certainly had my fill of distracted and condescending physicians who were too busy to return calls about things that were making me feel anxious.

        Just to clarify, my post above was not in any way a “threat,” rather it was a friendly heads-up in direct response to “Dr. Fieldings” inviting another poster to “figure out my real name first!” It appears that she is not aware that her identity is less protected than it is, and may be expressing herself in a way here that she might not otherwise.

        • Suzi Q 38

          Thank you for clarifying.

        • Miranda Fielding

          I hope I made things clear, that I dont really think that I’m being anonymous. I do thank you for your concern. And by the way, one of my children also has a serious chronic medical problem, so perhaps part of my “attitude” comes from the frustration of dealing with his physicians.

    • Miranda Fielding

      You found me out! Well, as my 21 year old son says, EVERYTHING we put on the internet is public. It’s why I am on Facebook and he is not. I have been thinking based on this storm of controversy that I should “come out” but seriously my concern is that the U may want to shut me down due to HIPA considerations, and now that I have started “talking” I dont want to stop. Especially since a lot of my blog is about my kids, dogs and horses and not about cancer at all. I do try to protect my patient’s identities, and when they have been identifiable, such as in “Only the Good Die Young”, I posted both on my blog and here with the family’s express permission. Yes, you certainly can find everything on the internet these days.

  • Jenna Smith

    Veterinarians charge appropriately for their services? Don’t make me laugh. The average salary for a veterinarian is around $80K (look it up on the AVMA’s website). I’d have done better going to nursing school, or PA school, or working as a part-time physician in family practice. Yes, I suppose I could raise my fees, but there are precious few clients able, or willing, to pay the fees I’d have to charge to raise my income into the realm of a physician’s income.

    Yet, I return my clients’ phone calls, 24/7. I often answer the phone. All that, with no concierge fee, and no charge for my time. I even talk to non-clients. Unthinkable. Why do I do it? Because it’s part of my job.

    • Suzi Q 38

      Bravo.

      A person that knows what she wanted to be, went for it, and understands the fact that she isn’t going to get a huge monetary bonus for calling her clients back.

      Doctor’s take note: Calling patients back, at least when it is important is not only customary and polite, but it is part of your job.

      If I were a teacher, I would have to call parents from time to time.
      If I were a mechanic, maybe I would have to call a client and tell them the reader’s digest version about what went wrong with their car repair.
      Maybe you think that with the advanced degree comes a certain celebrity about being a physician. You shouldn’t HAVE to call the little people back….(exaggeration, sorry). Well, indirectly, the “little people” pay your salary that gets turned into mortgage, insurance, car, loans, food, gas, etc.
      We are more important than you think. so consider our day for a change, even though I know yours is infinitely more complex.
      Collectively, you see a lot of really sick people. As patients, the illness is personal and definite.

      • DavidBehar

        Suzi Q 38: How about $5 a minute? If a call has any value, it is a money value. If you do not want to pay, it means the call has no value to you.

        • Suzi Q 38

          How about your child acts up in class habitually or sporadically. I give your child a detention after school and a “D” in high school Chemistry. You want to talk to me at a convenient time for you, which is after 5:00 P.M., when I am no longer working. You leave a message and say that you would like to speak with me regarding your child, his or her behavior, detention and the grade.
          I make sure to call you during your work time and leave a message to notify you to tell you that the fee for the call will be $5.00 a minute. That I would be happy to speak with you when you send me the retainer fee of $150.00, the estimated time of 30 minutes times the $5.00 a minute….
          Right when I come to the part that your child is still getting the “D” he/she deserves, I notify you that you have only 30 seconds left. do you wish to talk to me for another 10 minutes? If so that will be another $50.00. I will give you the information when I get another $50.00 from you. I hang up because my time is done.

          Please don’t tell me that you would not have a problem with that. I won’t believe you, LOL.

