Worth It

I saw the note on the patient’s chart before I opened the door: “patient is upset that he had to come in.”

I opened the door and was greeted by a gentleman with his arms crossed tightly across his chest and a stern expression.  I barely recognized him, having only seen him a handful of times over the past few years.  Scrawled on the patient history sheet  in the space for the reason for his visits were the words: “Because I was forced to come in.”

By stomach churned.  I opened his chart and looked at his problem list, which included high blood pressure and high cholesterol – both treated with medications.  He was last in my office in November…of 2008.  I blinked, looked up at his scowling face, and frowned back.  ”You haven’t been in the office for over eighteen months.  It was really time for you to come in,” I said, trying to remain calm as I spoke.

He sat for a moment, then responded with very little emotion: “I am doing fine.  You could have just called in an order for labs and called in my prescriptions.  I don’t know why I had to be seen.”

“You have hypertension and high cholesterol.  These are serious medical problems, and if I am going to put my name on a prescription for you, I have to make sure everything is OK,” I responded, trying to hide my growing anger.  ”I am not a vending machine that you can call to get drugs.”

“I’ll come in if I am sick, but I am not sick right now.”

“My job is to make sure you don’t get sick in the first place!” I said, my volume rising slightly.  ”I don’t bring you in because I need the business; I’ve got plenty of patients to fill my schedule.  These medications are not risk-free.  Besides, how do I know if your blood pressure is OK?”

“I check my own blood pressure at home and it has been good.  I can’t afford to come in to the doctor so much.  I have a high-deductible plan.  I had a stress test and a colonoscopy last year, and that’s enough spending for me,” he responded, his pitch and volume rising with mine.

“I have to say that I find this personally insulting,”  I threw back.  ”You don’t think I am worth paying to see.  You just want me to give you your medications, take the risk of adverse reactions, and basically work for free?”

“That’s not what I said!”

“It is exactly what you said!” I said, not hiding my frustration.  ”You want me to prescribe a medication, trust you for your blood pressure, interpret the lab results, and take the legal risk for your prescriptions and not get paid a dime for it!  You are asking me to give you bad care because you don’t think I am worth paying.  I don’t do that. I won’t give you bad care.  If you wan’t bad care, feel free to find a doctor who will give it to you; if you are going to come to this office I will make you come in on a regular basis.  If you don’t think I am worth it, then I am sorry.”

He sat quietly for a moment, and I took a deep breath.  ”Don’t you have a health savings account?” I asked, trying to calm my voice again.  ”Most people with high-deductible plans have HSA’s.”

“Yes, we have an HSA, but we are trying to hold on to that money.”

An HSA is an insurance plan!” I said, not hiding my incredulity. This is what you’ve been saving that money for!  I want to keep you out of the hospital, keep you from the emergency room, and keep you from spending all your money for a hospital stay.  One overnight stay in the hospital will cost you more than 100 visits to my office.”

He again sat quietly for a moment, and I directed him up on the exam table.  We talked about his medications and potential side effects.  I pointed out that there are cheaper alternatives for his blood pressure pill that have fewer side effects.  I discussed cardiac screening tests and explained the pros and cons of prostate cancer screening.

I changed his prescription to something cheap enough to recoup the cost of my visit in two months.  As the visit went on, his eye contact grew less and less.  My point was made.  I was giving him something the Internet or a “doc hotline” couldn’t give; I saved him money, educated him, and improved his life.

When I had finished with the visit, I handed him the clipboard.  ”I’ll see you in six months.”

He didn’t respond, but I could see that he got far more out of the visit than he expected.  I am the one doctor out there whose main goal is to keep him away from the hospital and away from having expensive tests.  I often tell my patients that my goal is to get all of my patients very old and to see them as infrequently as possible.

But I am not a vending machine for prescriptions.  I won’t work for free.  I won’t take risk without expecting to be paid for it.

I hope he comes back.

I hope he realizes I am worth it.

ROB LAMBERTS is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask "Hey, are you John Smoltz?" He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

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Chuck
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Chuck

Check the economic facts and figures from Europe, England, and Canada, costs are high, service is not near the level seen in the U.S. and deaths are higher in some areas. Socialism is and has never worked better than a competition based economic system. The U.S. was founded on free enterprise and it has worked, now with increased Federal regulations, higher spending etc the economy is failing and higher spending is not working even the medical fields will be pushed into ruin if things continue to be torn down by BIG governemt spending, regulation and thoughless ideas. The people should… Read more »

Chuck
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Chuck

Insurance is not the problem. Health care insurance is not a “huge” profit making business for the company or the company stockholder. Check profitable businesses on Google. Nationwide insurance sales would cheapen the cost, see auto insurance, life insurance etc. If we could only buy Apple computers in California what would the cost be? If we could only buy oranges in Flordia what would the cost be. Think about it.

