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Dr. Rob's Inbox


Dr. Rob's Inbox

I was excited.  Finally I could get my questions answered by America's doctor darling.  Since I know he's a busy guy, I thought I'd need to get his attention. No, I wasn't interested in the miracle antioxidant pill that detoxes my carotid arteries, reprograms my neuronal circuitry, melts away belly fat, and enhances me in the bedroom.  I know about that already.  I've seen his show.

No, my questions were far more important



A Letter to Patients With Chronic Disease

Dear Patients: You have it very hard, much harder than most people understand.  Having sat for 16 years listening to the stories, seeing the tiredness in your eyes, hearing you try to describe the indescribable, I have come to understand that I too can't understand what your lives are like.  How do you answer the question, "how do you feel?" when you've forgotten what "normal" feels like?  How do you deal with all of the people who think you are exaggerating your pain, your emotions, your fatigue?  How do you decide when to believe them or when to trust your own body?  How do you cope with living a life that won't let you forget about your frailty, your limits, your mortality?

I can't imagine.

But I do bring something to the table that you may not know.  I do have information that you can't really understand because of your unique perspective, your battered world.  There is something that you need to understand that, while it won't undo your pain, make your fatigue go away, or lift your emotions, it will help you.  It's information without which you bring yourself more pain than you need suffer; it's a truth that is a key to getting the help you need much easier than you have in the past.  It may not seem important, but trust me, it is.

You scare doctors.

No, I am not talking about the fear of disease, pain, or death.  I am not talking about doctors being afraid of the limits of their knowledge.  I am talking about your understanding of a fact that everyone else seems to miss, a fact that many doctors hide from: we are normal, fallible people who happen to doctor for a job.  We are not special.  In fact, many of us are very insecure, wanting to feel the affirmation of people who get better, hearing the praise of those we help.  We want to cure disease, to save lives, to be the helping hand, the right person in the right place at the right time.

But chronic unsolvable disease stands square in our way.  You don't get better, and it makes many of us frustrated, and it makes some of us mad at you.  We don't want to face things we can't fix because it shows our limits.  We want the miraculous, and you deny us that chance.

And since this is the perspective you have when you see doctors, your view of them is quite different.  You see us getting frustrated.  You see us when we feel like giving up.  When we take care of you, we have to leave behind the illusion of control, of power over disease.  We get angry, feel insecure, and want to move on to a patient who we can fix, save, or impress.  You are the rock that proves how easily the ship can be sunk.  So your view of doctors is quite different.

Then there is the fact that you also possess something that is usually our domain: knowledge.  You know more about your disease than many of us do - most of us do.  Your MS, rheumatoid arthritis, end-stage kidney disease, Cushing's disease, bipolar disorder, chronic pain disorder, brittle diabetes, or disabling psychiatric disorder - your defining pain -  is something most of us don't regularly encounter.  It's something most of us try to avoid.  So you possess deep understanding of something that many doctors don't possess.  Even doctors who specialize in your disorder don't share the kind of knowledge you can only get through living with a disease.  It's like a parent's knowledge of their child versus that of a pediatrician.  They may have breadth of knowledge, but you have depth of knowledge that no doctor can possess.

So when you approach a doctor - especially one you've never met before - you come with a knowledge of your disease that they don't have, and a knowledge of the doctor's limitations that few other patients have.  You see why you scare doctors?  It's not your fault that you do, but ignoring this fact will limit the help you can only get from them.  I know this because, just like you know your disease better than any doctor, I know what being a doctor feels like more than any patient could ever understand.  You encounter doctors intermittently (more than you wish, perhaps); I live as a doctor continuously.

So let me be so bold as to give you advice on dealing with doctors.  There are some things you can do to make things easier, and others that can sabotage any hope of a good relationship:

  1. Don't come on too strong - yes, you have to advocate for yourself, but remember that doctors are used to being in control.  All of the other patients come into the room with immediate respect, but your understanding has torn down the doctor-god illusion.  That's a good thing in the long-run, but few doctors want to be greeted with that reality from the start.  Your goal with any doctor is to build a partnership of trust that goes both ways, and coming on too strong at the start can hurt your chances of ever having that.
  2. Show respect - I say this one carefully, because there are certainly some doctors who don't treat patients with respect - especially ones like you with chronic disease.  These doctors should be avoided.  But most of us are not like that; we really want to help people and try to treat them well.  But we have worked very hard to earn our position; it was not bestowed by fiat or family tree.  Just as you want to be listened to, so do we.
  3. Keep your eggs in only a few baskets - find a good primary care doctor and a couple of specialists you trust.  Don't expect a new doctor to figure things out quickly.  It takes me years of repeated visits to really understand many of my chronic disease patients.  The best care happens when a doctor understands the patient and the patient understands the doctor.  This can only happen over time.  Heck, I struggle even seeing the chronically sick patients for other doctors in my practice.  There is something very powerful in having understanding built over time.
  4. Use the ER only when absolutely needed - Emergency room physicians will always struggle with you.  Just expect that.  Their job is to decide if you need to be hospitalized, if you need emergency treatment, or if you can go home.  They might not fix your pain, and certainly won't try to fully understand you.  That's not their job.  They went into their specialty to fix problems quickly and move on, not manage chronic disease.  The same goes for any doctor you see for a short time: they will try to get done with you as quickly as possible.
  5. Don't avoid doctors - one of the most frustrating things for me is when a complicated patient comes in after a long absence with a huge list of problems they want me to address.  I can't work that way, and I don't think many doctors can.  Each visit should address only a few problems at a time, otherwise things get confused and more mistakes are made.  It's OK to keep a list of your own problems so things don't get left out - I actually like getting those lists, as long as people don't expect me to handle all of the problems.  It helps me to prioritize with them.
  6. Don't put up with the jerks - unless you have no choice (in the ER, for example), you should keep looking until you find the right doctor(s) for you.  Some docs are not cut out for chronic disease, while some of us like the long-term relationship.  Don't feel you have to put up with docs who don't listen or minimize your problems.  At the minimum, you should be able to find a doctor who doesn't totally suck.
  7. Forgive us - Sometimes I forget about important things in my patients' lives.  Sometimes I don't know you've had surgery or that your sister comes to see me as well.  Sometimes I avoid people because I don't want to admit my limitations.  Be patient with me - I usually know when I've messed up, and if you know me well I don't mind being reminded.  Well, maybe I mind it a little.