          Imagine that we are talking instead about a health problem that your daughter has.
          I am not saying that I would not pay it to get the information, but I would pay it only under protest and attempt to change this ideation of yours that makes you think that you are above it all.

          You, your boss, the hospital, clinic, or university has chosen to accept my PPO or regular medical insurance in exchange for providing decent or good medical care.
          If the insurance is not enough, do not accept that type of insurance. Opt out.

          Give me a chance to go choose another doctor that will respond to my calls for information, direction, or help.

          My Internal Medicine doctor is from another country.
          He came here and had to take the boards in English, which was probably NOT easy for him, as English is his second or third language.
          He gets to his office and starts seeing patients BEFORE his nurse or receptionist gets there. If I don’t get the coveted 8:30 AM or 2:00 PM appointment, I have to wait awhile. If I call and say that it is important, he calls back and does not charge me $5.00 a minute.
          If it is really, really important, I wait until 5:00 and go straight to his office. His nurse likes me and has taken me back to see the doctor. I tell them that they can go ahead and charge my insurance for the visit, but they never have.
          I have only done this once, but it works.

          He is an internal med doctor, so please don’t say that it isn’t part of your job.

          On the other hand, so many things are changing.
          if my insurance company is not paying my doctor enough, I just buy him a really good Christmas gift.
          This last time I got my doctor a $200.00 gift card to Costco, with a very nice thank you note.

          I think he was floored. His wife wrote me a very nice thank you note, and I believe he was proud of the care he provided for me as evidenced my my note and gift.

    • DavidBehar

      Jenna: Do my lawn. Do it for free. You are such a victim, you would do it.

      • Suzi Q 38

        This is not the same analogy, and you know it, LOL.
        She is not a gardener, and the service is in no way related to you or your dog (client and patient).
        “Dr. Behar, come over and wash my car. Do it for free, LOL.
        While you are at it, pick up my groceries at Trader Joe’s on the way to my house. You are passing by my house anyway…”
        That example is not really a good one.
        Try again.

    • Suzi Q 38

      No jenna,
      You do it because it is not only part of your job, it is a reflection of what you think about your career. It appears to your clients as if you care. That they would not call you unless they were worried about the well-being of their pet, who is important to them.
      You probably realize that calls are part of doing a good job, and providing a good service.

  • azmd

    Really, this post, and this whole debate illustrates a polarization in our profession that is really an echo of our polarized society, where the elite are gaining ground and the rest of us are losing it. The disparity is not just about income, it’s about the ability to control your destiny.

    On the one hand, we have specialists, who are well-paid and able to practice under relatively humane conditions (although anyone who practices medicine is going to be working very, very hard,) On the other, we have primary care docs and other lower-paid specialties who are being increasingly squeezed,financially, and otherwise by healthcare organizations and third-party payers.

    One of the most corrosive aspects of this division is the tendency of the elite to excuse their privileged position by chalking it up to their being harder working, more responsible, or somehow more deserving than those less fortunate. Of course this is a rationalization. As an Ivy-trained physician, I am keenly aware that my background has allowed me to make choices and stand up for myself professionally in a way that some of my colleagues cannot. None of it has anything to do with my being harder working or better than anyone else. I was just lucky enough to be born into a certain family and with a certain brain. Those attributes do not allow me, in my opinion, to tell other physicians what their obligations are, especially if I have not had to walk in their shoes.

    The more divided we become as a profession, the easier it will be for others outside our community to seize control of how we manage our work. If it can happen to primary care docs, it will inevitably happen to specialists. We all need to stick together to try and make our system work better, for our patients and for ourselves. Pointing fingers and assigning blame is not a good way to do that.

