Why Doctor Visits are Frustrating and What You Can Do About It

You wait weeks to see the doctor. You could have scheduled a visit sooner, should have scheduled a visit sooner, but life and time got away from you. It has been so long since you have been in and you want to make the most of your visit so you make a list of the things about which you are concerned. Not all of the things are major or important but you figure you might as well bring them all up, because it may be a while before you make it in again.

The receptionist was in a hurry when you called so you did not bother to tell her all of the issues you wanted to address, you mentioned the back pain and the blood pressure that you have been ignoring since the last time you were seen 2 years ago. You will bring the rest up when you see the doctor.

After a 30 minute wait in the waiting room and another 15 in the exam room the doctor hurries in. He greets you briefly before turning to his computer. “I see you are having some back pain and your blood pressure is still high,” he says without turning to look at you, “How long has your back been acting up?”

You want to give him the full story, so you begin to tell him about how it all started 4 years ago lifting boxes at work, and how it has been bad off and on since then but has been really bad for the last 3 weeks. He interrupts you 15 seconds in, “How long for this episode?”

“Three weeks, but it all start…” interrupted again, “Any weakness or change in your bowel or bladder?”

“No, but…” you reply, “Let me have you sit up here,” again interrupted, you sit on the table and the doctor does a quick exam on your legs, checking your reflexes and strength. He doesn’t even look at your back. Within what seems like seconds he tells you that he is going to give you an anti-inflammatory medication and send you to physical therapy. If you are not better in 3-4 weeks you are to come back for a follow up visit.

He then tells you that he wants you to check your blood pressure at home 2-3 times a week and return in a month for a follow up blood pressure check as you may need medicine. He says you also need lab work and tells you to pick up the order at the desk on your way out. As he reaches for the doorknob he says you also need a mammogram and a colonoscopy and that he wants you to pick up the paperwork for those at the desk as well.

“Okay, but there were a few other things I wanted to talk to you about,” you plead.

“We can discuss those when you come back in a month,” he replies as he disappears out the door.

The entire interaction took about 10 minutes and you are left wondering what happened. You are walking out with several recommendations you did not ask for, little attention for your main issue and no attention at all to the remainder of your list. You ask yourself, “Is this why I have health insurance?”

Welcome to modern medicine, where the doctor does what he is required to do and the patient feels as if nothing has been done at all. Here are the things you need to know to help you understand and navigate this seemingly uncaring healthcare system.

1-      Routine visits are scheduled 15 minutes apart. Most doctors do not type well and electronic records are horrendously slow and inefficient, so the time available for the doctor-patient interaction is a net of 10 minutes or so. If there are two issues to be addressed, that is 5 minutes each. Very few doctors can effectively treat more than a few complaints at a time, and you really don’t want them to!

2-      Longer visits cost the doctor money. In a perfect world physicians would make the same for one 30 minute visit as they do for two 15 minute visits. The world is not perfect and they don’t. Under many insurances a long visit may only pay an additional 50% over a short visit. Doctors can do the math, so instead of scheduling long visits they ask you to return if there are many issues to address.

3-      Common complaints don’t usually require much thought or attention. Back pain in a healthy person without weakness or incontinence is almost NEVER anything to worry about. It will go away in 3-4 weeks with or without treatment. MRI’s and X-rays don’t change this fact. For many mild illnesses and conditions there is not much to do. If lengthy discussions and examinations don’t change the treatment plan, why do them?

4-      Doctors are responsible for your preventative health screens, whether you are interested in them or not. We get evaluated based on the percentage of patients who have mammograms, colonoscopy, PAP smears and appropriate immunizations. As we do not know if or when a patient will return for follow up we are forced to squeeze time for these recommendations into other visits. The result- We may not have the time for everything you wanted to discuss.

5-      There is much more to a doctor’s day than patient visits. Doctors spend a minimum of 2-3 hours a day working on issues outside of the exam room. Medication refills, phone questions, review of test results and lab results, disability and FMLA forms, home health orders, consult requests, referrals and appeals of insurance denials are endless. Doctors get paid for none of this work. We frequently try to do some of this work between visits, which further cuts into patient care time.

While this explains why your doctor is hurried and grumpy, there is still the question of how you get the care you desire. Here are somethings you can do to help your doctor take better care of you and get your health issues addressed.