You know better than anyone that we docs are just people - with all the stupidity, inconsistency, and fallibility that goes with that - who happen to doctor for a living.  I hope this helps, and I really hope you get the help you need.  It does suck that you have your problem; I just hope this perhaps decreases that suckishness a little bit.


Dr. Rob

Post Script: This post has generated a huge amount of conversation and interest (as witnessed by the large number of comments!).  I very much appreciate the dialogue it has spawned both here and across the web.  I've subsequently written follow-up posts explaining my thoughts in more detail - largely in response to the comments here.  One of them discusses in more detail my own experiences as a doctor and the second talks of the importance of  knowing and being known.  Reading these will give you a better picture of my thought process and perspective on this. Dr. Rob



10 Rules for Good Medicine

The recent discussion of the appropriateness of bringing patients back to the office has really gotten me thinking about my overall philosophy of practice.  What are the rules that govern my time in the office with patients?  What determines when I see people, what I order, and what I prescribe?  What constitutes "good care" in my practice? So I decided to make some rules that guide what I think a doctor should be doing in the exam room with the patient.  They are as much for my patients as they are for me, but I think thinking this out will give clarity in the process.

Rule 1:  It's the Patient's Visit

The visit is for the patient's health, not the doctor's income or ego.  This means three things:

  1. All medical decisions should be made for what is in their interest, including: when they should come in, what medications they are given, what tests are ordered, and what consults are made.
  2. Patients who request things that are harmful to themselves should be denied.  People who ask for addictive drugs or unnecessary tests should not get them.  Patients who are doing harmful things to themselves should be warned, but only in a way that is helpful, not judgmental.
  3. All tests done on the patient should be reported to them in a way that they can understand.

Rule 2:  Minimize

Many doctors and patients have a "more is better" mentality.  This not only costs more money to the system, but it can cause harm to the patient.  Here's what I think should be done:

  1. Patients should only be seen when a visit is appropriate.
  2. Use as few medications as possible, and when necessary, use the cheapest one that will do the job.
  3. Order as few tests as possible.  No test should be ordered for informational purposes only; the question, "What will I do with these results?" should always be answerable.  If it is not, the test should not be done.
  4. When changes are made, make only a few at a time.  Many simultaneous changes make it hard to tell what helps and what hurts.

Rule 3: Relationship = Better Care

Relationship is one of the best tools for achieving optimal care.  This means that the patient knows the doctor and trusts them, and the doctor knows the patient.  This does not happen with sporadic care, but instead with consistent, long-term care by one provider.  The result of this includes:

  1. Patients with long-term significant medical problems should come in on a routine basis.
  2. The best-case scenario for regular visits is that there are no medical problems, in which case the visit will be mainly social.
  3. There is a medical benefit to the social visit, with the doctor understanding the patient better and the patient trusting the doctor more.
  4. There are frequent cases where the patient doesn't think there is something wrong, but a regular visit reveals either serious problems, or allows intervention to prevent a serious problem.

Rule 4: Keep Priorities Straight

When a patient comes in with a problem, there are three goals:

  1. Rule out bad things
  2. Make the problem better
  3. Make a diagnosis

#'s 1 and 2 are of equal importance, with #3 a distant third.  This means that you always should address the fear that caused them to come to be seen (e.g. patients with chest pain should be reassured it is not the heart, if possible).  But stopping with #1 is unacceptable; #2 must be done as well.  Sick people want to feel better, and it is the doctor's job to try to accomplish this.

Rule 5: There is ALWAYS a Reason

It's very easy to actually believe that people's actions revolve around you when you are a doctor.  It's not only human nature to take this view, it's a natural response to the stress and pressure of the job.  But there are bad consequences to this state of mind:

  • If you can't figure out why people come in, then they are just wasting your time
  • If you can't make sense of symptoms, then they are not telling the truth
  • If a person is acting in a way that is irritating and annoying, they are doing so by choice to bother you
  • A person who seems emotionally weak is that way by choice

Avoiding these assumptions will make care better, both in the ability to see things objectively and to offer care and compassion.

