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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Spiritual Outside, Empty Inside

It is not often the big sins that destroy us. Most of us are too proud, too cautious or too concerned with the opinions of others to allow ourselves to fall into the major traps. We would never kill or steal, never physically abuse a child or a spouse and even in our darkest moments would not consider being unfaithful to our spouse. We forget that little sins can be equally deadly. Like slow acting poisons or a chronic disease, they chip away at our spiritual health until our lives are in shambles.

Joe learned this lesson the hard way. He had been married for over 10 years and had what appeared to be a perfect life. He was financially secure, active at church and even gave significant time serving the poor. If there was a goodness list, he seemed to be systematically checking all of boxes. At each visit he about family, church and ministry to the point where I was impressed by his obvious spiritual commitment. It seemed that the right things mattered and that his life was in balance.

It wasn’t. The illusion of success and harmony was shattered by his wife’s decision to leave him. He was committed to church, attended a weekly small group and served in ministry but he was failing in the one area where the Bible gives specific instruction. He wasn’t putting his wife first. The attention, love and devotion that should have been hers was consistently directed outside the home. She grew weary of being ignored and set aside, ultimately reaching the point where she decided she couldn’t take it anymore.

Her decision pulled back the curtain on his life and revealed him for the man he truly was. The external man visible to the world, active in church and talking about spiritual things, was just that, external. His motive for service was the way it made him feel and they way others viewed him. He made a show of grand acts of service but the simple essentials of being a good man at home were ignored. The smaller, unseen sins of selfishness and neglect of his wife went unaddressed and eventually brought him down.

His story reminds me that this is a common problem in our culture today. Our interactions with one another are brief and our conversations shallow. We define goodness and spirituality by readily observable actions and activities- Good people go to church, really good people attend a small group or a Bible study, and Godly people give a few hours a week to the poor. The reality is that these activities do not require goodness and do not require significant change in our hearts or attitudes.

Just as physical health is more dependent on daily habits than on a thrice weekly exercise program, spiritual health is more dependent on daily faithfulness than church attendance and small group meetings.

True Christian character is not defined in superficial terms or occasional activity. Godliness is best defined in the drudgery of daily life, in the daily interactions we have with our family, friends and co-workers, in the relationships in which we spend the majority of our time. It is by being faithful in even the smallest details of our lives that our light truly shines the brightest and best and is least likely to fade over time. 

My prayer is that I will be faithful first in those areas of my life that the outside world doesn’t see, in ways my church friends could overlook. May my life be characterized by love, kindness and forgiveness in my home, may I treat my patients and employees with grace and gentleness, may I overlook slights and mistreatment at the hands of others, and as I do, may the character forged in these daily endeavors serve as a foundation for greater service.

-          Bart

The idea of our daily lives and interactions being the way in which we shine the light of Christ to the world was a major them in Jesus’ teaching in the Sermon on the Mount and was the subject of a sermon I shared recently with a church group. You can watch the clip here.

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The Lesser of Two Evils is a False Choice

The king was backed into a corner. His small country, founded on religious principles, was no longer a major force. Unable to protect himself form the powerful nations that surrounded them he felt no choice but to align himself with one of them. The nation was Judah and the king was Jehoiakim. To his north was the Babylonian empire, to the south the Egyptians. Neither of these empires shared the culture or values of his people but his only hope seemed to be aligning with one of them.

Four years earlier it seemed as if the Egyptians were the major force. The Egyptian army had swept through Israel in its way north to challenge the mighty Babylonians in battle. Jehoiakim’s father died in a foolish attempt to halt the progress of the Egyptian army. A short while later the Egyptians joined the Assyrians in battle against Babylon and were defeated. Pharaoh and his army went home defeated. The King of Babylon followed south to Jerusalem and besieged the city, forcing the new king Jehoiakim to surrender.

Since that time Judah had been forced to pay tax and tribute to the pagan nation of Babylon. The burden was great on the people and the city of Jerusalem was divided in its opinions. Some felt Egypt was still its greatest hope, others were persuaded that subjection to Babylon was the only way forwar (perhaps because Babylon allowed them to continue with their own king and customs.) For four years the allegiance to Babylon held sway.

At that time a second battle between Egypt and Babylon led King Jehoiakim to question his loyalty to the Babylonian king Nebuchadnezzar. Nebuchadnezzar’s army had tried to expand its influence further south into Egyptand had been repelled by the Egyptians. Jehoiakim king of Judah again had a choice between two evils. With whom would he align? He chose Egypt, hoping the might of the Pharaoh could save him. It didn’t.

A short while later Nebuchadnezzar returned with his army and laid siege. King Jehoiakim died during the siege and before long the city fell. Nebuchadnezzar and his army took Jehoiakim’s son and thousands of the nation’s best and brightest away into captivity in Babylon. Leaving behind a puppet king to rule in Nebuchadnezzar’s name.

The new king, Zedekiah, did not learn from the mistakes of his predecessor. A new Pharaoh came to power in Egypt, and once again the King of Judah was tempted to change his alliances and allegiance. He too rebelled against Babylon.

Only 4 years after Jehoiakim fell, Nebuchadnezzar and his army arrived again outside the gates of Jerusalem. This time, his wrath was not contained. He laid waste to the city and destroyed the walls and its temple. He killed Zedekiah’s sons right in front of the king and then put out his eyes, making the death of the sons his final visible memory. Judah was no more.

The fall of Judah reminds us of the challenges of choosing unholy alliances. The kings of Judah repeatedly saw only two options available, Egypt or Babylon. Neither option was good, neither nation shared any of their cultural values. One can imagine the debates in the courts of Jerusalem as people argued for one position or the other, trying to point out minuscule areas of good or potential incremental preserving of freedoms as they agonized over which evil was lesser.

They repeatedly out their hopes in powerful Pharaohs, setting their beliefs and values aside in favor of an alliance that might give them the best hope of preserving the greatest portion of the society in which they lived. Egypt may well have been the lesser of two evils, but they were still a bad choice. Judah lost everything.

What makes the story even more tragic is that Judah should have known better. The premise of having to choose between two earthly evils had been proven false many times in their history. Over and over again, their small nation had been threatened with destruction at the hands of overpowering enemies and over and over again they had been delivered, not through allying with another army but by trusting in their God. They should have recognized the false dichotomy. Their choices were not limited to Egypt or Babylon. There was a third way. They could have chosen to turn to God, returned to their values, and stood alone, trusting only in Him.

Modern day American Christians have much to learn from the lessons of Judah. We should resist the foolish claims of those who tell us that we have to choose between two evils. When both choices require us to compromise our values and deny who we are and what we believe, we need to choose the third way. If we do not, we should not be surprised when we find ourselves in trouble.

- Bart

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