1-      Take responsibility for your preventative screening needs. Schedule a wellness visit and ask what you need. Write it down, or save a link to recommendations. Enter the dates in your calendar or cell phone and then get the screenings done. If you take the time to make sure you are up to date your doctor won’t have to.

2-      If you have a number of issues you want to discuss, prioritize them. Tell the receptionist and the nurse the issues so the doctor will know when she comes into the room. Tell the doctor the items that are most important to you and be willing to come back if more time is needed.

3-      Don’t expect a lengthy visit for a common problem. Doctors sometimes see simple complaints such as acute back pain, bladder infections and colds as short visits that allow them to catch up when they are behind or to gain time after a complicated visit.

4-      If you do not feel comfortable with your visit, let the doctor know. Try saying something like, “I sorry, but I am confused. Could you explain this to me?”

5- If you need a lot of time, ask for it! You may need to come back, but most doctors want to help and may be willing to spend the extra time you need.

- Bart

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A Big Mistake in a Doctor's Office

My office was blowing it. I didn’t know it until just this week, but we had a serious customer service problem. Patients were having their phone messages and questions ignored. They called the office with a question, need or request, and the person taking the call was not consistently entering the message into the chart or writing it down. I missed the early warning signs (a few patients told me personally they had left a message that was not returned but I thought it was a voice mail issue) so by the time the problem was discovered it had been going on for a while. As it was only a few times a day and not all patients complained it took weeks before there were enough cases for me to recognize the issue. By that time we became aware of at least 15 patients who had been slighted or ignored, there may have been more. Something needed to be done.

Dealing with the employee in question was straightforward. When someone fails in one of their position's foundational tasks on a repeated basis (apparently after being counseled by other employees) a change is in order. After dealing with the disciplinary issue I faced a bigger challenge. How could I fix the problem? I worried that the cases I had discovered were just the tip of the iceberg. What if there were dozens of overlooked patients? Customer service is key to my reputation and I pondered what I could do to rebuild lost trust.

I decided to reach out to patients and address the problem. I sent a mass message to all of the patients on our email list, over 2500. I described the issue, told them that I had just been made aware of the problem and that if they had left a message and not received a response to let me know. I shared our policy that all calls should be returned same day and all emails within 24 hours, and I asked that they notify me if we fail to meet that standard in the future. Within a few hours the replies started pouring in. There were a few who were letting me know of a failure to receive a response but the vast majority said something unexpected. The majority of the messages said, “Thank You!”

It seemed that my openness and honesty about the problem and quick action to address it had made an impression on my patients. One patient who is a business consultant wrote, “Way to own it.” Another hotel manager praised our “great customer service.” All of them appreciated our efforts to make things right. To date I have not received a single negative response.

The gracious responses received remind me of the importance of honesty in everyday relationships. Nobody is perfect and everybody knows it, so mistakes are to be expected. It is how we respond to our mistakes that defines our character. There is a tendency to cover up and hide and explain things away but that path does not lead to success in the long term. The gracious responses of my patients remind me that honesty is truly the best policy.

-          Bart

A Second Opinion Saves a Patient

“They are telling us he needs emergency surgery. What should we do?”

The woman was clearly frightened. The night before her husband had suddenly developed the signs of a stroke. His facial muscles had gone limp and his speech was slurred. In a panic they had hurried to the closest emergency room, a local hospital where I did not have privileges. Several hours, many tests and multiple vials of blood later the diagnosis of a stroke was confirmed and he was admitted to the hospital.

The following morning a doctor came in and told them the reason for the stroke. One of his internal carotid arteries, the major supplier of blood to the brain, was severely narrowed. So narrowed, the doctor told them, that urgent surgery was required to open the vessel and prevent a further stroke. The family was caught completely off guard, for the morning had brought profound improvement in his condition. His speech had normalized and his facial muscles had improved. They wondered why the surgery was so urgent. Unsure of what to do or how to proceed, they called me.

They told me that the doctor was insistent that he needed urgent treatment. They then asked me if they could transfer to another hospital where I had privileges and could assume his care. While this was possible I had a number of questions I needed to answer before I could say "Yes.". Foremost among them was why the doctor was recommending urgent surgery in the first place. There very few circumstances in which the surgery needs to be performed urgently, but I wanted to be sure he was not one of those rare patients. At the same time in the majority of cases performing urgent surgery dramatically increases the risk of complications so I did needed to get all of the information I could before making a recommendation.