Rule 6: If the House is Burning Down, Don't Cut the Lawn

Focus is one of the most important things in an office visit.  Both doctors and patients can lose sight of the purpose of the visit. I use this line whenever someone asks me about minor issues in the face of bigger things.  Weight loss may be important in the long run, but it is not pertinent when a person is in the office with a heart attack.

There are no quick fixes or magic wands.

Rule 7: Compliance follows Communication

I have a hard time remembering things, so I am not surprised when my patients aren't compliant.  In my experience, it is far easier to remember things I think will benefit me.  My job is to help my patients with this, not seeing perfect compliance as the norm.  The best way to do this is to communicate.  I need to communicate in a way that doesn't just convince them of my opinion, but gives them reason to change theirs.  This means that I need to know what they think is important (by listening) and then find a way to turn that into motivation.

100% compliance is not expected, but it is nice to see motivated patients; it's my job to encourage, not judge.

Rule 8: People Come to the Doctor's Office

When people come to see me, they interact with more than just me; they interact with my staff.  They deal with our system that we have set-up, good or bad.  A bad experience in the office usually has nothing to do with the quality of medical care, it usually is because of a poorly run office encounter.

A big part of taking care of patients is running the office efficiently (which was one of my biggest frustrations in a practice run by the hospital - they didn't care about the patient encounter, they cared about the referrals).  This takes a lot of work that doesn't seem to be reimbursed and doesn't seem pertinent to medical care, but patients who are frustrated and upset don't listen as well, and frustrated healthcare workers don't give as good of care.

Rule 9: The Buck Stops Here

I believe in primary care.  I believe it is I am the one who my patients call "my doctor," and I see this as a big responsibility.  I need to know as much about them as possible, getting information from anywhere else they get medical care.  My problem and medication lists need to be as accurate as possible.

I am advocate, doing what is in the best interest of the patient, not the drug companies, hospitals, or specialists.  I am confidante, listening to anything the person has to bring to me and knowing as much about them as anyone on the planet.  I am advisor, collecting medical information and giving them an opinion as a trusted person with their best interest in mind.  I am comforter, shutting up and listening when that's appropriate to do.

Rule 10: Enjoy the Good Stuff

There's a lot to complain about in our system.  There are a ton of stressful things and a lot of bad stuff we see.  The simple fact that so many of us keep going back to work is witness to a lot of benefits.  Remembering what's good about being a doctor is key to maintaining the energy to face the rest.  Here are some of my favorite things:

  • I have a lot of patients who I really like, enjoying my interaction with them.
  • I see a lot of inspiring people, getting up when they are knocked down time after time.
  • I get to play with babies and tickle kids (and get paid for it!).
  • I save people's lives and make them feel better.
  • I get to say the right thing at the right time, really making a difference when it counts.
  • People openly tell me how much they appreciate what I do.
  • I work with a bunch of folks who are good to be with and like-minded in their desire to help our patients.

These things are what get me up in the morning.  They are what make dealing with insurance companies, stupid government policies, and rude doctors and patients possible.  They are the balance to the suffering and pain I see.  No, they greatly outweigh all of that stuff.  Really.  I wouldn't do the job if that weren't the case.



Coding A Morning


Alarm goes off.  Hit snooze button. CIRCADIAN RHYTHM SLEEP D/O IRREG SLEEPWAKE TYPE ICD-327.33


  • Alarm goes off for third time.  Ready to hit snooze button, but knee in ribs from wife prevents more snooze button procrastination.  CONTUSION OF CHEST WALL ICD-922.1, ADULT MALTREATMENT UNSPECIFIED NEC ICD-995.8
  • Feeling tired, go to make a pot of coffee. CAFFEINE ADDICTION ICD-304.40
  • Fill bowl with Lucky Charms and start eating. UNSPECIFIED NUTRITIONAL DEFICIENCY ICD-269.9, HYPERGLYCEMIA ICD-790.29


  • Realize that coffee pot needs to be turned on for it to make coffee. ATTENTION DEFICIT DISORDER, ADULT ICD-314.00, LISTLESSNESS ICD-780.79
  • Turn coffee pot on and wander to check email, blog, Twitter, Facebook, etc. OBSESSION ICD-300.3
  • Daughter wanders in with dazed expression and blanket draping shoulders.  STUPOR ICD-780.09
  • Speaks only in soft, irritated grunts. SELECTIVE MUTISM ICD-313.23, E/M 99212 ENCOUNTER, ESTABLISHED, BRIEF


  • Bring cup of coffee to wife in bed.  She moans when she looks at the clock.  Another morning headache.  E/M 99215, ENCOUNTER, ESTABLISHED, HIGH COMPLEXITY; OTHER COMPLICATED HEADACHE SYNDROME ICD-339.44, OTHER SPEC MENOPAUSAL&POSTMENOPAUSAL DISORDER ICD-627.8
  • Wake up other children who return evil glares for gentle nudging.  CHILD EMOTIONAL/PSYCHOLOGICAL ABUSE ICD-995.51; E/M 99214, ENCOUNTER, ESTABLISHED, MODERATE COMPLEXITY
  • Walk to shower and get frustrated at towels not hung up. ANGER ICD-312.00


