What is Your Doctor Worth?

How much is your doctor worth to you? For most people the answer appears to be, “Not very much at all.”

In the current rapidly changing health care environment patients are seeing their insurance coverage change on a regular basis. Their in-network physician can become an out-of-network physician overnight. Continuing under their physician’s care then results in additional charges for each visit. These charges are typically in the range of $30-$50. The vast majority of patients are not willing to pay the additional fees and therefore switch to a new physician. For healthy patients who do not have a well-established relationship this makes sense. Why pay extra to see a doctor you have only seen once or twice for a head cold?

For patients with chronic illness and who have more complex issues the decision is more significant but the outcome is seldom different. In the minds of many patients doctors are  like any other product they would purchase at the market. The name on the package may be different but the basic product is the same. They see no reason to pay more for something when they can get the same thing somewhere else at a lower price. Even when a doctor has provided exceptional care there is little extra value perceived.

Several years ago I had an active senior citizen come to me saying that he was getting more fatigued with exercise. He had no chest pain or pressure but I asked the appropriate questions and felt there was a significant chance of coronary artery disease. Although the symptoms were not classic I referred him to a cardiologist for an urgent evaluation. Further testing revealed significant blockages of his heart arteries and he underwent angioplasty. It is not an exaggeration to say that my thoroughness may have averted a heart attack. A few months later he learned that I might not continue to be covered by his health plan and that in the coming months he might have to pay an additional fee. He changed doctors immediately. I may have saved his life but I was not worth an extra $30 a visit.

For physicians who truly care about their patients this can be very discouraging. Last year I made a change in my schedule, lengthening routine appointments by 33%. Patients appreciate the time and attention and I think it has greatly improved the quality of medical care I provide but at the end of the day the percentage of patients willing to pay more for the extra time, attention and quality is discouragingly low. We live in a world where people who pay $5 for a cup of coffee, $15 to see a movie and $150 a month for cable TV are unwilling to pay more than the minimum to see their doctor.

This is part of the reason many doctors have converted to concierge practices, models in which patients pay an upfront fee to be a part of a quality practice. For fees of  up to $3000 a year or more patients are guaranteed same day access, rapid telephone and email responses, and lengthy appointments. Patients get high level service and physicians get patients who value their time and expertise.  

While concierge practices have much to offer they are out of the reach of the vast majority of patients. As appealing as the arrangement is from a financial perspective I cannot bring myself to closing the access door to longstanding patients of modest means. For the moment I plug along doing the best I can at current reimbursement levels, knowing that my current strategy of providing the highest quality care and service I can may not be sustainable in the long term. My hope is that over time more of my patients will grow to appreciate the value of the service we provide. If not, we will all have difficult decisions to make.

- Bart

When Your Kidneys Fail at 30, Life Changes

His kidneys were almost completely shut down, functioning at less than 5% of normal. The lab results were the worst I had ever seen. His blood count was less than half normal, his kidney disease so advanced it had suppressed his ability to manufacture blood cells. According to the lab work he was near death.

Remarkably, the lab work ordered was just routine, done to complete the evaluation of his elevated blood pressure. He walked in for his visit and did not complain of any symptoms at all. When the labs came across my desk I called him right away. He did not answer his cell phone because he was at work. He was in need of emergency dialysis, and he was at work!

He was stunned when I gave him the news and told him to go directly to the hospital. How do you process the news that at the age of 30 you need dialysis and a blood transfusion? The ensuing few days were a medical and emotional whirlwind for him as he received a blood transfusion, 3 rounds of dialysis and was told he might want to reach out to family members to see if any might be willing to be a kidney donor. It was a lot for him to process.

His story weighed heavily on my mind for the next several days. I was reminded of the fragility of life and health. We go about our days with the illusion of control and a false sense that our futures are secure. It can all come crashing down in an instant. We know that terrible things happen but we tell ourselves that the terrible things will happen to someone else. We are seldom prepared for the crisis when it comes.

As it always does, his health crisis brought a new perspective on life, faith and relationships. He gained a new appreciation for his girlfriend, who stayed at his bedside during his time in the hospital. He was forced to deal with the reality of his mortality and he was given the motivation to consider the meaning of life and what comes when life is over.

As I talked to him I was reminded of how blessed I am. I have health issues, but thus far none of them threaten my survival. I am blessed with a woman who has been by my side through thick and thin for 33 years. I have a future and an eternity that is certain and secure, guaranteed and sealed by the sacrifice of my Savior.

May his story be an encouragement to us all to take time to evaluate our lives and our relationships, of the supremacy of faith, and of our need to live beyond the moment. None of us is guaranteed additional time.