    • southerndoc1

      Many good points in your post. However, when you say that “we all need to stick together,” it’s way too late for that. Primary care doctors are very aware that, more than anything else, it is the AMA’s RUC that has destroyed primary care in this country. It is our fellow physicians who have designed, disseminated, and maintained the tool which CMS and the insurers use to grossly devalue our work. Pleas to the sub-specialty socieities to help in changing this have fallen on deaf ears. Primary care docs feel (correctly, I think) that they have been stabbed in the back by their peers, and, as you can see from some of the posts here, are very bitter and resentful. Sadly, I think it’s too late to “work together.”

      • Suzi Q 38

        I think that you are right.
        You should see what the California Teacher’s Association gets done here in California, for the good of the teachers, without caring about what happens to the children they serve. It is not that they do not care, it is that they make sure their needs come first.

        That, is another story….

        My point is that you DO have to get together and talk as a group.
        The teachers donate a good amount of money through union dues that are set aside to fight their causes.
        Think of the average teacher’s salary of 60K.

        The dues represent a rather large amount compared to a doctor’s salary.

        The problem is that doctors are so busy treating patients that they have not figured out how to come together to be stronger. by the time that you have devoted 10 years or more to learning your profession, it is now time to pay the loans, not to mention getting through your difficult days.

        Who has the time to devote to become the next Cesar Chavez of downtrodden PCP’s??? Most of the public would look at your salaries and laugh. “What do they have to complain about?” they would retort.

        They do not realize the years and years of studying, learning, and treating patients that you have done. Not to mention the money and personal sacrifice that is involved.

        If I were you, I would look at the teacher’s union model.
        They seem to get what they want, so why not doctors?

        How you feel about us patients affects the care that I receive.

        If It would be better that I give you $50.00 cash per visit and you not bill by insurance, please let me know.

        I had no idea that I could help.

  • Suzi Q 38

    we already pay $850.00 extra a month (above and beyond the $1,000.00 a month that his employer pays) that my husband and I pay for 2 adults for PPO.
    Isn’t that already “concierge medicine?”

    Maybe expecting a call back from a doctor is asking too much.
    Maybe he or she is not smart enough business wise or socially to understand the ramifications of not doing so when it is important.

    Being smart enough to pass medical school and boards does not mean that you are “street smart.”

    Giving a little and calling that patient when it is important speaks volumes about how serious you are about their care.

    • azmd

      I honestly don’t think this discussion is about whether your doctor should call you back. It’s about whether your insurance premiums go towards paying the doctor enough to be able to reliably provide the level of care that we all agree that we would like to provide, and that our patients deserve. Unfortunately, for primary care MDs, the answer to that question is frequently “no.”

      In order for me to find an internist who would reliably call me with lab results, etc, I have had to establish a relationship with one who does not accept insurance. And since I cannot afford the premiums for the PPO plan at my job, I just pay out of pocket for every visit to my doctor. Is this annoying? Sure, a little bit. But you get what you pay for. And my insurance does not pay enough for my visits for providers for them to provide highly personalized care. Do I recognize that it’s a failure of the system, rather than a moral failing on the part of the doctors who accept insurance? Yes, I do.

      • Suzi Q 38

        azmd,
        I will admit that you make some interesting points.
        Not everyone has access to decent insurance.

        I have decided that driving a “beater” car is preferable because I need the money to help pay for our monthly PPO bill, which is $850.00 a month.
        I have friends that drive expensive cars, have beautifully decorated homes, and take lavish vacations. Their insurance??? HMO all the way. They have to ask to get to see certain doctors. It sometimes takes months.
        Not for me.
        If I were young, I could take a chance like you do and just pay cash and pray that I don’t get into a car accident, or get cancer at a young age.
        Once you turn about 40, as you know, your body starts breaking down slowly with the aging process, sadly.
        You just can’t take a chance with paying cash for doctors in lieu of insurance. One major illness and long hospital stay can wipe you out both physically and financially.
        My brother in law died at age 52 within 6 weeks from pancreatic cancer, my sister just got diagnosed at age 51 with colon-rectal cancer. I had uterine pre-cancer, and a spine problem. I am not at he age where I can qualify for medicare, as I am only 56.