  • Shower, shave, and get dressed.  LACERATION, FACE ICD-873.40
  • Walk downstairs to find kids sulking and wife frustrated.  UNDERSOCIALIZED CONDUCT D/O UNAGRESSIVE UNSPEC ICD-312.10
  • Say: "We have to leave in five minutes!" in an angry voice.  PROBLEMS WITH COMMUNICATION ICD-V40.1



  • Finally in car with daughter, driving to school.  CRITICAL CARE INTERFACILITY TRANSPORT EA 30 MIN CPT-99467
  • Daughter still not talking more than mumbles.  OBSERVATION CHILDHOOD/ADOLES ANTISOCIAL BEHAVIOR ICD-V71.02
  • Turn on iPod and play music daughter doesn't like.  PASSIVE-AGGRESSIVE PERSONALITY DISORDER ICD-301.84


  • Daughter dropped off, running frantically to not be tardy.  Angry that "we are always late."  UNSPEC EMOTIONAL DISTURBANCE CHLD/ADOLESCENCE ICD-319.3
  • Don't attempt to explain that it is seldom the chauffeur's fault.  HEARTBURN ICD-787.1
  • Nod and smile.  FEAR OF WOMEN ICD-300.29
  • Drive to work.  AGGRESSION ICD-312.00



  • Arrive at work, greeted by a long list of unsigned charts that materialized mysteriously overnight.  DEPRESSION, SITUATIONAL, ICD-300.4
  • Go to kitchen and pour another cup of coffee - mega jumbo size.  CAFFEINE EXCESS ICD-305.90
  • First patient status is "arrived" even though appointment is for 8:45.  Sigh loudly.  AVOIDANT PERSONALITY DISORDER ICD-301.82
  • Check email, blog hits.  DEPENDENCE ON OTHER ENABLING MACHINE ICD-V46.8


  • See patients, answer phone messages, assess lab and x-ray results, and periodically check email, blog, etc. ADVERSE EFFECTS OF WORK ENVIRONMENT ICD-V62.1,
  • Talk with drug reps who explain advantages of drugs which have been out for many years. AMNESIA, PSYCHOGENIC ICD-300.12; E/M 99213 ENCOUNTER, ESTABLISHED, LOW COMPLEXITY
  • Get another mega jumbo cup of coffee. PREMATURE ATRIAL CONTRACTIONS ICD-427.61;  POISONING BY CAFFEINE ICD-969.71; EROSIVE GASTRITIS ICD-535.40

Note: This is a caricature, not my real life.  My wife and kids are generally very nice to me and I do like my work.



Radical Moderation

I am a flaming moderate.  Yes, I know that is an oxymoron but the fact remains that I am both passionate and moderate in my political opinions. And I am in the mood to rant, so beware.

Living in the deep south, I often seem like a radical communist to those I see.  I frequently get patients asking questions like "So what do you think about Obama's plans to socialize medicine?", or "I wanted to get in here before Obama-care comes and messes things up."  I usually smile and nod, but find myself getting increasingly frustrated by this.

The house is burning down, folks.  Healthcare is a mess and desperately needs fixing.  How in the world can someone cling to old political yada-yaya-yada when people are dying?  I am not just talking about the conservatives here because to actually fix this problem we all have to somehow come together.  A solution that comes from a single political ideology will polarize the country and guarantee the "fix" to healthcare will be one constructed based on politics rather than common sense.

No, this doesn't frustrate me; it infuriates me.  The healthcare system is going to be handed over to the political ideologues so they can use it as a canvas for their particular slant.  In the mean-time, people are going to be denied care, go bankrupt, and die.  Yes, my own livelihood is at stake, but I sit in the exam room with people all day and care for them.  I don't want to be part of a system that puts ideology above their survival.

So here is what this radical moderate sees in our system:

  1. The payment system we have favors no one. Every single patient I see is unhappy with their health insurance to varying degrees.
  2. Stupid and wasteful procedures shouldn't be reimbursed. This is business 101; if you don't control spending, you will not be able to sustain your system.  This means that we have to stop paying for procedures that don't do any good.  Some will scream "rationing" at this, but why should someone have the right to have a coronary stent placed  when this has never been shown to help?  Why should we allow people to gouge the system for personal gain in the name of "free market"?  I got a CT angiogram report on patient today who has fairly advanced Alzheimer's disease.  I twittered it and the Twitter mob was not at all surprised.  These things happen all the time.  The procedures do no good and cost a bundle.  The procedure done today probably cost more than all of the care I have given this patient over the past 5 years combined!
  3. The government has to stop being stupid. Why can't I give discount cards to Medicare patients?  Why can't I post my charges, accept what Medicare pays me, and then bill the difference?  The absurdity within the system is probably the best argument against increased government involvement.  Who invented the "welcome to Medicare physical??"  I never do it because the rules are utterly complex and convoluted.  If the rules can be this crazy now, how much worse will it be when the government takes over?  If my medicare patients are confused now, how much more will we all be if the government grabs all of the strings?
  4. The money is going somewhere. In the past 10 years, my reimbursement has dropped while insurance premiums have skyrocketed.  There are more generic drugs than ever and I am no longer able to prescribe a bunch of things that didn't get a second-thought 10 years ago.  Hospitals stays were longer and procedures were easier to get authorize.  So where is the money going?? We do know the answer to this question - there is no single culprit.  Drug companies were to blame for a while, but now they are going to the dogs; and yet the rates aren't dropping.  The real problem is that there are far too many people trying to capitalize on the busload of money in healthcare.  Shareholders, CEO's, and simple corporate greed has bled money out of the system like a cut to the jugular.
  5. Docs have to stop being idiots. We like our soap boxes to rant against EMR, malpractice lawyers, drug companies, and insurance companies.  We stand on different sides yelling our opinions but don't come up with solutions.  Instead of doing what is right for our patients, we join the punching match of politics.  Is EMR implementation important?  Duh!  There is no way to fix healthcare without it.  But the systems out there are designed by engineers and administrators and don't work in the real life.  So why can't we computerize ourselves?  Every other industry did.  Why must we cling to the archaic paper chart because we don't like the EMR's out there?  Aren't we smart people?  Aren't we paid to solve problems?  Stop throwing darts and start finding solutions.  Med bloggers are terrible in this - they rant constantly against EMR, but don't ever say what would work.  It's fun to criticize, but nobody wants to propose an alternative.
  6. We need to get our priorities right. Healthcare is about the health of the patient.  Yes, it is a job for a lot of people.  Yes, it is an investment opportunity.  Yes, it is a good thing to argue about - whether it is a "right" or not.  Yes, it is a major political battleground.  But in the end, these things need to be put behind what is most important.  As it stands, we are more passionate about these other things than we are about the people who get the care.  In the end it is about making people well or keeping them that way.  It is about saving lives and letting people die when it is time.  If we were all half as passionate about what is good for patients (and we are all patients) as we are about these other issues, we wouldn't have half of the problems we have.

As a flaming moderate I get to offend people on all sides.  We need to fix our system.  It is broken.  It is not a playground for those who like to argue.  It is not a place to be liberal or conservative.  This is our care we are talking about, not someone else's.  The solution will only come when we all come to the table as potential patients and fix the system for ourselves.

Is it easy?  Heck no.  This rant is not meant to show I am smarter than the rest of you; it is meant to get all of us away from the other issues that make any hope of actually fixing our problem remote.  Given the fact that we all are eventually patients, our political posturing and plain stupidity may come back to haunt us.  No, it may come back to kill us.



Re-Post: Pay 4 What you Will

Since many of my readers are newer, they may not have gone through all of my old posts (if you did, I give you my deepest condolences).  For this reason, I am re-posting some of my favorite oldies. The following appeared in October 2007.

The payment system in the US is complex. There are multiple payers, uninsured patients, concierge care, CMS, e/m coding, CPT, ICD-9 (soon to be 10), EMR, CPOE, and a multitude of other nuances that make the alphabet soup of American medicine. Confused by it all? You are not alone. It seems that solutions to the current mess just make the situation more of a mess.

Perhaps the hottest topic in medicine is Pay for performance (P4P). While P4P has gotten lots of attention, as well as taking much fire from critics, it is not the only way to pay physicians. To help you through the quagmire I have set up a table of some of the more common forms of payment:

Acronym What it stands For What it looks like in Real Life Pay
P4P Pay for Performance Paying money to doctors for meeting certain "performance" criteria (such as preventive care or diabetes care ??
P4SLOP Pay for Seeing Lots of Patients The current form of medical reimbursement for primary care. The more people you see in less time, the better paid you are. (AKA PM4L- Pay More For Less) $$
P4PREP Pay for Performing Really Expensive Procedures Another means of making money in the current system. This accounts for the high pay of may subspecialists $$$$$
P4SCOOP Pay for Steering Clear of Objectionable Procedures How to deal with managed care. If you stay away from unauthorized procedures, your staff can do more important things than sit on the phone talking to an elf in front of a computer $
P4TOPTAR Pay for Treating Only Patients That Are Rich Concierge medicine. Charging a large fee for patients to get "access" to care. Then offer these "select" patients a level of care that the general population cannot get. $$$
P4PIE Pay for Placating Insecure Egos Cosmetic Surgery $$$$$$$$
P4ALH Pay for Avoiding Living Humans Pathology $
P4SCP Pay for Solving Crossword Puzzles Anesthesia $$$$
P4SPA Pay for Soothing Parental Anxiety Pediatrics $
P4KBH Pay for Keeping Banker's Hours Radiology $$$$
P4POOP Pay for POOP Gastroenterology $$$$
P4PEA Pay for PEA Urology/Neprhology $$$$/$$
NP No Pay Psychiatry NA

Do you have more? I would like to hear other payment criteria I have missed.