Bart

Thanks for reading. I post 2-3 times a week on matters of health, family and faith. Those who wish to have future posts delivered to their email can click the subscribe button on the page. Blog posts are also linked on my twitter feed @bartbarrettmd. The share button is the most important link on the page, as it is how others learn about the blog. Feel free to use it!

A Backwards World. Late Patients, On-time Doctor

It seemed no one was on time. Patient after patient came in late for their scheduled appointments. I wondered how I would keep up and if I should ask the late patients to reschedule. I didn’t ask them to reschedule and I did keep up. Here is how it worked out and what I learned.

The first late patient was arrived over 20 minutes after her scheduled appointment time and had multiple issues she wanted to discuss. She had a 15 minute appointment and 30 minutes worth of problems. Knee pain, back pain, neck pain and headache. I addressed the neck pain and the knee pain and discussed treatment options and briefly discussed the headache. Out of time, I explained that we were starting a process, that I wanted to check an xray and have a physical therapist evaluate her neck, and asked if she would be willing to come back in a week or two to take the next steps. Because I was not at all behind when she arrived I was not too far behind for my next patient, who was 30 minutes late for his new patient physical.

He was so late that I called out to the front office, “Did our 10:15 patient no-show?”

My nurse answered back, “He just got here!” She was in the process of calling the patient back to the exam room. A few seconds later the patient sheepishly appeared behind her, spewing apologies for his tardiness and thanking me for taking him anyway. I wondered how I would manage to do a complete evaluation and still be on time. I didn’t have to worry, for while the patient was being roomed I answered the office phone. It was my 10:45 patient. He was stuck in traffic and running late. He wondered if I would still see him. I knew that he was commuting from 90 minutes away. “Of course I will, but it may be a bit of a wait!” was my reply.

The physical exam didn’t need a full physical exam after all and the visit did not take as long as expected. The patient was so appreciative of the service and care he received that he made up his mind to refer his brother to me for care while he was still in the exam room.

The next late arriving patient came into the office well after his scheduled appointment, but late enough to where I was able to be right on time for my 11:00 appointment. It all worked out.

He was followed by a long standing patient who I had scheduled for an hour long appointment into my lunch hour. He has been cursed with skin that likes to grow skin cancers and he needed so many biopsies that there was no good place to fit him into my normal schedule. I had the staff book the procedure during my lunch hour so I could devote the time needed. When he arrived he asked if we could do fewer biopsies than planned. He wanted to make sure I had time for lunch.

Sure enough, I finished all of my morning charting and was able to have a little over 30 minutes to grab a sandwich at the local café. As I ate my sandwich I thought of how at one time in my career I would have been stressed and angry at patients arriving late and would have demanded that they reschedule. I remembered that I was less happy and content with my practice back then and that my patients weren’t as happy either.

Later that afternoon I fell behind again when a procedure took longer than planned. I was 30 minutes behind when I entered the room of the patient that followed. I handed him a Starbucks gift card as an apology for his wait. He accepted my apology with grace, reminding me that we all need forgiveness at times and that grace and kindness make the world a better place.

-          Bart

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A Heart Attack in the Medicine Cabinet

People don’t like pain, even in small amounts. Look in any medicine cabinet in America and you are likely to find multiple medications for pain. Among the most common and most effective are anti-inflammatory medications such as Motrin, Advil and Aleve. Millions of people take these medications on a daily basis to treat headaches, muscle pain and arthritis. New evidence now suggests this may be dangerous.

While doctors have known for a while that there was a slight increase in heart attack risk in patients taking anti-inflammatory medications the risk was considered to be negligible. We knew about it but we didn’t talk about it. We are in the business of making people feel better and when patients are in pain we want to do something about it. Non-steroidal anti-inflammatory medications (NSAIDs) make people feel better. They are inexpensive and available over-the-counter in low doses or by prescription at higher doses and the benefits of decreased pain and improved function seemed to greatly outweigh any concerns. 

It seems we were wrong.

Recent studies have demonstrated that the risk of heart attack and death was significantly increased. The strongest evidence came from an analysis of several studies totaling over 120,000 patients. The analysis revealed an average of 3 more heart attacks over 10 years for every 100 patients. As the patients in the study averaged an age of 61 and were not typically at high risk for heart disease the results are particularly concerning.

One expert, Dr. Peter Wilson of Emery University is quoted in the NY Times,-

“The over-the-counter medications, which have the lowest doses, probably increased risk by about 10 percent, he said. Low-dose prescription medications were likely to increase the risk by about 20 percent and higher-level dose prescription medications by about 50 percent”

Interpreting these numbers requires an understanding of a patient’s baseline risk. Using myself as an example, as a 54 year old man with normal blood pressure and high cholesterol treated with medication my risk of having a heart attack in the next 10 years is about 4%. If Dr. Wilson is correct, over-the-counter medications cause a net increase of 0.4%, low dose prescription medications 0.8% and higher dose NSAIDs have a risk increase of 2%.

