By ROB LAMBERTS, MD
He came in for his regular blood pressure and cholesterol check. On the review of systems sheet he circled “depression.”
“I see you circled depression,” I said after dealing with his routine problems. ”What’s up?”
“I don’t think I am actually clinically depressed, but I’ve just been finding it harder to get going recently,” he responded. ”I can force myself to do things, but I’ve never have had to force myself.”
“I noticed that you retired recently. Do you think that has something to do with your depression?” I asked.
“I’m not really sure. I don’t feel like it makes me depressed. I was definitely happy to stop going to work.”
I have taken care of him for many years, and know him to be a solid guy. “I have seen this a lot in men who retire. They think it’s going to be good to rest, and it is for the first few months. But after a while, the novelty wears off and they feel directionless. They don’t want to spend the rest of their lives entertaining themselves or completing the ‘honey do’ list, but they don’t want to go back to work either.”
He looked up and me, “Yeah, I guess that sounds like me.”
“What I have seen work in people, especially men, in your situation is to get involved in something that is focused on other people. Volunteer work at the food pantry, work for Habitat for Humanity, or anything else that lets you help other people. I think the reason people get depressed is that they turn their focus completely on themselves, which is not what they are used to when they are working.” (I knew that this man had a job that helped disadvantaged people).
“That’s great advice, doc.” he said, with a brighter expression on his face.
“It’s from experience,” I responded. ”I’ve seen a lot of retirees start to feel like they are on a hamster wheel, just entertaining themselves until they die. I know I wouldn’t want to retire that way. Knowing you, I wouldn’t imagine you would either.”
We talked for about 15 minutes about the various groups around town that would need someone of his skills. I told him about how my parents went to Africa for a year after Dad retired. He actually taught physics over there, but that is what they needed. Of all the time I spent with him, over half of it was regarding his post-retirement “blues.” He wasn’t clinically depressed, so I couldn’t charge for depression as a diagnosis. The code I used? 99214 for Hypertension and Hyperlipidemia.
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I saw her name on my schedule. She’s a dear woman whose husband passed away recently. I have cared for her and her husband for many years; they would always come in together – he with his dry wit and she with her motherly hugs. I was both happy and sad that she was coming in.
When I walked into the room she looked at me with bloodshot eyes and said, “I am doing OK” with a wavering voice.
I didn’t say anything; I just went over to her and hugged her. She hugged me tightly and neither of us said anything. Her visit was officially listed as a recheck of her hypertension, but we spent the vast bulk of the time talking about her husband. She laughed because her blood pressure was actually lower now than it had been before. ”I guess I know who was causing my blood pressure to go up,” she quipped with a hint of tears still in her eyes.
I laughed, did my documentation as we talked, and scheduled her to see me back in a month. She didn’t need to be rechecked in a month for a medical problem, but I knew she would want to see me soon.
I coded it as a 99214 for hypertension and grief reaction.
——-
With the debate about our healthcare system heating up, I think we lose focus on the point of the system in the first place: care. I knew both of these patients well, which made these special interactions possible. I didn’t have to do the extra stuff as a doctor, but the human side of me made it impossible not to spend the extra time. Primary care is about relationship – about doctor knowing patient and patient knowing doctor. It is an opportunity for people to get help and to get care.
I am not unique in my relationship with my patients; this is why most people go into primary care in the first place. But I do think the pressure to become an E/M coding machine, for focusing on the business over the patient, is getting progressively stronger. To the system, each of these encounters are simply codes and numbers. But they were obviously so much more than that. They were about the humanity, the contact, the care that is becoming a scarce commodity in our system.
Some people may not want a doctor who spends extra time with them, but most people do. Our system is progressively snuffing this out by belittling the importance of relationship and stressing drugs and procedures. Both of these patients are Medicare, and so the idea of my practice dropping Medicare bears their faces along with many others. Yet I can’t really afford to take a 21% pay cut, so we’ll have to figure out something.
Medically, these visits were routine and uninteresting. But those moments are the pearl at the center of any system we set up. We need to value that pearl. We need to encourage medical students to go into primary care, so that when I get to the age of these patients, I will have someone to care for me – to really care, not just code and document. Right now, encouraging students into primary care is like encouraging them to stand at the muzzle of a loaded gun. We are endangered. These visits are what is really at stake.
Does Washington realize this? Does Washington care?
Rob Lamberts, MD, 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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The brothers were born into a family of farmes who raised corn. The father, Liu Yanding, was born hearing impaired; their mother had always been in poor health.
You can only say that you love that person if you have time for him or for her and of course showing your care for that person. The post is really inspiring and it made me some realization that I should care for somebody. Even in the Internet I can see the heart of the author that he wants us to care also for someone.