It's not our Fault

Dear Patients: I know you get frustrated with our office.  We make you come in for visits when you think we should handle things over the phone.  We seem more focused on your chart sometimes than on you.  Sometimes you may even wonder if money has become more important than patients. 

To this, I say: I'm Sorry.  It's not our fault. 

We are part of an insane system that requires us to do things in a way that makes life harder for us both.  We would love to practice medicine differently, but we simply can't.  Here are some examples:

1.  Making You Come in All The Time

I would love to handle your simple problems on the phone or via e-mail.  The problem is that if I do this, I am giving free care for which I am liable.  People are being sued for nearly everything.  If we give you a medicine without seeing you, we are actually more at risk than if you come in.  Plus, the only way we can get paid is to bring you in.  Insurance won't pay me for handling your problem any other way.  Even if we both agreed, we couldn't have you pay for a phone call or e-mail, because we would be breaking our contract with our insurance company.*

2.  Not ever giving discounts

If I choose to give you a break and not charge you for a visit, I am being nice. Right?  Well, according to our government, I am actually committing fraud.  That's right, fraud.  You see, I can't offer anyone a discount that I don't offer to Medicare patients; and not charging you would mean I have to not charge my Medicare patients.  Ridiculous, isn't it?

3.  Getting lost in notes

Why do we spend so much time taking notes and not talking to you?  Is it so that we can do better medicine?  No, we actually think that all this charting is stupid too.  The problem is that we don't get paid to see you, we get paid to chart about you.  We are paid based on a complex set of rules of documentation and if we are able to document more, we are paid more.  If we cut corners so we can spend time with you, we are again viewed as committing fraud.

4.  Obsessing about money

When you get your bill from us, you may wonder what all those charges are.  And why are we forcing everyone to pay up front and sending people to collections?  The problem is, while healthcare insurance premiums have gone up and inflation has raised everyone's cost of living, our reimbursement has dropped.  We get paid less and less for taking care of you, so we have to become much stricter in how we run our business.  The practice of medicine has turned into the business of medicine.  We didn't do that, nor do we like it.  But we have to stay in business, so we do what we must.

5.  Not seeing you in the hospital

It seems like the time you most need your primary care doctor is when you are in the hospital, yet we don't see adult patients in the hospital.  Believe me, we hate that as much as you do.  It is very hard to give your care over to others who see you as "another patient."  They don't know your history like we do and are often too busy to answer your questions.  We try to communicate with them, but it is just a hard thing to do.

The problem is that we can't afford to see patients in the hospital.  The amount of time it takes for the money we get is just not worth it.  It came down to what was the least-bad thing to do: stop seeing patients in the hospital, see our families less, or see our salaries drop.  As PCP's we are not paid enough to let our salaries drop, so we chose our families.  It was one of the hardest choices we ever made.

6.  Acting paranoid

Why does the nurse always tell you to go to the ER when there is even a small chance there may be a problem?  Why are you treated like a criminal if you ask for pain medications?  The answer?  Lawyers.  Lawsuits are so rampant in our culture and so it makes us practice "defensive medicine."  This means that we can't do what makes sense, we must do what minimizes risk. 

And if we are ever thought to be giving pain medications too liberally?  We can lose our licenses and even go to jail.  It's a dangerous business we are in, but we don't want to do anything to make it more dangerous.


I am truly sorry for the state of things as they are.  Perhaps better days are ahead of us.  Some politicians are actually talking about paying primary care doctors more.  Some people are suggesting that they stop paying just based on charting, but actually reward better work.  And some people are even talking about limiting malpractice rewards. 

These all sound promising, but remember who it is that is making the decision:  It isn't the doctor or the patient, the two people who the whole thing is about; it is the politicians, bureaucrats, and insurance companies controlling this stuff.  Unfortunately, with them in charge it is probably not wise to hold our breath.

Stay healthy, and have a great day!


Dr. Rob

*In response to some of my comments here, some insurance companies do pay for this type of visit.  We are allowed to charge people and even collect with private insurance, but few (we have found) pay for them.  If we charge Medicare and Medicaid patients, we not only won't get paid, but it would be illegal to collect the unpaid balance from the patient (even if they agreed to pay it).



House of Cards

houseofcards I was sitting in a conference recently;  the speaker was talking about the Medical Home and how one practice was getting nearly $150K for managing a patient population using a new computerized tool.  Sounds good. During the question and answer period I asked the speaker:  "Shouldn't we wait until insurance companies are willing to pay for this before adopting it?  If we start giving this care on our own, what motivation will they have to pay us for doing it?"

The speaker smiled and agreed that the "market would have to mature" before this technology could be adopted.  If we do adopt too soon, we run the risk of giving higher quality for nothing.  We do extra work - above and beyond what we are doing now - and do so "for the good of the patients."  Yet while the patients and payers benefit, our hourly rate goes down.


Here is a technology that improves care and potentially saves lives, and yet we are waiting for a good business case to do it.  Only in America.

A physician came up to me after the talk and said, "No matter what happens, we physicians are going to get screwed."