For men like me this translates into one more heart attack for every 250 patients for OTC use, one of 125 patients for low dose prescriptions and one in 50 for high dose medications! If I had diabetes and was treated for high blood pressure those numbers would double. When I realized that the medication I was taking every day to manage my arthritis pain had a 1/50 chance of leading to a heart attack in the next 10 years I decided my pain wasn’t as bad as I thought it was! 

While younger people at very low risk for heart attack can take these medications with little concern and occasional use for headache and back strains is not likely to have much of an impact for anyone, the reality is that a large number of older patients have been taking these medications on a daily basis. This new data will require us to reevaluate our approach to arthritis pain.

Here are some of the approaches I am considering-

1-      I am having individual conversations with all of my patients who are on daily NSAID medications

2-     I am encouraging my patients to consider acetaminophen as first line treatment for pain

3-     I am revisiting the lifestyle changes that can help ease arthritis pain. Obesity is an important factor that patients typically do not want to address. It can no longer be ignored.

4-     I am becoming more willing to tolerate mild to moderate pain. I stopped my daily medications 2 weeks ago. My pain has increased significantly, but it is not unbearable.

5-     I will consider prescribing more medications that are pain modifiers and not pain relievers such as certain anti-depressants (duloxetine is a common medication for this) and seizure medications (such as gabapentin)

6-     When necessary I will be more willing to consider narcotic pain medications

Medicine is changing. Treatments we once thought to be safe weren’t. Doctors will need to individualize approaches to the management of pain and patients will need to be willing to consider new options. It is not hyperbole to say that lives are at stake.

Bart

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An Atheist Asks for Prayer

“Doc, you know I’m an atheist, but I know you are a man of faith and I am going to ask you to pray for me.”

Atheists do not usually ask for prayer but this was a special circumstance. Being diagnosed with cancer causes people to reconsider beliefs they had previously rejected, to look for help in new places. Although my phone call to him delivering the biopsy results was not unexpected the diagnosis still hit him pretty hard. He had cancer and it was serious. He took only a moment to absorb the information before telling me he was not ready to die and he was afraid.

He had been battling a number of health issues for several months. First had come an unusual cancer of the skin and superficial tissue of his back, a cancer so rare that none of the doctors had seen it before. Shortly after the final surgery and radiation treatments for that cancer he developed an irregular heartbeat and was diagnosed with atrial fibrillation. Blood thinners became a part of his life. He had always been strong and healthy and now he was on chronic medications. He was no longer invincible.

While he dealt with the stress of these diseases he began to battle another problem. He developed severe stomach upset that made it difficult for him to eat. Heartburn, indigestion and nausea became his daily companions. He lost 50 pounds. He saw a specialist, but the specialist was concerned about doing an endoscopy and biopsy while he was on the blood thinners so definitive testing was delayed. After several weeks of waiting he called me and asked for a new GI doctor. A few weeks later the new GI doctor called me to let me know that he had done an endoscopy and discovered a cancer in the stomach. That news led to my call to the patient and to his unexpected prayer request.

A few weeks later he scheduled an appointment with me to go over his options and ask my opinion. We discussed what we knew (which was too little for me to give him a decent prognosis) and we discussed several possible outcomes. Although the cancer is serious and life threatening he is determined to survive. He again asked me to pray for him. I told him that I had been praying and would continue to do so.

As often happens during life and death conversations the discussion drifted to other areas of his life. He talked being estranged from his son and how difficult that had been for him. He shared about a recent school reunion that was bittersweet, as the joy of renewing old friendships was tempered by the gravity of his diagnosis. He told me about his journey away from faith many years ago, how travels to Europe and Africa had included visits to concentration camps and  areas of mass genocide. Faced with such evidence of evil he had rejected the idea of God's existence.  

Time and circumstances made deeper conversation inappropriate but it seemed to me that there was much he wanted to discuss, many more issues of the heart he desired to explore. It seemed that my years of caring for him had resulted in me being someone he felt he could trust. I wrote down my cell phone number and handed it to him.

“Anytime you want to talk, I’ll buy the food or the coffee. Not as your doctor, but as your friend.”

He promised he would take me up on the offer. I pray I will be an encouragement to him if and when he calls.

When he left I was again reminded of how important it is to not only care for my patients but to care about them. Sometimes the greatest therapeutic tool available is our ears. We just need to listen.

- Bart

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