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Top 10 Ways Doctors can Annoy Patients

Someone suggested I was being mean or making fun of patients in my previous post. Those of you who read this blog regularly (aside from needing serious psychiatric evaluation) are aware that I am quite sympathetic of my patients' position in this relationship.  Mine is a position of power, while they are coming to me with an admission of weakness.  There is no doubt that I would rather sit in the doctor's chair than that of the patient - and that's not just because my chair has wheels on it. My intent in writing this blog is to show the doctor/patient interaction through the eyes of a physician - a perspective most people don't get very often.  Even though I have lots to be thankful for in my profession, I still have things that regularly annoy me.  For me to voice that annoyance in a light manner is meant to both educate people of my perspective, and entertain those who share it.

Enough of that.  Now it's time to move on to the strategies we physicians use to get back at patients for their shenanigans.  You may not realize it, but we have a special class in medical school dedicated solely to the ways to annoy and embarrass our patients.  It's an art, really.

Here's my list:

1.  Require ridiculous paperwork

At every visit, a patient should be required to fill out paperwork that captures information that they have provided at every previous visit.  Certainly it makes sense to ask if a person has changed insurance since the last visit, and wanting an updated medication and allergy list is good practice.  The true art, though, is in asking questions like: "Has your mother's maiden name changed since your last visit?" or "Please list all medications (including over-the-counter) that you have taken over the last 3 years?"

2.  Waiting Room Lottery

Being called from the waiting room to the exam room should not depend on when each person arrived; it should be totally random.  Few things frustrate as much as seeing someone who clearly came in after you get called back before you.  It is quite fun to watch the reactions of people when others are called before they are.  Many office staffs take bets on who will be the first to erupt.

3.  Use a complicated and unreliable voicemail system

It is unacceptable for people to be able to actually talk to humans unless they have spent a minimum of 15 minutes meandering through the voicemail system.  The reason for this are as follows:

  1. It weeds out people who aren't all that sick as well as those who are not going to be dedicated patients.
  2. It increases the volume of patients coming in with high blood pressure and ulcers.
  3. It creates a convenient scape goat if anything goes wrong.  "Dang.  It must be our lousy voicemail system again..."

4.  Have unreasonable rules

Patients who are more than 30 seconds late for their appointment must be made to reschedule, and that appointment should be a minimum of two weeks after the missed appointment.  We only hope that patients don't notice it when we are 45 minutes late to see them....  Charging $10 per page for people to get their own records is another way to create fury.  It's good fun.

5.  Use the scale strategically

The scale in a doctor's office is a powerful weapon that should be wielded with skill.  Many patients are as nervous to stand on the scale as they are coming to the doctor in the first place.  Increasing weight should always lead to a lecture about the dangers of obesity, and the weight on the scale should always be set to read at least 10 pounds more than is accurate.  Having the scale in a public place or having a staff member with a very loud voice can increase the trauma the scale can inflict.  Always check blood pressure immediately after weighing the patient, as the inevitable high reading can give extra fodder for lectures on the dangers of obesity.

6. Lecture

"Do you realize smoking is bad for you?"  That is one of my all-time favorites.  It assumes that the patient has missed the news about cigarettes not being a fountain of youth.  Perhaps they haven't discovered that newfangled invention called television.  But lectures about the dangers of cigarette smoking, heavy drinking, or poor eating habits should not happen once - most patients expect that to happen;  they should be given every visit, even the ones that have nothing to do with these vices.  Have a foot fungus?  Expect a lecture about not exercising.

7.  Look frazzled

Some doctors are masters at always entering a room looking harried and rushed, which makes the patient feel guilty about burdening the doctor any more.  It really is bothersome for these patients to come with so many problems.  Giving a pained expression when the person starts talking about things is sure to shorten the visit.  So what if they are paying to be seen, the doctor is having a bad day and they should be nice to him!

8.  Don't explain much

Prescribing medications or ordering numerous tests is part of the job.  We are paid to make all the decisions and patients should trust us!  Why should we have to explain to our patients why they should take the medication we give?  Why should they know the purpose of having a cholesterol rechecked every 3 months?  Leaving patients a little unsure about why tests are ordered will keep them from asking those pesky questions about interpretation.  Just tell them that "it looks fine" and that should be enough.