That is the climate we practice in.  Morale has never been lower among physicians.  We are all tired of bearing the responsibility for change without sharing in its fruits.  Any new program that comes along is suspect.  Where's the catch?  How is this "great new idea" going to lower my bottom line?

Why can't we just get paid for doing a better job?

Let me make this clear:  I do whatever I can to maintain the best quality care for my patients as is possible.  I am proud of the quality I do.  Our practice has actually surpassed most reported quality numbers by far.  We do well despite this climate.  But the rank-and file physician is frustrated with having to choose between good care and good business.

I really see an attitude - especially among primary care physicians - of resignation.  I think a bunch of doctors are on the verge of either totally dropping insurance, or quitting medicine altogether.  This will make an already bad situation for patients disastrous.  Sometimes I even wonder why my practice keeps accepting insurance.  It certainly is not because it is a wise business move.

Note to politicians:  be careful what you do.  A bunch of physicians are hanging by a thread.  They are tired and cynical.  Make the wrong move and the whole house of cards will crash.

Some "insiders" have told me that the folks in Washington really get it, and primary care is about to get a really big boost.  Well, I hope so.  But I am not keeping my hopes too high.  I am planning for the worst.

And I am one of the more optimistic physicians.




Getting along: Part 2 - Patient Rules

I kind of figured that I would not get much disagreement with my previous post (at least from patients).  It is easy for me to criticize my own profession and feel fairly safe, but turning the spotlight on patients makes is riskier. My purpose in writing these posts is to get both sides looking at things through the other's perspective.  In this post I don't want to get patients feeling sorry for doctors; I want them to understand how they can either help or harm that relationship.

So here are the Patient Rules:

Rule 1:  Your doctor can't do it alone

The best doctor can do very little with patients who ignore instructions.  Sometimes noncompliance is partly due to physicians not explaining things well, but medical compliance is ultimately in the hands of the patient.

I am mystified as to why some patients will ignore nearly everything I say and yet continue coming in for regular appointments.  It is frustrating, causing some physicians to get angry with these patients (and even discharge them). I figure it is the patient's dollar that is being spent, not mine.

Going to the doctor has no therapeutic benefit in and of itself.  If you disagree with what is recommended, don't pretend you agree and then ignore your doctor's advice.  I would much rather have a patient tell me "I am not going to take that medication" than have them accept the prescription and not get it filled.  Your doctor prescribes them for you, not for him/herself.

Rule 2:  Be Honest

Webb Nobody likes to look silly.  I think the main reason most people are untruthful is that they are embarrassed about the truth.  But sometimes symptoms are strange, like the man having a heart attack who described it as "a cold feeling when I take a deep breath."  Sometimes symptoms are embarrassing, like a testicular lump.  Sometimes you just don't want to feel like a wimp, so you downplay your pain.

While I can sympathize with this feeling, I don't see any good reason to be anything but truthful with your doctor.  Yes, your symptom might sound strange.  Yes, you may have flubbed up and not followed instructions properly.  Yes, you may be afraid of what some of your symptoms may mean.  But the goal is to fix (or prevent) problems, and trying to do that with bad information is an exercise in futility.

We physicians hear it all.  There are very few things a person can say to me in the exam room that will surprise me.  My job is to help people, not judge them as "weird", "crazy", "wimpy", or "panicky."  Don't worry about making a good impression on your doctor.  Just give the facts.  That will give the best chance to get the desired outcome.

Rule 3:  I don't play favorites

00e7_1_sbl I have over three thousand patients.  I try to do right by all of them.  I build relationships over years and even develop quasi-friendships with some patients.  But I am professionally obligated to keep emotional distance.  Overly liking or disliking a patient will cloud my judgment, and so I try to treat everyone the same.

It drives me (and my staff) crazy when patients come in and demand "special treatment" because "Dr. Rob knows who I am."  It is worse if people try to pretend they are my friends by using my first name.  Yes, there are special circumstances where I do see a patient who walks in, but that is dictated by the medical condition, not by how well I know the person.

Doctors I take care of can be the biggest offenders.  I try to make it clear from the outset that I will treat them like any other patient and not necessarily give them better access because they are doctors.  If I have to give them special access, then something is wrong with the system.  Besides, special access for some generally means worse access for others.

Rule 4: Don't mess with the staff

My staff takes an incredible amount of abuse at the hands of some of my patients.  It surprises me what they are willing to say to my nurses and clerical staff but not to me.  In general, people see them as an obstruction to being able to see their doctor, and so have little patience for any delay.

There are certainly times that my staff is worthy of criticism, and I expect to hear some complaints.  But in general, it is not the individual staff's fault for things not running well, it is our system that causes problems.  We have a system for the entire patient experience in our office, and it works most of the time.  There are times, however, when circumstance makes things fall apart.  There are also times when the deficiencies of the system are exposed.

My staff has a very demanding job.  Remember that you are not their only responsibility - you may be the 100th job for the day.  If they don't meet your expectations, yelling at them won't fix the problem.  Talk to me or my office manager.  Better yet, put it in writing so that I have ammunition to change things, because chances are really good that your frustration correlates to a frustration I have.