  • DavidBehar

    I am certainly willing to pay my doctor $10 a minute for a phone call. Even a lengthy conversation is cheaper and less disruptive than a visit, requiring a drive, taking time off from and rescheduling a clinical load about 3 times busier than hers. The Obama administration has decided to refuse to fund telemedicine, and she would be charged with fraud, if she accepted payment for my call. We must go after the lawyers tormenting us and our patients, with their know nothing policies.

  • Suzi Q 38

    I will admit that I am unfamiliar with your type of practice.

    I checked out the link and saw that your fees were less than the $5K per year that the author of this story cared to pay.
    I know that you are offering more services, and a more personal approach to patient care, which could appeal to a lot of people.
    Do you accept and bill HMO for the regular medical costs?
    Do you only accept PPO?
    Do you tell prospective patients that want to have you for a doctor but can not pay the fee that you can not care for them?

    How are you doing, business wise with this model?
    For my husband and I, this would cost approximately $250.00 extra per month, in addition to the $850.00 per month for my PPO insurance. That is $1,100.00 a month, cash or $13,200.00 per year for my insurance needs.

    If this is so, I am not in the “market” for this service, although I respect what you are doing and understand why you would do it.

    There is a market for almost any good service, so why not health care?

    I just would not pay for it at this point.
    I realize that there are others, perhaps other physicians, or people that make over what Obama considers wealthy Americans (over $250K per year) that can afford to pay.

    • MedStudent89

      Suzi, you’re insane. Maybe you should use your PPO to go see a psychiatrist?

      • Suzi Q 38

        Very funny.
        I trust that you are serious, though.
        I don’t need a psych consult, I need a doctor that will call me back when it is important.
        As evidenced by some of the posts, those doctors are “out there.”
        Maybe you should “get out” of medicine before you figure out it is the wrong line of work for you.
        Calling people like me that have an opinion “insane” only illustrates you budding frustration at a profession that you have chosen.
        At least I will expect a call if it is important.
        You will be treating many. many patients that will expect more calls…get used to it.

        As of now, it is considered part of your job, and the right thing to do.

  • http://twitter.com/sarasteinmd Sara Stein MD

    Oh for heaven’s sake. Why are you letting that dog suffer? Think about the patient’s comfort, not your need not to grieve, doctor.

  • ticktickdoc

    “My husband and I are third generation practitioners” = we had our Medical School paid for with a golden spoon and probably don’t realize how hard it is to pay off school loans and raise a family.

    “My husband and I are third generation practitioners” = our children don’t have to pay for Medical School and they may also dump on Family Medicine.

    “My husband and I are third generation practitioners” = look at the shortage of Family Medicine Docs and the RVU difference between them and specialists and STILL NOT understand why concierge medicine may be the correct path for some physicians.

    • Miranda Fielding

      Actually, my daughter took out loans for medical school because I was paying for my two sons to go through college at the same time. And as for your other post, I really dont understand your hostility towards me. I had the same conflicts as you trying to raise my children and have a full time career. In all of my years of practice I worked five full days a week–in the academic practice I am in now I work four full clinical days and spend one day doing research. Obviously you think that medicine is a job, not a calling. And shame on you for dumping on another female physician who blazed the path for you. That would be me. And you know NOTHING about me to speak so hatefully. That’s all I have to say.

    • Miranda Fielding

      Oh, and PS. Despite her heavy medical school loans, my daughter is applying for residencies in Internal Medicine. You must have missed that part. Now, go take care of your kids.

  • RJones

    I have a consierge doctor, and I love it. They are relaxed, professional, and I can always get an appointment, sometimes the same day.
    Their waiting room isn’t over crowded, and I feel like I’m getting excellent care.
    What is wrong with that? Nothing.