The next 24 hours consisted of me doing online research and making multiple phone calls to specialists to review his case. Each article and conversation confirmed my initial suspicions. Urgent surgery was absolutely not indicated. There was no reason for him to remain in the hospital. I called the family and shared my recommendations with them. Emboldened with the information I had given they declined the surgery. Angry, the doctor that night wrote transfer orders without discussing the case with me, a significant breech in protocol. Transfers are not possible without doctor to doctor conversation so he remained in the hospital overnight.

I spoke with the doctor the next morning. I asked him about the patient’s status and X-ray results and why the surgery was deemed urgently necessary, “He could have another stroke!” was his reply. I shared with him that I had reviewed the literature and discussed the indications for surgery with three different specialists and that I could not see any medical reason why the surgery needed to be done right away. He got angry and started to attack me personally. I stuck to my guns and suggested that it seemed that the patient was stable enough to be discharged from the hospital and that he could see a surgeon in a few days. He finally relented and within a few few hours the patient was safe at home. The risky and unnecessary surgery was avoided.

I was deeply troubled and emotionally shaken by what had transpired. The patient had come dangerously close to needlessly undergoing a risky surgery. I was grateful for the opportunity to help but I wondered how many other patients had not been as fortunate over the years. Second opinions are important!

- Bart

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Drug Secrets Your Doctor May Not Know

The patient was angry. His pain management doctor had written a prescription for a new pain medication and the patient expected it to be covered by his insurance. It wasn't, and the patient was stunned by the drugs $320 price tag. There was no way he could afford the drug and he went home empty handed and in pain. 

Stories such as this are not at all uncommon. Prescription coverage varies widely from one insurance to the next and seems to change daily. It is impossible to keep current. Previously covered and once inexpensive generic medications become uncovered and expensive seemingly overnight.

A week ago I wrote a prescription for doxycycline, a 48 year-old antibiotic that  a few years ago had a cash price of $4 at Target and Wal-Mart.  Imagine my surprise when the pharmacy called saying it was not covered by insurance and the cash price was now $65! How does that happen?

A few months ago a patient called asking for help with his sleep medication. His insurance would not cover generic Ambien and he could not afford the $85 his pharmacy charged for 30 pills. I had my staff check on what our cost would be if we ordered it ourselves. Our price- 100 pills for $3.10. The pharmacy was charging $85 for a medication that cost them $1!

100 mg Viagra tablets cost almost $30. Five 20 milligram tablets of the same drug from the same manufacturer, sold under the brand name Revatio, can be purchased for $4. When I asked the drug company salesman why this was he could not provide me with an answer.

There are many aspects of medical practice that are frustrating but medication costs and coverage are of particular concern. New drugs are always ridiculously expensive, with thirty day supplies of new medications consistently above $150. The prices are often concealed from doctors by sales people whose presentations focus on co-payments and discount cards instead of total costs. 

What can patients do to navigate such a system? I am often confused and perplexed by insurance coverage of medications, how can a lay person be expected to know what to do? We are in desperate need of greater transparency in how medications are priced.

While we wait for that day to come here are a few recommendations-

1- Tell your doctor when a medication is expensive. There may be less expensive alternatives. My daughter was once prescribed a medication that cost $700 a month. The doctor was shocked to learn of the cost and changed to a more affordable option.

2- Shop around. Prices can vary widely from pharmacy to pharmacy. A few years ago I called several pharmacies to check their price for generic Prozac. The four prices were, $7, $11, $25 and $40 for a one month supply. Do not feel as if you do not have choices.

3- Ask for an inexpensive drug. For common conditions such as high blood pressure, diabetes and sinus infections there are usually very inexpensive options. Target and Wal-Mart sell a 30 day supply of many common generics for $4.

4- Use coupons. Web sites such as goodrx.com can offer sizable savings. Almost every brand name medication will have coupons on their websites.

5- Fight when needed. I recently had a patient who was taking a medication twice a day for chronic pain. It worked well but wore off in the middle of the day. I gave him a sample and suggested he try taking the medication three times a day. He was thrilled to report dramatic improvement so I sent the new instructions to the pharmacy. His insurance denied the claim saying they would only cover the medication twice a day. I wrote two letters and personally called the insurance but they did not budge. He appealed the denial all the way up to the California Board of Managed Care. The Board notified him yesterday that his insurance would be required to pay for the medication. It took more effort than it should have, but he won!

