It was the Patient's Fault

Doctor House was right. Everybody lies. Well, almost everybody.

She was a poorly controlled asthmatic.  Perfectly controlled asthmatics can often make do with one inhaler a year. She consistently used 200 puffs a month. She was not doing well.

I had quizzed her on her need for inhalers at multiple previous visits. Over and over that she was doing everything I had asked her to do. She had gotten rid of her cat and avoided triggers. She was taking her medications exactly as prescribed. Her recurrent asthma attacks were a mystery it took me months to solve out. In the end the answer was simple- She was lying to me.

Her secret was revealed to me as I drove the mile from my office to visit my grandmother in her assisted living facility. As I waited at a light I saw my patient standing on the corner waiting to cross the street. In her right hand was the smoking gun, a smoking cigarette. 

I drove through the intersection and pulled over, waiting for her to cross the intersection to where I was. As she approached I got out of my car. She did not look happy to see me. “You are so busted!” was my less than tactful greeting.

She was visibly embarrassed. She lowered the cigarette, trying to hide it from my view behind her leg.  “This is my first cigarette,” she proclaimed, “I have been under a lot of stress lately!”

“So throw it away then,” I replied. She did, apologizing profusely and telling me that she was not going to smoke anymore.

She was lying again.

I found out two days later when my nurse saw her at another intersection, again with a cigarette again in her hand. At her next visit I was finally able to address the real reason for her asthma problems. Sine then, her need for inhalers has decreased dramatically.

Her story reminds me of a basic truth in medicine. Doctors are only as good as the information we get from our patients. Patients who lie get poor care.

Doctor House was right.

Bart

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The Doctor will see You... For $3500

My grandmother went to the doctor this week with a sore on her leg. She came home with a bill for $3500. The bill had nothing to do with the treatment of her leg wound. The bill was to cover the doctor’s new annual membership fee. If she does not pay it she will be forced to seek care elsewhere. She is 95 years old and on a fixed income and will need to either pay up or move on.

Her doctor left me a lengthy voice mail explaining his fee, informing me that it will allow him to spend more time with each patient and provide high quality care. What it won’t do is cover any of her visits for the year. Those are extra and will be billed to her insurance. The $3500 is for access alone.

The fee seems exorbitant and it is. A typical senior citizen goes to the doctor 6 times a year. The fee works out to a payment of an additional $600 per visit, an astronomical sum.

While the charges are insanely high they are becoming increasingly common. Doctors who cannot make ends meet on what insurance companies pay are looking to their patients to pick up the slack. Especially for older and sicker patients, insurances don’t pay enough to cover the time needed, typically only about $120 for a 30 minute visit. This may seem like a lot, but after factoring in overhead ($160 an hour) and unpaid time spend on refills, phone calls and emails, the end result for the doctor paid this fees could be a salary of about $120,000 a year. While this is a good wage for many people it isn’t enough for a doctor with student loan debt to live in Southern California, where mortgages for a modest home can exceed $4000 a month. Many doctors are desperate to find a way to increase their income.

While this is understandable, the $3500 fee seems excessive. It seems that a doctor with 2000 patients in his practice could make ends meet by charging much less. $100 a year would result in a $200,000 a year increase in salary and make up for what insurance pays. Why charge $3500.

My recent experience answers the question. The majority of patients won’t pay the smaller amount either. My office provides a wide array of services, from guaranteed same day access and short wait times to digital visits and email communications, that are not covered by insurance plans. To cover the cost of these services, on January 1 of this year we started charging an annual access fee of $120. While we thought this was reasonable and affordable we have lost over half of the 1000 patients to whom we billed the fee. In their minds the additional access and services just aren’t worth it. It is apparently easier to find 200 patients willing and able to pay $3500 a year than it is to find 1000 patients willing and able to pay $120. My grandmother’s physician has figured this out.

This does not bode well for the future of medicine. None of the current health care plans being discussed in Washington D.C. or Sacramento address the reality that good medical care costs a lot of money and that quality doctors require competitive salaries. Patients unwilling or unable to pay extra for services will find it increasingly difficult to find a primary care doctor willing to see them and will be increasingly unhappy with the options available. It seems we are headed for a crisis of inaccessibility.

The solutions to this problem are too complex for a blog post but there is one thing of which I am certain. These solutions will not be easy and will be expensive.

-          Bart

A Baby Taken, Hearts Broken

I wasn’t ready for the tears. Patients don’t typically cry during visits for diabetes, especially when their sugars are well controlled and their labs are all normal.

The tears started when I deviated from the standard medical questions. As I was wrapping up the visit I asked, “How is the rest of your life going?” Immediately they came, prompting the need for a box of facial tissues as well as additional questions. It was clear her heart was broken.

She had lost her grandchild a month earlier. The child hadn’t died, it had been taken away.

He son and daughter-in-law had adopted a daughter. Unable to have a child on their own their prayers had been answered when their adoption attorney found a woman unable to care for the baby she was carrying. They brought her home the day she was born. Life was perfect and she was perfect and my patient was in love with her grandchild.

28 days later the birth mother changed her mind and in an instant the child was taken, taken to live in a car with her birth mother, never to return to the family that had fallen so completely in love with her. They were left with an empty nursery, broken hearts and the question, “Why?” echoing in their minds.

My heart broke along with my patient’s as she told me her story. I battled to hold back tears but eventually gave in and let them flow. I thought of my adopted daughter, of how she had immediately and permanently captured our hearts, and imagined the magnitude of my patient’s loss and the depths of her grief. I struggled to find words of comfort and solace. we talked for nearly 20 minutes. 

