Complaining About Everything and Changing Nothing. Thoughts on Protesting Trump.

I don’t get yelled at by patients very often but when I do there is one question I want to ask the offended and angry person. “What are you hoping to accomplish by yelling at me?”

I have been yelled at more than once for not prescribing antibiotics for a viral infection. Each time I wondered if the patient thought my medical opinion was so weakly held that it would change once a certain decibel level had been reached, if antibiotics were indicated not based on the severity of the infection but on the anger of the patient.

I have had patients yell and scream over the cost of an office visit. Some have threatened to seek care elsewhere if I did not waive my fees, apparently oblivious to the fact that no doctor wants patients who don’t pay their bills in their practice. Their behavior guaranteed an outcome opposite of the one they were seeking. Instead of begging them to stay I was glad to see them go.

These encounters came to mind this week as I watched the anti-Trump demonstrations. While Donald Trump has given Americans myriad reasons to be upset and angry I find myself wondering, “What are they trying to accomplish?”

There is no chance of a do-over. Elections do not work that way. No amount of yelling is going to change Trump’s mind. No clever sign or intensely chanted slogan is going to change the outcome. Instead of persuading others the most likely result of these protests is to galvanize those who against them. Those who voted for Trump rightly feel that their vote is being devalued and attacked. The natural result will be greater support for Trump among his voters and those who almost voted for him, making his policies more likely to succeed. This is not what the protesters want but it is what they will get.

If these protesters truly want to change people’s minds they are going to need to do it the old fashioned way. They will have to leave the bubble in which they live and engage in dialogue with those who disagree with them. They will have to listen, understand, and provide reasonable, rational and respectful explanations for their point of view. This will take time, effort, and patience. If they are as passionate as they claim they will make the effort. If they don’t, their words aren’t worth the poster board they are printed on.

If they want to impact elections they will have to do this the old fashioned way as well. They will need to register and vote, and support candidates with whom they agree. They will need to volunteer their time and donate their money. If they don't they will continue to feel as if they are outside of the process, because they will be outside of the process.

Bart

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Respect. The Lost American Value

He was in his twenties, had a high school diploma and no college, and was the manager of a shoe store in an aging open air mall. I was terrified of him. I worked in the strip mall and he was my manager. He was a shoe selling wizard, a company man devoted to footwear excellence. I was 17 and a senior in high school, working for $3 an hour plus commission. Every time I worked with him I was nervous.

My fear and respect of managers persisted in the years to come. After I graduated high school I worked on the loading dock at a Montgomery Ward store in Costa Mesa, California, where I found myself again intimidated, this time by the dock manager and the other workers. They were all bigger, older and stronger than me. During my brief time there I was constantly fearful that I would fall shirt and fail to meet expectations.

After I moved out of the house I worked as a box boy for a Vons supermarket in Whittier, California. The manager was a man named Tom Moore who had a perfect haircut, a full mustache and a strong personality. He had worked his way up from box boy to store manager in the company and managed several stores. He had no education beyond high school but he knew what he was doing and was good at it. I respected and feared him.

Looking back, I realize that these managers were not the type of man many would now find remarkable. They were not highly educated and did not seem to possess broad based skills. They were simply good at what they did. I did not know it at the time but I possessed more innate managerial talent and leadership potential and was probably more intelligent. They did nothing to earn my respect or to prove themselves to be my intellectual superior but I respected them all the same.

I respected them because they were in authority over me. I knew nothing about their moral character, school grade point averages, SAT scores or personal lives. They could have been terrible people outside of work. In spite of all of this, I respected them from the moment I started each job. That is how I was taught bosses were supposed to be treated.

The world has changed. Respect for position and authority has almost completely disappeared from our culture. I have seen this in my own profession. I have had my knowledge and authority questioned by job applicants and patients who knew nothing about my record of success or commitment to excellence. I have been cussed at by 10 year-olds and had my advice dismissed out of hand by millenials who believed that a semester of psychology and the ability to perform a Google search rendered them my medical equal.

The lack of respect in the current generation has not only damaged professional relationships, it has inhibited learning. While some would consider my high school educated managers to be inferior, they were not. I learned something from all of them that I could not have learned on my own. Richard, my shoe store manager, taught me how to sell, the importance of asking for help, and how to relate to others. On the loading dock I learned how to organize, pack, and move a refrigerator safely. Tom Moore taught me about business, how to manage large groups of people and the importance of improving overall company performance and not just individual work. I could write multiple pages of the lessons learned from every less educated manager for whom I worked.

Most importantly, they taught me the importance of respect and the value of submission to authority.