- Bart

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The Day I Learned Not to Trust Doctors

When I entered medicine I believed I was entering a field comprised of noble professionals committed to taking care of others. I did not expect to encounter doctors who would put personal convenience before the needs of a patient. When I did, I did not handle it well.

I remember well when I first learned that not all doctors put the patient first. It was 1991 and I was an intern working on the OB floor. It was a Saturday and I was responsible for managing the residency program patients who were in labor. There was an experienced obstetrician supervising me, there to observe and provide guidance and to be available should a c-section be necessary.

I had been managing the care of a young woman whose labor had not been progressing well. There had been no significant change for a few hours and we were debating giving up and performing a c-section. The decision was made for us when the woman developed a significant fever and the fetal monitor showed early signs of distress. I went to the charge nurse to make arrangements for the surgery and was told that we could not go to the operating room, that a doctor had scheduled a c-section for another patient who had presented in early labor with the baby in breech position. As both patients “needed” surgery and the other doctor had asked first she told me that I would have to get the other doctor to agree to being “bumped” if I wanted to take my patient back to the operating room.

I asked a few questions about the woman with the breech baby and learned that she was in very early labor. Her cervix was only dilated 1-2 cm, which meant that there was no urgency in performing her surgery. As it was clear to me that my patient’s need for surgery was more pressing I sought out the other OB for what I assumed would be a simple and collegial conversation. I was wrong.

When I presented him with the details of the cases, he replied, “You will have to wait. My patient is breech and in labor!”

“She 1 cm and contracting irregularly! Why not get her an epidural, keep her comfortable, and wait the hour until our case is done? There is no risk to your patient but there is risk to ours!” I was incredulous.

He repeated his same assertion. I was dumbfounded. I was just an intern, but I was a good intern who was knowledgeable in the management of labor. This was not even a close call. It was a no-brainer. Good medical care demanded that he allow our case to proceed. I went to the charge nurse and asked her to tell him that he had to wait. She refused. She might have agreed with my position but in a debate between an attending and an intern she knew who was going to win. It wasn’t me.

I was overcome with anxiety. A million agonizing thoughts and questions were racing through my mind. Was I supposed to just give up? How could I? I was supposed to advocate for my patients, to fight for there care. But how could I fight when I had no power? The obstinate obstetrician was an established member of the medical staff and a faculty member in the residency program. What would happen if I pushed back to hard?

I decided that personal consequences were irrelevant. It was about my patient and her baby. I went back to the resistant obstetrician to again plead her case. I asked him for details about his patient and why should could not wait. He got angry and told me I was out of line. I wish I could say that I took it well. I didn’t. I told him in no uncertain terms (and with significantly elevated volume) that he was willfully and knowingly putting my patient at risk and that if anything happened to her it would be on him. Defeated but realizing I had done all I could I went back to check on my patient.

I walked away disillusioned. I had honestly believed that the other doctor would do what was right. I later learned that his recalcitrance was based on the fact that he had family plans that would have been disrupted if he waited. Knowing that a patient was put at risk out of convenience was unfathomable to me. I had looked up to this doctor before, had sought his counsel and learned from him. My trust and confidence were permanently damaged. The fact that my patient was not ultimately harmed by the delay did little to ease my frustration.

My frustration increased a few days later when I was called in to the office of the Residency Director. He sat me down to lecture me on my impertinence, telling me how inappropriate it was for an intern to challenge an attending physician. In typical Barrett fashion I did not back down. I apologized for my tone but made it clear that regardless of my standing or level of training I would always put the patient first.

As we talked, I realized that he didn’t really disagree with me. He knew that the attending was in the wrong. He also knew how the world worked. In order to run a residency program he needed faculty, and the only source of faculty he had was the medical staff at the hospital where we were located. Not all of them were noble and excellent but they were all we had. He admired my convictions but wanted me to understand the need to carefully choose my battles.

It was a difficult lesson for me to accept and it is one with which I continue to struggle. I have lost many battles that I should have known to be futile, died on too many hills trying to do what I believed to be the right thing for my patients. I have also saved lives by speaking out. I have learned that most doctors are good people but we are still people, with all the selfishness and inconsistencies personhood brings.  The learning process that began 24 years ago on that OB floor continues to shape me. Although I use less anger and volume one thing that has not changed is my commitment to doing the right thing.

- Bart

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