9.  Tell them there is "nothing wrong"

The baby was up all night screaming with a temperature up to 103.  Yet when they come into the office, the child looks fine and is sleeping...like a baby.  The best response from the doctor is to look at the parent with a "Why did you bring a healthy child in to see me?  Why are you wasting my valuable time?" expression.  Look the child over and declare the child healthy.  The fever and screaming are probably things the parents just made up to get attention; either that or they were hallucinating.

10.  Always somehow relate their condition to a mental health issue

Relating all problems to depression or "stress" is a great way to put patients in a difficult position.  Assuming it before any tests are run is even better.  "I know how hard things have been for you over the past few months" is a good way to get things going.  The chest pain is probably hysteria of some sort and a good prescription of Zoloft will clearly make things get better.  This allows everything the patient says to be taken lightly, as it all represents part of their defense mechanisms in dealing with their mental problem.

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This was actually a little harder to write than I expected.  I didn't want to sound too harsh or cynical, but it kept coming out that way.  I am sure many people will have more to add.  I really do think there is a long legacy of doctors being in charge of the relationship and so abusing their status to patronize patients.  Thankfully, this is a legacy of the past and is hopefully becoming less common.  I do still, however, hear things that doctors do that make me wince with a disturbing frequency.

For all of the idiot doctors out there I offer my deepest apologies.  Don't take it.  Leave them and put them out of business if they don't clean up their act.

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Top 10 Ways to Annoy Your Doctor

Top 10 lists are back! I forgot about this kind of post, and a reminder by a reader is bringing them back.  They are really a fun and easy kind of post to write, so you may see a fair number of them (read: Rob is getting lazy).  I thought I’d start back with some suggestions for disgruntled patients (or grutled ones, for that matter) to make their doctor’s day much worse.

1.  Require the doctor to keep things secret from your child or your elderly parent. Insist that they can’t know about their cancer, depression, ADD, or foot fungus.  Call the medication the doctor prescribes “vitamins.”  Alternatively, you can threaten your child by saying that if they don’t behave better, the doctor will give them a shot.

2.  Disguise the real reason for your visit with something simple. For example, if you have depression or chest pain, set up an appointment for a sore throat.  Make sure you leave all of the office staff in the dark as long as possible.  It’s a bonus if you end the office visit asking them to check your hemorrhoids or help with a certain discharge you have been having.

3.  Call your children nicknames that have nothing to do with their real names. Let’s say you have a son named “James Wadkins Smith”; you should call them “Trent” or “Flippy.”  A daughter named “Anna Rose Jones” can go by “Jenny” or “Eva Marie.”  You get extra points if you change what you call them every few months.

4.  Smoke a pack of cigarettes or several cigars just before going to the doctor’s office. Then when you are asked if you smoke, say you don’t.

5.  Ask for doctor’s notes for anything. If your car doesn’t start and you miss work, call to get a doctor’s note.  If you don’t like fluorescent lighting and want incandescent lights at work/school, ask your doctor to write a letter stating that this is a medical necessity.  Asking for a few days off of work because of “stress” is sure to have the desired effect.

6.  If you are an employer or school district, make your employees or students get documentation for every single sick day. Make the docs fill out FMLA paperwork for sinus infections, and disability forms if it lasts more than 2 days.  School districts should require a detailed asthma management plan on all patients with asthma.

7.  Call frequently stating that you have a personal issue you need to discuss with the doctor, refusing to talk to anyone else. It’s best to call the office acting like you know the doctor well, referring to them by their first name.  When you do get the doctor on the phone, start talking about your anxiety, depression, or bowel problems.

8. Send your teenage son or elderly parent with dementia to the office alone. Make sure you don’t leave any contact numbers and don’t tell the boy what you are sending him to the doctor for.

9. Invite friends and family. Having as many people in the examination room as possible is the goal.  Having young children with ADHD is the ideal.  Think clowns in a Volkswagen.