Chuck
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Chuck

All doctors should make a living wage and repay the schools they attended. No profit no care Supply and demand. As a retired person with health problems I have insurance and medicare enough to keep the economic wolf from the door. I have never questioned a doctor for over charging of services rendered but I do talk with them enough and they recognize I understand economics enough to “questioin” over billing etc. I have fallen into the “do nut hole” two years in a row now, that hurts the budget and I am in hopes the Congress will do some… Read more »

hh
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hh

I understand wanting him to come in and be seen after almost 2 years, but my doctor can see me 3-4 weeks ago and still want me to come in and pay another co-pay to get a Rx refilled. He does not even see me, I pay my co-pay and the front desk lady hands me the Rx. I try to make my appointments around the same time I need a refill, but sometimes that is not possible.

rbar
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rbar

Nate, You conveniently “overlooked” point 2 (point 1 is still valid, you point out that some things staid the same, while dismissing change): Here it is: “2nd, look at bills for outpatient care in 1970 and 2010. If I need to elaborate on that, let me know” So either you alrady know your argument is not defendable, or you unaware of the incredilble explosion of complexity of medical care, and the exploding variety of choice: CT, MRI, PET, advanced chemo, genetic testing, development of medical SUBspecialties, open heart surgery, ambulatory surgery … thanks to progress (some important, some so-so) we… Read more »

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Rob Lamberts
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Mike: It seems as if you judge me on this one post. To most who read my writing, I am very much of a patient-centric doc. This post was written in my blog, so it was meant to be read in that context, which is quite significant.
It really doesn’t seem like I am the one with the problem passing judgment on others. You are certainly easy to appall.

Nate
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Nate

“just respect basic social norms.” Not all social norms are to be respected. Sexism and Racism for example are socially acceptable in many places, that doesn’t mean they should be respected and accepted. On THCB there is a very liberal bias, you will see posters degrade and belittle conseratives all day but at the first mention of something derogatory to liberals shreak in offence. The social norm here is insulting those on the right is ok insulting the left is not. If someone is going to write an entire series calling other people liars then fill that with lies what… Read more »

Mike
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Mike

I must say I have little sympathy for Rob Lamberts in this case. The basic truth of HSAs versus conventional insurance is that in the latter case patient interests and physician interests are aligned… they both get something out of a visit. But with HSAs the physician’s gain is by design the patient’s loss, and unless patients perceive the compensatory health value, they are going to struggle to figure out whether it is in their interests to incur that loss. That’s the whole theoretical point about HSAs… to dis-align physician and patient economic interests. I find Rob’s lack of interest… Read more »

Rob Lamberts
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There was a degree of hyperbole here – the post is not 100% in sync with the visits it’s based on. It is very rare that I do respond to patients. This patient, however, was quite blatant and, to be honest, insulting. He doesn’t like my rules, and complains about it. I defend my rules, and he will live with it or find another doctor. I have plenty of patients who value what I do. I am not going to bend because someone doesn’t want to get $80 out of their HSA. That is my choice, and patients rarely complain.

MNinMN
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MNinMN

I sent this thread last Friday, when just a few comments were out there, to an environmental consultant friend who I debate health care with (I work for a health plan), and I thought his response was worth passing on…(although I am cursed/blessed with seeing both sides and definitely value a doc who cares): I just got around to reading the article. Sounds like the doctor lost control of his inner censor. I’ve had many similar conversations with belligerent clients in my head – but I would try to purge those thoughts before the meeting. It’s particularly funny that the… Read more »

Rob Lamberts
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Maggie: Agree 100%. I sympathize with the man’s desire to not spend money; I just don’t like being told to my face that I am trying to make money off of him when I am being reasonable. Update: Saw a patient this morning who I ‘forced’ to come in (like the other guy) and noticed oral cancer. He said to me “thanks for making me come in, because I wouldn’t have gotten it seen if I didn’t already have an appointment.” He’s cured and very happy. He’d be dead if I didn’t “force” him to come in. Yes, it’s an… Read more »

rbar
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rbar

Nate, I am happy to read that you feel that your verbage is appropriate. You should not deride others’ arguments as lazy when you just made the lazy argument par excellence (“Please, what has changed in basic healthcare? You still go to the doctor for an office visit, you still pickup your Rx at the pharmacy. What exactly has changed”). I answered to that, and you don’t even try to defend it, probably knowing that you don’t have a chance on that one. Why do you even post? You don’t need to question or adjust your position when debating (some… Read more »

Nate
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Nate

“(no, I will not follow your typical communication pattern of insulting people who have a different opinion).” rbar your making the wrong connection, I don’t insult people who have a different opinion, I insult people who lie and make things up they have no knowledge of. It just so happens these people tend to disagree with me. There are plenty of people who disagree with me that I have never said an unkind word to. Have an honest and educated conversation and I show all the respect in the world, be lazy with your argument and lie and I’ll point… Read more »