The conundrum of communication and uncompensated care

Going to the doctor starts as a disconcerting experience: Getting naked, physically and emotionally; talking about your weight, your smoking, your divorce. You count on your doctor’s ear and her discretion. Often enough, a patient will apologize for taking my time or for crying or whatever. I remind them that this is what the exam room is for, this is what they pay me for.

How far does this special relationship extend? Primary care doctors can’t bill for time with their patients unless it’s face-to-face. This is one of the reasons your doctor might not want to spend a lot of time on the phone or email with you. It’s also one of the reasons we may require you to come to the office to complete complex forms or change a prescription. These activities require work, and our main work is thought. Without you in my exam room, I’m not sure about that medication change or that disability form. And I can’t ignore the fact that I’m not paid for my time unless you’re in the office with me.

In my opinion, some doctors go too far, requiring monthly visits for simple prescription refills, but there are times when it’s necessary to drag someone in to make sure the drugs are working and not causing harm, or to make sure you are working on your dietary habits and exercise.

Saying “no” to patients isn’t easy; we’re in this job to help. But it’s often the right thing both clinically and economically. This brings up another question, one we don’t often talk to patients about: How should we treat our time when the office is closed? The tradition has been to take patient calls after hours and on weekends, perhaps rotating this time on call between partners.

But there are murmurings out there about this uncompensated time. After all, what can I do for someone on a weekend? It’s not usually wise to diagnose someone over the phone. It’s also not so good to renew prescriptions on the weekend; it’s a poor use of time and for those of us with paper charts, it’s nearly impossible to know what’s appropriate.

For a primary care doctor, the answer to many phone calls is, “Call the office on Monday,” or, “Go to the ER.”

As a patient I want to be able to reach my doctor on a weekend, but I would understand if he should decide to change his policy.

What say you? How can we maintain communication and deal with the problem of uncompensated care?

“PalMD” is an internal medicine physician who blogs at White Coat Underground.

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  • Suzi Q 38

    “How far does this special relationship extend? Primary care doctors can’t bill for time with their patients unless it’s face-to-face. This is one of the reasons your doctor might not want to spend a lot of time on the phone or email with you. It’s also one of the reasons we may require you to come to the office to complete complex forms or change a prescription. These activities require work, and our main work is thought. Without you in my exam room, I’m not sure about that medication change or that disability form. And I can’t ignore the fact that I’m not paid for my time unless you’re in the office with me……”

    If it is important, someone else needs to call or email your patient(s). Possibly the nurse, PA, NP, or receptionist.
    It is not prudent to ignore such calls or emails, as patients may worsen and they may not know what to do.
    I appreciate the fact that you are not paid unless I come in and show my insurance card.
    I am going to have to thank my doctor, as he has filled out paperwork for my referrals to a major teaching hospital, my MRI’s, and my long term care insurance. I did not come in because he did not request that I do.
    He just did so without expectations of payment.

    I will have to buy him a bunch of food at Costco or something.

  • RuralEMdoc

    A great article. Well thought out.

    I agree that it is problem of physician wellness. You want to make yourself available to patients for all emergencies, but you also need personal time with your family, hobbies, etc…

    The reality is that we live in an increasingly restless and impatient society. The result is too many “emergencies” for things that really could wait. Most people can’t wait 5 minutes until they are no longer driving to send a text message reply of “Not Much”, why would they be expected to wait for your office to be open in the morning.

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