Let’s talk about your doctor’s office

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?

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  1. Vicki

     /  March 9, 2014

    I want to be able to call my doctor on the weekend for certain kinds of follow-up, something like “you said to call back if it wasn’t better by Monday, but it feels/looks like it’s gotten worse.” (My most recent visit was on a Friday and did have “come in again if that symptom doesn’t stop by Monday,” but I think that was to allow a fixed amount of time, and it did improve slowly but steadily over the weekend.)

    For other things, the important point is that I can reach someone for medical advice: if my doctor isn’t going to have my records handy at home, and she’s not, a nurse helpline can probably advise me just as well. In particular, they’re likely to be just as good for telling me whether I need to go to the emergency room, or find an urgent care clinic, or make an appointment and in the meantime rest and maybe take an NSAID.

    In some sense, the right answer for “dealing with uncompensated care” is to move either to a model where doctors get a salary rather than effectively being paid for piecework, or find some way that you can bill for talking to me on the telephone as well as in your office. But I don’t know how to do that: it’s a political problem, and one that the U.S. has been struggling with for a long time.

  2. Shirah

     /  March 9, 2014

    The times I’ve used after-hours calls, have been times where I *suspect* it can wait, but want an actual doctor (or triage nurse) to clear it. I’ve also used it to call shortly before they actually open to say, “It’s urgent but not emergent. Should I go to the ED or wait for my GP?” Generally speaking I’ve been able to wait and see my doc, but everyonce in a while it’s off to the ED. I’m hugely appreciative of the ability to talk to one of the MDs on the team since it helps avoid expensive ED visits plus GP or specialist follow-up. Not to mention clogging up the ED with a potentially unnecessary visit– but that’s NOT my GP’s issue to fix/ it is a seperate issue entirely. If they dropped the service, I’d understand. Compensation: I really wish they WOULD bill for the call consult– even if it means something like giving my billing info to a triage nurse over the phone! I’d pay for the calls, happily.l

  3. Corinna

     /  March 9, 2014

    I read your blog because you write well, and because it gives me a clearer perspective on the medical system in which I live … one that I feel is now threatened by the government in power, though was already starting to show signs of stress under the previous government.

    I live in Australia, where we have a Medicare system paid for by our taxes that was set up to ensure that anyone who needs medical attention – either with a local GP or in a hospital setting – receives it regardless of their financial situation or the time they fall ill. This has included attending after hours clinics, after hours doctor home visiting services, and attending emergency departments.

    Over recent years it has started being chipped away at: fewer GPs bulk bill for consultations (though children under 18 years old are still always covered by bulk billing), and the government has pushed for more people to take out private health insurance (though private insurers can at this time still not include GP visits in their policies, only specialists and ancillary health services), with a Medicare levy being charged to people over a specified income if they do not take out private cover.

    There are flaws in this system: in regional areas, that are always short of doctors, after hours services are always impacted by the capacity and good-will of those doctor(s) living in the area; and there are problems around continuity of care, as the current system enables you to visit different doctors at different times or for different reasons … and one doctor doesn’t need to be aware you’ve been treated by any other unless you divulge this information voluntarily. An effort to introduced an e-Health record was undermined by poor implementation by the government that initiated it … followed by change to a government of a different persuasion with a different health care agenda.

    There is no question that health care costs as an overall proportion of the national budget will continue to rise in Australia, as they will in other parts of the world, particularly if we can’t reign in spending on treatment costs of some ‘life-style’ diseases. It’s also true that the current Medicare tax-supported system in Australia is unsustainable at the current rate of tax input.

    What worries me, especially when I read your blogs and the conditions you and your patients work within, is that our government seems determined to adopt a US-style health care system. It’s a shame we can’t work together across the international divide to make it clear to the Australian government where the strengths in our Medicare system are and help our politicians work with our society to identify ways to make it work more efficiently (to reduce costs now) and ways to protect it for future generations.

    That’s the idealistic me. The realist me says that you rarely appreciate what you had until you lose it … and then it can be damn hard to get it back.

  4. It honestly never occurred to me that my doctor might be available during non-business hours. I’ve always worked under the assumption that urgent care or an emergency room are the best options when I can’t make an appointment with my doctor. Granted, I don’t have any chronic illnesses and I’m still relatively young and in good health so perhaps my views on this will change as my health concerns change.

    I do think it’s pretty expensive and wasteful for everyone if doctors must bill insurance companies for a full office visit for something they could have done in 10 minutes without brining the patient in. With my insurance, it’s $25-40 co-pay for each visit to the office. With money being tight that could be a deterrent for me to make follow-up appointments. I have no doubt there are many people who can’t afford to take time off from work or who need to make special arrangements for transportation to go to the office. If our healthcare system wants to best utilize resources and put the least burden on everyone, it would make sense to find a way to compensate doctors for some amount of administrative work and email and phone consultations. I imagine it would be a challenge, but clearly, what we are doing now is not the best option.

  5. Our pediatrician has an online symptom checker tool. It’s not perfect, but it’s a pretty good general guide about when to wait for office hours, when to call the on-call doc, and when to call an ambulance. Also has a lot of advice about home care and whatnot. I find it reassuring when I’m caught up in the concern about a sick kiddo.

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