At the end of our conversation we walked out of the exam room together. I stopped at the nurse’s station and said good-bye. She turned to walk to the exit, paused for a moment, then reached into her purse and turned back. As she did I noticed she had her phone in her hands. “I want to show you something,” she said.

She quickly scrolled through her photos and stopped on the image of a beautiful month old baby. Her hands trembled as she showed it to me. “This is her,” she said, telling me what I already knew. My heart broke again for her as I looked at the photo. Impulsively I touched her shoulder and guided her back into the exam room. I closed the door and held the phone with her, joining her in staring at the picture.

“Can I pray for her?” I asked. I looked at the photo with tears in my eyes and prayed. I prayed for God’s protection and love, that the child would grow up healthy and loved, and that she would one day be reunited with her adoptive family in heaven. It was a helpless prayer, the only thing I could do. I gave her the phone and a hug and she left the office. 

Her story reminded me that I live in a world full of hurting people. I am surrounded by broken and breaking hearts, by people wondering where God is and what he is doing, people who are losing hope and struggling to make it through the day. People who have a burden they need to share with someone else, people who need love and prayer and someone to care.

I am reminded that no matter how busy I get, I should never be too busy for them. I need to be open and aware, to be the one who asks the right questions and then takes the time to listen.

- Bart

Thanks for reading and sharing. Please pray for the baby, for the family that has her and the family that lost her. 

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Learning to Prescribe Kindness

“You’re different than you used to be.” The comment came at the end of the visit with a patient I have known for over 20 years. “I’m not sure how to describe it, but you are different.”

“I’m nicer,” was my reply.

“That’s it! You are nicer.” It was as if she was afraid to say it for fear of insulting me. She didn't need to apologize. She wasn't the first person to notice. What she did not know was how the change occurred. I shared with her that one day over 15 years ago that I had stopped to perform a self-assessment, asking myself what people would likely say about me if I were to die. As I listed my dominant personality traits- passion, integrity, honesty, commitment to doing the right thing, I realized that there was something missing. I doubted that anyone would say I was kind. It was a sobering realization.

I told her that became my prayer, that God would make me kind. It proved to be a costly prayer, as within a few years a virus attacked my spine, bringing severe and debilitating pain. The pain faded, but the weakness and numbness never left. A few years later came panic attacks and anxiety disorder. These conditions brought me to my knees and opened my eyes to the struggles of others. They softened me and made me kinder.

She shared with me that she knew that I was someone keen on becoming a better person. She told me she was an avid reader of this blog (Hello Ms. D!) and that she had concluded that I was someone who was working on myself, someone who was trying to improve. I thought this was an incredible compliment, for to me, this should be one of the defining characteristics of a Christian.

We are all sinners, we are all broken and selfish. One of my greatest areas of brokenness over the years has been the tendency to use being “right” as a justification for not being kind or compassionate. God has been working on this part of my life for years now. I still have a long way to go, but if I am becoming a kinder person, if I can be described as someone who is less broken and less selfish with each passing day, then I am comforted knowing that God is doing his work in me. Which is... nice!

-          Bart

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Adding My Name to a List of Uncaring Doctors

She has been in constant severe pain for over 15 years. The pain in her upper back defied explanation, identification or treatment. It continued its relentless course undeterred by needles, pills, scalpels and physical therapy. Family physicians, internists, orthopedic surgeons and pain specialists all failed in their attempts to provide relief or answers. The universal response was an increase in pain medications, with the end result being a daily dose of morphine 5 times the recommended limit yet no discernible change in her pain.

She came to me hoping against hope for an answer. At a previous visit I had promised to set aside time to review whatever records she could provide. She scheduled a lengthy visit and came with a CD of her medical records. I opened the electronic copy of her chart and reviewed with her the 240 pages of data it contained. It contained volumes of data but no answers. All of her tests, MRIs, blood tests and CT scans, were normal. Like so many chronic pain patients multiple explanations had been eliminated but no cause had been found.

The only treatment not yet tried was a frightening one. Research has shown that there are many patients whose pain is actually worsened by high doses of pain medication. “Opioid induced hyperalgesia” is the big-worded label for the condition, a fancy way of saying that not only has the patient become tolerant to pain medications, the pain medications have actually caused the pain to increase. The only treatment is to stop the medication, all of it. For the immediate term, pain is certain to increase. What isn’t certain is that the pain will be better in the long term. As bleak as this choice is it was her only hope.

My heart broke for her as I entered into the computer a referral to the addiction specialist who could guide her though her detoxification. Her tears and fears were overwhelming. The recommendation was so easy for me to make yet the road would be so difficult. I felt a sense of sadness and anger at the failure of the medical profession to help her and my inability to provide her with an answer. Her unhappiness and disappointment were palpable.

A few days later I received a sad and angry email message. In great detail she shared her feeling that I had failed her, that my name was being added to the list of doctors who had dismissed her concerns and failed to listen. She had hoped for more tests, more specialists, more… something. My inadequate reply was that I did not see any other options and my opinion was that stopping the pain medications was the best option.

I have thought about her ever since. I have reviewed her chart over and over again in my mind, wondering if there was any diagnosis that I might have missed. Sadly, the location and nature of her pain had been thoroughly and extensively investigated. There is nothing more that I can do. Her hope in me was misplaced.

My name has been added to her list of uncaring doctors. Her name has been added to my list of patients to pray for. 

- Bart

Thanks for reading and sharing, and for praying for this patient.