When it comes to my patients, waiting is unacceptable

The waiting is the hardest part
Every day you see one more card
You take it on faith, you take it to the heart
The waiting is the hardest part.

-Tom Petty and the Heartbreakers

I’ve never been good at waiting for anything. Instant gratification has been my middle name, and I’ve gotten in lots of trouble because of it. I think that I have improved with age—I am less likely to become apoplectic when the stoplights fail to coordinate to green, or when the driver in front of me creeps along at a snail’s pace, or when the line at the movie theater is longer than I expected, or, God forbid, the line for the heavily buttered newly roasted popcorn after I’ve gained entrance to the theater means that I might miss the opening scene. Knowing that the popcorn is always better than the movie, I wait.

When it comes to my patients, though, the waiting is still unacceptable. We have a rule in my office — a referral must be seen within a week of getting the phone call or faxed request — sooner if that patient is in pain, or has symptoms of airway obstruction or spinal cord compression or is bleeding from his cancer. The problem for many of my patients, especially here in Southern California, is that they have often waited far too long already. The paperwork and time and energy spent making phone calls and filling out forms is staggering. Primary care doctors are overwhelmed. Insurance companies are obstinate. It is not uncommon for a patient to have been diagnosed for over a month or longer before they are seen by me.

When we moved here from Massachusetts in 1993, I had already grown accustomed to patients having to wait for treatment. Massachusetts is a “CON” state, meaning “Certificate of Need”. In order to purchase and install new radiation therapy units, which are considered “high tech” and very expensive, one had to petition the state, and undergo scrutiny and a series of tedious hearings held by self-important politicians who clearly never had a close friend or relative with cancer. I remember treating upwards of fifty patients a day on the linear accelerators, and having to triage patients with cancer into urgent, and less urgent cases. Lung cancer and brain cancer first, prostate cancer last, and everything else in between. How does one place a value on a life hanging in the balance?

When I arrived in California in 1993, and joined a private practice, the founder of the practice, Dr. Jack Abrams, who hired me had a very simple philosophy: “See ‘em, sim ‘em and treat ‘em.” Meaning that if we got a call from a referring physician, we were to see the patient within 24-48 hours, perform their simulation, otherwise known as the treatment planning session, the same day or the next, and start their treatment the day after that, or even the same day if necessary. This was SERVICE, defined as I had never seen it defined before. The referring physicians and the patients were very grateful and I am quite certain that this philosophy cured more cancer than the waiting, and the wading through mountains of paperwork.

Jack Abrams is long gone now, but the philosophy of service that he ingrained in me twenty years ago remains. If you are one of my primary care physicians who needs your patient seen today, just call me on the phone. I will stay late and see your patient, and so will my wonderful oncology nurse. My superb chief radiation therapist will do that CT simulation the same day if necessary, and my dedicated physics staff and radiation therapists will stay as long as is necessary to get your patient — no, our patient treated. No one will suffer needlessly on our watch. This, I promise. The waiting is the hardest part.

Dedicated to Dr. Jack Abrams — we did not always agree, but you were a fine example of our breed.

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

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  • http://twitter.com/DinoDocLucy Lucy Hornstein

    Cool. I feel the same way, though I’m primary care. We call it Open Access, but it means, “You call today, we’ll see you today” (or tomorrow). Patients love it.

  • buzzkillerjsmith

    If you are not in primary care, you have no standing to comment on how we practice.

    • Homeless

      I know there is some animosity between Dr.Fielding and primary care physicians but do you really want to take the stance that open access isn’t desirable for primary care?

      • buzzkillerjsmith

        Yes. Open access will grind us into paste. Hear me know and believe me later–or not.

        • Homeless

          For me, that is the main reason the primary care has no value…what’s the point of having a relationship with a doctor when he abandons you when it gets hard.

          • buzzkillerjsmith

            Fine. Go the ER.

          • N N

            With a patient such as yourself, based on your posts, I am glad that doctors can discharge a patient from their practice. Newsflash to you Homeless, when you say that certain doctors have no value, they will believe that YOU have no value.

          • Homeless

            It is clear that I have no value beyond what can be extracted from my wallet.

      • Caitlin Peebles

        Open Access may or may not be suited to primary care, but that’s not what this post is about.