” I think the Patient-Centered Medical Home model will make it much more attractive to be a primary care doc as some of the administrivia is removed from us”
Dr. Coffey:
I look at the PCMH model and all I see is an enormous increase in the “administrivia”
and no increase in payments to cover it: that is, my nurse and I will spend much more time on bureaucratic chores, and have much less time to spend with patients. Look at the evaluation reports on the National Demonstrative Project: a real disaster.
Rob, you should have a TV show or at least a regular column or syndicated column.
AnnR: Does your hubby listen to you? Send him a bill next time, and he might pay attention. Ha? Women ! and Men!! Can’t live with them, or without them, my Daddy used to tell me.
Women!
Always jumping to bad conclusions about men! He had the appointment for his blood pressure and cholesterol. My taking extra time with him and probing deeper is what brought this out. Wives don’t always tell their husbands about this kind of thing, and since I’ve seen a lot over 15 years I figured it out quickly.
The talk I did added no additional charge to the visit, as I would probably have done a 99214 for that kind of visit anyway.
Men!
The recently retired man’s wife has probably been urging him to get involved in something since he started hanging around the house all day. She’s been honey-do’ing him in hopes he’ll think up something else he’d rather do…..
Did he listen to her? No, he had to go rack up an $84 dollar bill to “hear” what she’s been telling him for weeks now.
It was a lovely post..so caring it was! As Michael said it’s a more of caring business than the health business.
A tight hug to a worried soul says a lot than words or medical care. That was really great!
Maggie:
Thanks, but the perception is so pervasive among physicians that it might just as well be real. Many are no longer accepting new Medicare and all are weighing if we can afford it. If all we hear is that things are going to get worse, we tend to believe it. The voice of reassurance is very quiet. Perception is reality to those perceiving, and unless the propaganda tide gets switched, it won’t matter what reality is.
Great, great post! You write well. And you practice medicine well.
Statistics / numbers are the patients with the tears wiped away. Thank you for reminding us that the numbers are ancillary.
Rob —
Wonderful post.
Please don’t worry about the 21% cut. This is something that the AMA and conservatives use to fear-monger– it will never happen.
It is a very crude solution to health care costs–even our Congressmen understand this. That is why they never implement it.
On the other hand, moderates are afraid of upsetting conservatiive voters by killing it. So they just keep postponing it. And then conservatives use the fear of it to advance their agenda with doctors.
But it won’t happen.
By contrast, what is real is your idea of primary care. It is about care, comfortand compassion, not just “cure.”
Cure is wonderful–but, as you know better than I, you can’t “cure” a widow’s grief or a retired person’s sense of displacement, his sense of having lost himself.
Thanks again for a great post,
” Of all the time I spent with him, over half of it was regarding his post-retirement “blues.” How much time did you spend with the computer?
Level 99214 for those ICD9 codes?? Wait for your RAC Audit.
Rob,
Loved the post, and the title. As a fellow family doc, I feel that we are in the caring business even more than the health business.
I have chosen to be unabashedly optimistic about the future of primary care, as I see signs around us that people finally understand its importance and are willing to adapt the system to make primary care attractive. I think the Patient-Centered Medical Home model will make it much more attractive to be a primary care doc as some of the administrivia is removed from us and we can free ourselves somewhat from the fee-for-service treadmill. We need to attract more students into primary care, because when I am old, I want to have a doctor like you.
And great advice to your retired patient. It reminds of a passage from a great book called The How of Happiness:
“In 1932, an Australian psychiatrist named W. Beran Wolfe summed up his philosophy like this: “If you observe a really happy man you will find him building a boat, writing a symphony, educating his son, growing double dahlias in his garden, or looking for dinosaur eggs in the Gobi desert.” He was right. People who strive for something personally significant, whether it’s learning a new craft, changing careers, or raising moral children, are far happier than thos who don’t have strong dreams or aspirations. Find a happy person, and you will find a project.”
How about CPT 309.89 – Adjustment reaction – for the retired guy?
(309) Adjustment reaction
(309.0) Adjustment disorder, depressive
(309.2) With predominant disturbance of other emotions
(309.8) Other specified adjustment reactions
The time you spent with both these patients was worth reimbursement, every penny of it and probably much more than you received. It is these human interactions that make what we do so worth it – for us and for our patients. Great post.
For 99214 in GA, the payment is $84.
No, I don’t wear the hat. It’s a nice hat, though.
two questions:
What did you get paid, actually?
Did you wear your hat when speaking to the patients?
Amen
Washington wouldn’t know if they never come across articles like this.
Yes, there are still people in Washington who CARE; not all of them care, but not all of them are bad apples either. Just saying….