10. Bring your spouse or child to the office so the doctor will convince them that you are right. Open hostile arguments are important for the doctor to see just how wrong they are.  Make it clear to your family member that the doctor is against them.

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How to Bug a Doctor

Mad at your doc?  Frustrated at being made to wait?  Allow me to let you in on ten secret ways to really get under your doctor's skin.  These tried and true techniques are sure to bring down even the best meaning physician.

  1. sleepyTalk about your cousin who is also their patient, but don't ever say their name.  This is even better if you don't have a cousin.
  2. Call all of your children by names that have nothing to do with their first, middle or last names.  For instance, if your child's name is "George W Bush", call them "Sally-Jo."
  3. If you hurt your left hand or have a pain in your left ear, alternate saying "left" and "right."  When he asks, get annoyed like you are saying the same side.
  4. Page her at 2 AM to ask for something to help sleep.
  5. Body fluids.  Bring them in by the gallon.
  6. Call in for refills on medications you have not taken for 2 or 3 years.
  7. 95029222qu3Go to the local child rental agency and rent 3-4 preschoolers to have in the exam room with you.  Make sure to give them plenty of caffeine.
  8. Circle every item on the review of systems, as at some time in your life, you have had those symptoms.
  9. Have your teenage boy capable of only mumbling "uh-uh-oh" (I don't know) and "nuh-un" (Nothing) or your grandpa who has fairly advanced dementia come into the office unaccompanied.  Make sure there is no way to reach other family members.
  10. Use lots of Ben Gay.

Take my word for it, these are really tried and true.

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10 Dumb things about Medicaid

I read many rants on Medicare (and write some myself), but what about Medicaid?  To those who don't know, Medicaid is a health insurance plan funded by the federal government, administered by the individual states, aimed at people who are living in poverty.

We accept Medicaid mainly for the kids.  A significant proportion of Children are on Medicaid or other related plans, and so most pediatricians accept it.  A lower percent of family and internal medicine practices accept it (see below).

In general, our practice tries hard not to disrespect our Medicaid patients (as other practices are known to do), treating them the same as our "paying" patients.  Still, while many of the stereotypes about these patients do not apply to every patient, these stereotypes came to be for a reason.  Perhaps it is a minority of the Medicaid population, but it is a substantial minority.

So here is the stupid things about Medicaid.

  1. Reimbursement - I sound like a broken record, but the reimbursement for medicaid is very bad - especially for adults.  With the complexity (both medically and socially) of the adult Medicaid population, it is extremely hard to make ends meet on what they pay.
  2. Different Medicaid for different states - This is bad if, like us, you live on a state line.  You need to deal with totally different plans with their own idiosyncratic rules.  At least with Medicare you need to learn one set of hoops to jump through.
  3. No humans - If you have problems with the way Medicaid does things, you rarely can get a person on the phone.  There are no medical directors to appeal to.  In general, if you have a problem with their decision, you have to live with it.  This is not true with the Medicaid managed care products.
  4. Medicaid Managed Care - Yes, you can get a human, but generally someone who knows only what is in front of them on the computer screen and yet has power to say you are wrong.  They have totally different rules, different formularies, more arduous authorization processes with each of these plans.  We have two of them in our state and it is like having to choose between hanging or being shot.
  5. Drug Seekers - No, not all Medicaid patients are drug seekers, but a disproportionate number of them are.  These people are constantly finding ways to get you to write a controlled drug, often going to other providers when you won't comply.  Drug seekers hurt all Medicaid patients in that they put a cloud of suspicion over any Medicaid patient that seems to be in pain.
  6. ER overuse - The cost to Medicaid patients of going to the ER is the same as it is to go to see you.  Nothing.  This means that far more of them will be willing to take their kid to the ER for an ear infection, even when you have a walk-in clinic they can go to.  This means that you don't know really what medications many of them have gotten, since their care is so fragmented.
  7. Entitlement - The entitlement mentality is one in which the person does not think they should be expected to pay for things.  They are so used to getting a free-ride that they recoil at the idea of paying for things.  I get many requests for prescriptions of OTC medications or cough/cold equivalents that are prescription.  I have to pay for them, why shouldn't they?
  8. Cancellation - Patients can mysteriously be canceled for Medicaid, and have no recourse but to wait until the next month to be reinstated.  This means that we are caught having to decide if we are going to charge normal amounts for these folks with no insurance, hoping when it is reinstated they will pay retroactively; or we try and drag our feet until it is reinstated.  If we do the former, we are stuck with a bill to a person who cannot pay.  If we do the latter, we may harm people.
  9. Formularies - These have gotten out of hand lately.  It used to be that we could write generics and they would all be accepted.  Any of the cheap cough/cold medications would also be paid for without having to hoop jump.  Now they only accept certain generics and pay for certain cold medications.  Often the pharmacist has no list as to what is accepted, and so they have to run one drug through at a time.  It is costing us dollars to save them pennies.
  10. Fear of Audit - Like Medicare, it is a criminal offense to bill incorrectly to Medicaid.  This means that if you don't document exactly to the letter of the law (see Happy for more details on that one), you could be brought up for defrauding the government.  With how little you get paid, it is sometimes not worth the trouble and you just end up down-coding the visit to play it safe.