Bart

Annoying Patients, Frustrated Doctor

Some people are difficult. They don’t mean to be. They are not intentionally rude, they do not try to be annoying or combative or abrasive, it is just the way they are. Sometimes it is lack of knowledge, sometimes they are just socially awkward. When they come to the office communication is challenging to the point where everyone in the office heaves a collective sigh when their name appears on the schedule.

Visits with these patients are often a struggle for me. I do not delight in rambling questions or in patients who feel the need to give a lengthy explanation of their self-diagnoses made with the assistance of the internet. Debunking their confidently held but ridiculously inaccurate medical opinions tries my patient and consumes an inordinate amount of time. I find my self emotional and cognitively drained by the interactions. It is difficult to remain focused on the medicine instead of the annoyance.

Over the last few years I have worked on a solution to the problem. When the ramblings become unbearable, when I feel the urge to run from the room, I take a breath, mentally pause and do something I never used to do. I pray for the patient.

Silently in my mind I ask God to help me see the patient as He sees them. I ask Him to help me listen, to be patient and to be kind. I ask Him to help me love the patient and meet their needs. I remind myself that I have my own problems and annoying idiosyncrasies and ask God to help me be patient and gracious with theirs.

It works.

The patients are still difficult and the visits still challenging, but I change. I become less concerned with the length of the visit and more concerned with identifying the real needs of the patient, the unspoken needs of which they may not even be aware.

As I have done this I have learned an important lesson. I have no power or ability to change others. I do have the ability to change myself, and that can make a difference.

- Bart

Why I Don't Accept Medicare

It is Medicare open enrollment season, the time of year when my office receives several calls a day from seniors looking for a primary care doctor. “Does Doctor Barrett take new Medicare patients?” is the common question. The sad answer is, “No.”

I stopped accepting traditional Medicare patients several years ago. Patients with Medicare who wish to join my practice can do so only by enrolling in a Medicare Advantage HMO plan (Such as SCAN or BlueShield 65+). Many patients cannot understand why I do not accept traditional Medicare. It takes only a few moments to explain my reasons.

1-      Medicare does not pay for some needed services.

If a 65 year-old patient is newly diagnosed with hypertension, many experts recommend an electrocardiogram (EKG) to see if the heart is enlarged. Medicare does not seem care what these experts say. They refuse to pay for the service. As Medicare does not allow me to bill the patient, I must either provide the service for free or not provide it at all. This does not happen with HMO patients. The payment model for Medicare HMO allows me to provide all needed care.

2-      Medicare has arbitrary and foolish limits on testing

For diabetes, the most important test is a hemoglobin A1c, which provides an estimate of the average blood sugar for the previous 3 months. This test is infinitely more valuable than a single blood sugar. When I make medication changes in a patient whose diabetes is way out of control I will sometimes order the A1c after a month or two. While the value has not yet reached a steady level, if the number is moving downward the result is encouraging to me and the patient. If it is not decreasing I know I need to make additional changes. Medicare does not share my belief in the value of the test. They will only pay for the test once every 90 days. Make a mistake and send the patient to the lab on day 89 and the lab will send the bill to the physician. HMO's allow me to order tests whenever I feel they are necessary.

3-      Medicare provides no support for quality care.

Medicare HMO’s provide real time data to help me manage patient care. When a Medicare HMO patient comes to the office the electronic record has integrated reminders telling me which screening tests the patient needs. Better still, with the HMO I receive reminders for patients who have not even come to my office yet, allowing me to reach out and encourage them to receive needed care. I have seen this save lives. For traditional Medicare, the patient and I are on our own. I know nothing about them until they come in, I receive no reminders of needed tests and if they don’t know what tests they have had I am forced to call previous doctors (if they can even remember who did the colonoscopy years ago), dig through their chart or log into the hospital system to find results. Frequently these efforts prove futile. Many doctors take the easier path and simply give up and repeat the tests.

4-      Medicare HMO’s invest in programs to improve patient care.

HMO plans pay medical groups flat monthly fees on a per patient basis, which means that when patients get sick, expenses go up and profits go down. As a result medical groups invest in programs to keep patients healthy. As an example my medical group, Greater Newport Physicians, has programs for diabetes management, in home health assessments and immediate post-hospital follow up, all of which help patients stay out of the hospital and none of which are available to patients on traditional Medicare.

5-      Medicare requirements for wellness visits are absurd yet mandatory.

Medicare pays for wellness visits once a year, but only considers the visit and charges valid if the doctor addresses every item on the Medicare checklist. Not all of the items are relevant. For example, doctors are required ask a health 65 year-old patient who plays tennis 6 days a week if he is able to dress himself, bathe himself and take care of his daily needs. Failure to ask these questions and document the answers in the chart puts doctors at risk for failing a Medicare audit and being charged with Medicare fraud. Even worse, an initial “Welcome to Medicare” visit for a healthy requires a routine EKG, even though the test has been proven to be useless and potentially harmful. (yes Medicare denies payment for a necessary EKG yet requires it when it is useless!)

