Good day, good night

Theoretically, doctors in the US are reimbursed for the amount of time and effort they put into a patient visit.  Theoretically.  The truth is far different, a frustration for many of us.  Unlike many other professions, we must temper our economic decisions with compassion.  If, say, a man has a 15 minute appointment scheduled but it turns out that his daughter has been killed in a traffic accident and he has chest pain, the rest of my day is shot.  There is only so much I can bill for the time I will spend with him, and those scheduled after him will suffer.  They will wait, become frustrated, and several will probably leave and hopefully reschedule.  There is no way I can make up economically for the time I spend with the grieving father except by seeing more and more patients, exacerbating the problem.

But most doctors, I hope, will still take the time, and because of our lack of business savvy and political organization, we will never get it together to lobby for rational reforms in the ways we are reimbursed.  There are all sorts of changes that are supposed to help, but it’s not at all clear to me that they do.  I can get paid extra (read: not penalized) by entering quality data on my patients with certain insurance plans.  The work is too complex for the front desk or a medical assistant, so that’s more time spent away from the patient.  Some of this can be improved by electronic health records but there is no real standardization in the industry, across practices, or between hospitals.

Over the years, much of this may or may not sort itself out, but the upside is I still get to take care of patients every day.  I just hope the economics never becomes so unfavorable that I work myself into the ground.  My daughter picks up on that sort of thing.

Since my wife’s illness (documented a few times on this blog between April and now; see the archives), PalKid has been rather clingy, understandably.  She prefers to stay up until I get home, to have me tuck her in, and then to have her mother finish getting her to sleep.  And for the last couple of weeks, when she wakes up in the night, she does not end up back in bed.  Last night I woke up to find her cuddled tightly to Mommy.  Mommy, though, likes a little space and retreated to the guest room.  We’re not sure what happened next, but when I woke up for work, PalKid was sprawled sideways across the bed, Mom was still gone, and Kiddo had no idea how she got where she was.

Pulling her off of me so that she could run back to the guest room to leech onto mom was hard, but at least I can look forward to my work.  I usually stop at the same cafe for an espresso, and walk into the office to a full desk, a full schedule, and hopefully a smiling staff.  And I get to take care of people.  Even though the economics are insane (and later I’ll tell you the insanity of board re-certification), it’s still a privilege.  I’m sorry if I’m running late, but the person before you may not be feeling well, and if you aren’t, you’ll get the same treatment.

At the end of the day, despite working in a broken system, I’ve helped a few people, and I get to go back home to play musical beds.  I can live with that.

 

4 Comments

  1. saffronrose

     /  September 1, 2011

    Unless I have something I need to do at the other end of a medical appointment, I don’t mind the wait. If I have a tight schedule, I can usually reschedule. In general, when I see someone getting actual help that’s taking a bit longer, I figure that if I let that happen, then when I need a bit more, or more perssonalized help, I’ll get it too, if only for the fact that I was seen to be politely patient.

    I am hard to fit with glasses: I may take up twice the time for the optician (not a Dr.) to get the temple pieces where I need them exactly. At the shoe store, when I can drag myself there, it may take 20 pairs before I find one that actually fits, and comfortably. In both places, I have allotted extra time, and have no problems letting someone with a short issue to go first, or in the midst of my travails.

    There have been times, when I’ve been behind a counter, or in a waiting room, where a conversation starts, and someone really needs to talk, or to be heard, and I know how important that is, even with a stranger. Just listening intently, sometimes asking leading questions, or prompting more, someone gets something they need that hour, that day. You do that professionally, I do it from the point of empathy, from having been there, or knowing I may be some day, and also because I have a hard time seeing someone in distress, without being moved to help. No, I couldn’t do this for a living–I don’t have the necessary distancing skills.

    Asclepius and Apollo bless you for your care.

  2. I actually read my EOBs, and I’ve often been disgusted at how little relationship payment has to effort. I had an internist spend over an hour with me once. She was amazingly thorough; this probably rates as the best office visit I have ever had, and I wasn’t sorry that I’d had to wait 90 minutes to see her–it’s the waiting 90 minutes to be rushed out that grates. Billed as a level 5 new patient visit, so probably as high as you can get for a primary care office visit. I think she got $170. Which doesn’t sound terrible as an hourly rate, but when you consider that my RE got $130 for an ultrasound that took 4 minutes, it starts to look considerably less lucrative. I don’t think my RE even gets more than a regular OB/GYN for that, so it’s not even a procedure performed by a highly compensated specialty. (Judging by my claims, OB may be the worst in terms of money for time, except for the hospital.)

  3. Karen

     /  September 2, 2011

    Three vignettes:

    My PCP has become skilled at staying on schedule… but as time goes on, he seems to listen less and less. He’ll retire in a few years — I’ve been his patient for 30 years — and maybe he’s just burned out. I stay with him partly to avoid the trauma of changing, and partly because my health plan allows me to pursue specialist care without prior approval.

    I recently went to see a podiatrist for foot pain, and he’s young and enthusiastic. He seemed to do all the right things, and admitted there was a choice of diagnoses… so he suggested we try addressing the most likely one first, which involves using a topical medication. I have a follow-up visit scheduled, but his parting words were, “if this works, cancel your appointment — save yourself the insurance co-pay — but EMAIL ME! I want to know how you’re doing!” I liked his attitude. I hope he can keep it going as he gets older.

    Then there’s my allergist. She’s getting toward retirement age, but I have a hard time seeing her retiring. She’s this amazing, tiny bundle of energy. She always runs really late; for a late morning or late afternoon appointment, figure at least an hour of waiting time. It’s because she’ll take as much time as I need, listen to all mycomplaints, explain which might and might not be allergy/pulmonology related, and harass me to see a specialist about whatever complaints aren’t within her specialty. She’s FAR more proactive about my general health than my PCP!

  4. Catherine

     /  September 3, 2011

    I wish I had more compassion for doctors.. but, for most, I do not.

    Five minutes is the standard appointment around here. More often then not, the doctor barely speaks english, asks NO questions ( are you on any medication, what sort of pain is it, where have you been, etc etc) We get ‘open your mouth’. ‘Oh it’s red, here, a script for anti biotics. Sign here please’ and shoved out the door.

    There are some FANTASTIC doctors out there… but it took me 5 years to find one, and he stopped practicing after a physical injury.

    So, to the good doctors, please, talk to your peers, educate them. Patients are not out of the book, those books at university are a guide, as is the MIMS book. We are real, we need your genuine care and thought, and in return, we will wait patiently, greet you with a happy face, feeling secure, knowing we have a practitioner who THINKS about what he or she does, and is NOT in it for the 55 dollars per 15 minutes.

    Kindest Regards,

    Slightly frustrated patient 😛 !! ( who misses her old doctor)

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