        • Homeless

          I read an article about a doctor who gets her patients in the door within a week. I read an articel about how waitng for appointment, expecially when in pain, is hard.

          I also read a comment that indicating that, as Lucy Hornstein put it, indicated open access is too hard for primary care.

    • Miranda Fielding

      How did you glean from this piece that I was telling YOU how to practice? I was only speaking about how I practice, and how things are in So Cal where nearly all patients are in managed care plans and have waited enough already, before they see me. Really, this is not about you.

      • Caitlin Peebles

        “Really, this is not about you.” Hahaha, I had the same thought. I can’t imagine going through life so defensive that I felt compelled to anonymously issue a pre-emptive snipe at anyone whose patients might be pleased with them.

      • buzzkillerjsmith

        Rads onc. That’s the life. I know a rads onc who literally played video games with his son at work. Paid much more than we are, completely undeservedly, for an essentially fart-around job. It’s subspecialists like you who have sucked up so much money, quite selfishly, and contributed to the degradation of medical care in this country.

        Of course this does not apply to surgeons and the like who really earn their money. Get outta town, doc.

      • buzzkillerjsmith

        Kevin seems to have deleted my recent reply to you. Perhaps that is for the best. Please feel free to practice the way you want.

  • Suzi Q 38

    Yes, I really appreciate your philosophy and attitude towards those of us that are ill and need physicians like you.

    My cancer teaching hospital did me a grave disservice by not diagnosing my spinal stenosis for a year and a half.

    I decided that maybe the cancer teaching hospital with only two neurosurgeons and one neurologist was preferable to do the surgery since it was very complex and the hospital was not considered a neuro hospital.
    It was a very good cancer hospital, though.

    I was angry that i was already feeling paralysis and they had not treated me correctly for so long, so I lost faith in their ability to do my surgery.

    i decided to get another opinion at another teaching hospital.
    Anyway, the nurse navigator and the neurologist refused to facilitate my referral to the neuro hospital in Los Angeles.
    I had to ask my PCP back in the town that I lived to do this, and he did.
    This took more time.
    When I finally got in to see the surgeon, he got the “creepy” feeling that it looked like MS.
    He didn’t want to do the surgery, but I told him that my surgeon at the other facility had already cleared me for surgery as I had the LP, brain scan, and MRI’s. All blood tests were negative for ms.
    He said that he could not take the evaluation of the regular neurologists (2), that he preferred an MS neuro to clear me.
    Well the wait time for an MS neuro was 2 1/2 months!
    I begged to get to the front of the line, but no avail. The surgeon didn’t think I was that bad, but every few days I was weakening and getting panicky about the whole thing. I almost went to another hospital, but I knew I would have to start all over again.
    In retrospect, I should have been encouraged to be evaluated by an MS fellow instead of the “famous MS neurologist.”

    Then, the MS specialist wanted me to wait a month to compare images in a 6 month interval. Then it was the holidays. I tried to wait, but I stood up one day and almost fell.
    My surgeon was on vacation, but when he came back I got in his face a bit. I told him that I needed my surgery. My legs weaken with exercise.
    I was thinking of getting a different surgeon at the same hospital, even though I perceived the one I had as the best choice. I was getting desperate, and finally called a friend of the family that was a neurosurgeon at Stanford. I would have to get on a plane, but so what.
    My family was freaking out. I was freaking out.
    I was ready to call his office for an appointment the next morning and book my flight. Thank goodness my neurosurgeon’s technician called with a surgery date a week away.

    So here I get bad medicine with the cancer hospital for a year and a half, then get punished again for choosing a neuro teaching hospital. A very famous one, I might add.

    Also, my MRI’s and reports were given to the surgeon all in a neat, easy to view folder, and he rejected all of my MRI’s. They were only a month old, and he claimed that they were not clear enough. I had to get them done all over again. More money and more time.

    I think the next time I need something done, I may have to consider the local, first tier private hospitals.

    I have not had good luck with the scheduling of these teaching hospitals.
    They simply are desensitized to our severe conditions and how scared we are when we need them. I never want to go through that again.

    I thank you for writing this today.

  • PollyPocket

    Great perspective. That kind of flexibility is just another benefit of specialization, in most cases. I don’t think anyone faults PCPs for not working themselves to death over non emergent issues.

    When someone calls our office and asks when they can get in, the answer is (or should be) “how soon can you get here?”

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