6- Traditional Medicare reimbursement is dramatically lower than Medicare HMO, and pays for the wrong things

With traditional Medicare, the more a doctor does to a patient, or the sicker the patient gets, the greater the payment to a doctor. For doctors like me who try to keep patients healthy and do only what is needed the end result is a low level of reimbursement. I prefer to treat patients in a system that pays me for doing the right thing.

It is for these reasons and more that I made the difficult decision to only accept Medicare HMO patients. It is always painful to say “No” to a patient who wants to be a part of my practice but my hope is that patients will come to understand that I want the very best for them and do not want to settle for anything less.

In spite of all of these challenges there is some hope for Medicare. In my area, medical groups such as Greater Newport Physicians and Healthcare systems such as MemorialCare are partnering together to try to find ways to improve care and provide better service to traditional Medicare patients. It may be years before the quality and service approaches that provided to HMO Medicare patients, but it is reassuring to know that the work is underway.

-          Bart

Missing the Most Important Diagnosis

I almost missed it. I had covered all of the essential medical details of the visit but I nearly overlooked the most important issue for the patient that morning. I caught as he walked out the door.

His appointment that day was for recurrent abdominal pain which was at times severe and debilitating. His problems began a year earlier when he had a case of diverticulitis that resulted in a visit to the emergency room and a week of antibiotics. That pain resolved but in the months that followed he had three more cases of severe pain in the left lower quadrant. He was seen by a doctor on each occasion but, unlike the first episode, diverticulitis was not the cause. All of the tests came back negative and the pains resolved. No one could tell him what was going on.

His most recent episode has been two weeks prior to the current visit to my office. It was bad enough for him to return to the emergency room. Again, no answer was found and the pain resolved. Although the pain had been gone for several days he came to my office to see what the next steps would be. He was full of questions.

“Could it be my gallbladder?” he asked. I explained that it could not be, as gallbladder pain occurred in the right upper quadrant, a completely different area from where his pain was located. His questions continued, and I patiently explained why we knew it was not diverticulitis (normal CT) or an ulcer. While I did a good job of explaining all of the things he didn't have I was not able to give him a definitive diagnosis. I decided to refer him to a specialist for help in determining what additional testing was needed. I completed the referral request online and wrapped up the visit, wishing him well.

As he left the room I walked alongside him, (not out of courtesy,I wanted a cup of coffee and needed to walk the same direction). As we walked I realized what I had missed. I had addressed his questions but I had not addressed his fear.

“It's frustrating not knowing what is going on isn’t it?” I said.

“It is,” he replied.

“It would almost be easier if it was diverticulitis,” I said, “because then we would at least know what we were dealing with.”

“Yeah,” he responded, “I am really worried about it.”

I stopped walking and looked him in the eye. “Don’t let yourself be too worried over this. In my mind there is nothing serious on the list of possibilities. Cancer is not even on my list. We are just being thorough. On a 1 to 10 scale of worry, this is about a 2. Nothing to lose sleep over!” I saw his shoulders relax a visible display of tension releasing.

“Thanks. That really helps.”

As he left I thought about the multiple times in the past that I had not had this conversation, about how many patients had walked out of the room with correct treatment but their major question unanswered. Uneducated in the mechanisms of disease, many patients don’t know which of their symptoms are serious and which are not. When confronted with any change in how they feel, especially a change they have never known about or heard about before, they often think of the worst. Fears of cancer, tumor, serious disease and mortality can often accompany mild illnesses. Doctors, whose medical knowledge allows them to dismiss such fears in an instant, can easily forget that these fears are intense in the minds of their patients. The result is patients who have correct care but still leave the office afraid.

As I reflected on this patient I was reminded of the words of the Apostle John, “Perfect love drives out fear.” As a man of faith, I am called to love the people God brings into my life. If I love, then the fear of others matters. Whenever possible, whenever it is in my power, I need to do my best to address these fears. While John’s words were addressing the truth that the perfect love of God means that His followers need not fear His judgment, I believe the application still applies. I need to reflect the love of God towards others. When I do, people's fears will be addressed and often eliminated.

This truth is not limited to doctors. Incomplete understanding can lead to fear in any circumstance. For me, my lack of expertise in things mechanical can lead me to worry about noises in my car, sounds in my attic, and smells in my garage. I am always grateful when my mechanics, plumbers and handymen are kind enough to explain what is going on and calm my fears.

My prayer for myself is that I will grow increasingly sensitive to the fears of others with each passing day, and that I will take the time to drive it away.

-          Bart

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