    • RJones

      BTW, my consierge service runs $129.00 per month for me. It covers only the doctor visits, and my doctor comes to the hospital if I am hospitalized. I have other insurance too, but that’s for tests, emergencies, surgeries or whatever else life brings. My $129 per month primary care physician is worth every bit of that cost to me.

  • 1themecca

    My daughter and I were both quite impressed with a surgeon who called to check her progress the day after her out-patient surgery. I can’t remember the last time a surgeon, or any other physician for that matter, called to check progress.

  • Suzi Q 38

    I am especially appreciative for all the comments from Primary doctors.

    My BIL died 4 years ago from pancreatic cancer with mets.

    His first complaint was a dull backache. Since he had recently moved a large television set, the doctor thought that lifting was the culprit. She advised him to take Advil. Over the next 6 months, the pain escalated, so next the doctor prescribed Vicodin. Within a year, the pain had escalated so much, that he was on bed rest and had to eventually be taken to the local E.R. The surgeon on call took a scan and saw the tumor. He asked if he could operate on it. He was not an oncology surgeon, and this hospital was a community hospital.
    Once diagnosed, he died two 2 months later, at that local hospital. The local cancer hospital could not accept him because what was done was done, and they could not add anything more. Besides, 75% of his insurance was gone.

    My sister (his wife) had a strange colored stool. This is for the physician that stated that he gets calls from patients about the color of their stools….She needed a colonoscopy anyway, so she went to a gastroenterologist. the results were not good. The pathologist decided it was adenocarcinoma, on her colon, near the rectum, near some lymph nodes. At least we got her to a oncologist at a cancer teaching hospital the first thing.

    A lot of symptoms that seem ordinary can be the start of something deadly.
    I have sympathy for those of you that have to work as “detectives” and work through all of this. Many of us don’t have a deadly disease.

    All I can say is that if it is abnormal and persistent, it is definitely worth looking in to with a couple of tests or scans, or follow-up phone calls.

  • Suzi Q 38

    Yesterday, I had a bad day physically.
    I wrote to my neurologist, then I phoned my neruosurgeon’s office.
    Yesterday was the first day back from the holidays, so I wondered after talking to several of you if anyone would call me back at all.
    I waited until 4:00 to call a second time. This time I was more direct with the receptionist. She asked me if I wanted to speak with the NP. I agreed.
    I got her voicemail. After I left a message, I got back on the phone and called the office again. I told the receptionist that all I got was the voicemail.
    “I am not dying, but I am experiencing a very serious condition,” I told her.
    The receptionist promised to let the nurse know that it was important.

    I had visited with a friend earlier whose husband is a pulmonary specialist at an HMO. She called, a bit concerned that no one had called me.
    She offered: “My husband comes home, eats a little dinner then usually spends an hour of his time calling patients that need to be called. Why hasn’t your doctor’s office called??”

    Thank goodness I received a call from the nurse at 7:00. I was able to tearfully explain my situation. She waited for the doctor to return. He did so at 7:30, so she called me again shortly thereafter.

    Now I am clear at what I need to to, and how to proceed with plans to possibly have my surgery soon or get to an E.R. if needed.

    I also have an appointment with the surgeon next week as he is going on a short but much needed vacation starting today and ending on Tuesday.

    I am so grateful that there are a few doctors or their nurses that can call me back if need be. I am more thankful than ever before.

    Thanks for letting me know how difficult it is to call a patient back.
    I had no idea. I will choose carefully when I ask to have the doctor or nurse call me back. I will offer to come in for an office visit instead.

  • Linda S.

    Easy for a radiation oncologist to say.

    • Alison Galvan MD

      Love to hear from a Canadian doc! While many US physicians shudder at the thought of a single payer system, I’m not sure that would be so bad. However, my understanding is that the Canadian system has very little bureaucratic burdens, that treatment decisions are made by patient and physician without government interference, and that administrative costs are low. I don’t have faith in my government’s ability to accomplish those things.

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