There are some things I do like about Medicaid.  The drug coverage is much better than Medicare, and they do pay for well care (and at a good rate for children).  But the pains of dealing with it have many providers saying "No" to Medicaid, which is a shame because serving the poor should be the rule for physicians, not the exception.

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Ten Dumb Things About Medicare

  1. Reimbursement - At least in my field, it is nearly impossible to run a practice off of what it pays.  Most physicians who are on Medicare offset its bad reimbursement with private insurance or procedures that are outside of Medicare.
  2. Prevention is discouraged - A person cannot come in if they are well.  They have to develop a disease before being seen.  They tried to fix this with the "Welcome to Medicare Physical," but the rules were so laborious, it is nearly impossible to take advantage of this.
  3. Fraud Accusations - If you do anything that is not by the rules, you are defrauding the government.  This includes choosing to not charge any of your non-Medicare patients.  If I choose to make less money on my poor patients by not charging them I am committing fraud because I am not offering that same discount to my Medicare patients.  Docs routinely down-code notes to avoid coming under scrutiny for fraud.
  4. Part D - The pharmacy benefit has helped some people, but the concept of the "donut hole" has caused many of my patients to go off of medications they need.  The system is so complex with so many Part D plans that I never know if a medication is covered until the patient tries to fill it.
  5. Stupidity - Drug companies give discount cards or coupons to us to give to our patients.  Medicare patients cannot use these cards.  Obviously it is not in anyone's best interest for Medicare patients to pay less for medications.
  6. Balance Billing - We must always accept whatever Medicare says they will pay and not balance bill the patients.  I can't set my prices.  Furthermore, the other insurance companies pin their fee-schedules on Medicare's rates.  There will never be "transparent pricing" as long as this is the case.  We cannot charge what we choose to charge.
  7. The RUC - The RVS update committee sets the Medicare fee-schedule.  It is dominated by specialists, and so it protects the interests of specialists over primary care.  It is so tied to special interest groups that it is hard to believe it is used as an "unbiased" source of advice for the fee-schedule.  Actually, it is a travesty to the system.
  8. Dropping Out - If you drop off of Medicare as a provider, you cannot reapply for 2 years.  This stung us when we tried to hire a physician who had previously dropped off of the list.  He simply could not see our patients.  I am not sure I understand the rationale for this.  Are they just spiteful?
  9. Sustainable Growth Rate - On the surface, this looks OK.  If we can't afford Medicare, it automatically cuts the reimbursement.  The problem is that the cut will be equal across all areas.  This hits primary care extremely hard, making it even more difficult to afford to take Medicare.  Specialists can afford to have office visits reimbursed less because they make most of their money off of procedures.  Are they hurt too?  Yes, but they are not living on the edge like PCP's.
  10. PQRI - The new "pay for performance" system is a mess.  The system is based entirely on billing (by putting in special modifiers when you bill), and reimburses a very small amount.  Plus, you don't ever know how you are doing and whether you will qualify for the bonus.  I look forward to my $30 check...if I get anything.

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