BITCH BITCH BITCH

Can I bitch and whine for a column? Join me in my world this month and you might have some insight into why there  are fewer and fewer doctors going into primary care. I’m not talking about the vast difference in reimbursement between primary care and specialists.  I’m talking about the hassle factors and frustrations of being a primary caregiver.

Forget about the fact that the insurance companies are charging 10-15 % more each year but I haven’t had a single raise in years and have absolutely no negotiating power. I am board certified in two specialties with over  two decades of experience but that’s not worth a penny extra to the insurance company. Recently one major insurance company in the area came to the office to review our mammography screening rates. Our results were at the top of the scale, well above the average and far above the worse performing physicians. What do we get for our superior care.? Nada…Zip…Zero. Why not at least publish this to the paper or to the patients with your insurance so they can see the individual doctors performance and judge for themselves who they want to see? What a shocking concept…giving patients real informed choices.  Instead the high quality and low quality is all mixed together and patients really have no idea about quality measures.

First it’s the insurance hassles. There are many different health plans and I have to hire a whole billing dept to sort through the different plans and deal with their individual convoluted coverage. These plans will cover shingles shots…these plans won’t . These plans cover this test…those plans don’t. Impossible to keep straight in your head. I have to hire another staffer to fight with the insurance companies to get  authorizations for MRI’s, stress tests, etc. Now some high school graduate with a checklist is saying the stress test is not covered because we used the term “chest pressure” not “chest pain”. So now I have to get on the phone personally to speak doctor to doctor to get this straightened out. Imagine doing this  multiple times every day of the workweek.

Likewise the insurance companies have their own strange and arcane rules regarding drug coverage…This company will cover these meds…that company will cover completely different meds for the same medical problem. They send us multiple faxes daily alerting us to possible drug interactions with our patients even if the possible reactions are rare or trivial . We have our own computer system that warns us of serious interactions. They send us notices when our patients don’t fill their refills as if I have any real control over that. Each year the plans can change what drugs they cover so the same patient with the same medicines may have the insurance company change their coverage yearly.  I can assure you this is not based on the quality of the meds or the benefits of the meds…it’s made on a $$$$ basis only.

Test results are another area of tremendous stress for the primary care doctor. Forget about the patient that gets sent for a test but doesn’t show up. You decide to skip a mammogram this year and if you get a breast cancer somehow it’s my fault . I can send  you reminder after reminder to get your colonoscopy or mammogram.but if you still don’t get the test it’s still my fault.  Trust me that’s how the courts look at it. Telling you to get a mammogram is not enough. Scheduling the mammogram for you is not enough. I have to stay on your case until it gets done or I am liable . At some point the patient has to take some responsibility but thats not how the courts see it. But the real hassle with test results is that the radiologists refuse to read any test as yes or no anymore. When I started in medicine…the radiologists would issue a simple report..”Chest X Ray showed pneumonia”. “Chest X Ray normal”  Now almost universally the reports hedge their bets …”Could be pneumonia…could be cancer…could be a variant of normal”  Almost all reports we get now suggest further more expensive testing which may or may not require further testing or more testing down the road. This is very frustrating for the doctor and even more frustrating for the patients. “How many tests am I going to have to do to get an answer?!” The test report may give me an answer about a specific issue but raise another one. “The spot seen on the x ray is shown to be nothing serious but on this scan I see a possible cyst on the liver”. The radiologist will suggest   more expensive testing now and or in 3-6 months which may or may not give a real answer and further testing could reveal new incidentalomas that have to be addressed. Patients get mad at me for all this testing but if we don’t check every possible problem out it could be you that suffers and me that gets sued. Not good for either one of us.

Noncompliant patients are another source of frustration to the doctor. Patients just don’t understand how seriously we take the doctor patient relationship. If we see patients regularly ..if we are in regular contact , then any potential problems can be followed and there are less complications down the road. When you let patients go for years without being seen any little problem from the last visit could grow into something serious or catastrophic. So when we send you three separate written requests to schedule an office call and also call you at least twice and get absolutely no response we have to discharge you from the practice.  One of the negative reviews we have on the internet addresses this. The patient complained that she was fired just because she never responded to our calls and letters. I’m not the publishers clearinghouse…I am contacting you for a reason and all you have to do is call us to stay in communication. Yes, it’s my business and I do think I know what’s right for you healthwise including how often you should be seen. We can discuss this and work out a mutually agreeable program but not if you never respond. No response = discharge letter. Another complaint about our office on the internet involves the no show fee. If you give me any notice at all…any kind of notice..even the same day ..there is no charge. But if you blow off a scheduled and confirmed appointment  there are consequences. Lawyers  charge by the minute when you call them.  I just want you to keep your appointment and if you don’t you have to pay a no show fee. If I miss an appointment with my massage therapist  or my Saxophone instructor I pay the full price for their time. That’s the right thing to do but not according to the guy who bitched about our no show policy on the internet.

I just took my annual recertification for malpractice. It’s always a depressing experience. Basically they remind you that each and every office call could lead to a major lawsuit. It’s also not the obvious problems like chest pain that the doctor is sued over…What you and the patient think is just a sore throat or arthritis of the back could turn into something potentially life threatening so there is no real “easy “ office call. Patients bitch if they think you are not taking their complaint seriously. Patients also bitch if you take their complaint seriously and suggest referrals to specialist.  Look what position that puts me in…It’s crystal clear that the main reason doctors get sued is “failure to diagnose”. The main defense against failure to diagnose is referral of the patient to a second opinion.  I would think patients would be appreciative of a medical office that was willing to be thorough and get a second opinion but judging by the mostly anonymous complaints I get they really don’t appreciate it. I tell my Nurse Practitioners to not hesitate to get a second opinion or do a referral if they feel it’s necessary.  I would rather have a patient bitch about too many referrals than a widow complaining  that we were not thorough enough!

Thanks for letting me give you a little glimpse of what the modern doctor has to deal with. Is it any wonder that more and more doctors just want to be hospital employees or work in a large group setting where they might be insulated from some of the hassles? Of course I’m sure they have their own unique hassles as well.

So, these are all the reasons primary care medicine is not the same anymore. The hassle factor is driving more and more doctors to chose other specialties and to retire early. Yes, even with all the hassles and decreased reimbursement and rising expenses doctors still make a good living but that’s not a primary reason why I went into medicine.  My interest in people and their medical problems hasn’t diminished. I still think I can make a difference. Of course, changing part of my practice to a personalized care service certainly has helped to ward off any doldrums. Despite all the hassles I still love going to work everyday. I hope you do as well!  Until next month, get well….stay well.

Dr. Barry