One of the only reasons patients are discharged from our office is when they abuse my staff.  A staff member is generally more valuable to me than a single patient, and I need to show my staff that they are valued by me.  It is my job to discipline (or fire) my staff, not my patients'.

Rule 5:  If you don't trust, leave

Trust is the commodity we sell.  People go to the doctor because doctors have unique knowledge and experience.  The stakes are as high as they can get, so why would you go to someone you don't trust?  I have seen many patients stick with doctors in whom they have lost faith "because I don't want to hurt his feelings."  That is ridiculous.

trust_doctorWhen you go to a doctor you don't trust, you will be suspicious about every bad outcome and won't even trust when things go well.  This  is a no-win situation for the physician.  It does not matter if everyone else says this is a good doctor; if you don't trust him, find another doctor.

I have some specialists I trust a lot and send many patients to.  Invariably, some people won't have a good experience - perhaps the doctor had a bad day, was in a bad mood, or the two just didn't get along.  If I hear that mistrust, I always suggest either a second opinion or a change of doctors.  None of my colleagues want someone sticking with them if the trust is not there; it is a very high-risk situation from a malpractice standpoint and studies have shown that negative attitudes make bad outcomes much more likely.

Find a doctor you trust.

Please note that trusting a doctor does not mean you should not ask questions. In fact, I think a physician who does not want to be questioned is one you should not trust.  Questioning is often the only way to build trust.  Unanswered questions tend to undermine trust.

Rule 6: No news might be bad news

"No news is good news" can be a fatal assumption.  Never assume that your doctor will call you if there is a problem.  I get 50-60 new documents (labs, x-rays, consults, hospital notes) every day.  I order hundreds of tests every week.  I just cannot keep track of them all.  Some will get sent to the wrong doctor and some results never get sent at all.  Despite our best efforts to develop a system that will close this loop, there are some documents I just don't get.

A doctor's office is always on the brink of chaos - with an incredible amount of information coming in and going out, a large number of phone calls, insurance company headaches, and personnel situations that can throw the best system flat on its face.  People forget that there are hundreds of other patients with thousands of test results the office is dealing with.  We do what we can to tell patients test results (and with our computerized records, we do a better job than most), and I see that as our responsibility.

If you don't get your test results, call.


One more point: we aren't that much different from you.  We have good days and bad days.  My staff cry sometimes when they are mistreated by patients.  I get discouraged and emotionally drained.  It really helps to hear thanks.  I don't expect it all the time, but when I do get a card or a nice phone call saying I am appreciated, it can really help.


It can happen.  Doctors and patients can get along.  Like any relationship, it takes effort and give-and-take on both sides.  The benefits of such a relationship are very satisfying and truly life-changing.



Getting along: Part 1 - Doctor Rules

Why are patients mad at their doctors?  In comments on my previous post, people expressed real frustration and distrust - mainly from a lack of listening and connection.  Those who loved their doctors (and there were some) expressed the opposite.  They had a relationship with their doctor. Here the rules I have for getting along with my patients:

Rule 1:  They don't want to be at your office

doctor2214627c9qk8 It may seem odd to patients, but most doctors forget that going to the doctor is generally unnerving.  We Work there, and being in a doctor's office is normal to us.

Not so with most patients.  The spotlight is on them and their health.  They stand on the scale, undress, tell intimate things about their lives, confess errors, are poked, prodded, shot with needles, lectured at, and then billed for the whole thing.  Yes, it seems that some patients are happy to be there - and I do my best to make my patients feel comfortable, but there is always an underlying fear and self-consciousness that pervades when a person is sitting on the exam table.

The best thing to do in response to that is to show compassion.  If you feel awkward, scared, or self-conscious, the thing you most want is for someone else to understand how you feel.  Patients are much more likely to follow a doctor's advice when the feel that the doctor understands.  Identifying the fear and relating to it are the first steps at building trust.

Rule 2:  They have a reason to be at your office

headache People don't like to waste time and money.  They don't come to the office to waste the doctor's time.  Yet early in my training I was incredulous at the reasons some of my patients were coming to see the doctor.  Why come in for a headache?  Why come in for a cold?  Doesn't the person realize that a stomach bug won't get any better by coming to the doctor?

It took me being in my own practice (and trying to keep my business going) to realize that there is (almost) always an underlying reason for a patient to come in.  Sometimes that reason is simple: they need an excuse from work, or they have terrible pain that needs to be treated.  Other times, however, the reason is more subtle.  When a person comes to my office with enlarged lymph nodes, for example, the real reason they are coming in is that they are afraid it is cancer.  When patients have chest pain, they are afraid it is their heart.

On every visit I try to identify the real reason (or the real fear) that brings them to see me.  I don't end the visit until I have addressed that reason.  If they have an enlarged lymph node, I make sure and say "I don't think this is cancer because...."  If they come in with chest pain, I say "This doesn't sound like a heart attack because....."  If I fail to do so, then they leave the office with the fear and feel ignored.

Rule 3:  They feel what they feel

Patients will often tell me their symptoms in a very apologetic tone.  They seem to think that they have to come to me with the "right" set of symptoms, and not having those symptoms is their fault.  Sometimes those symptoms make no sense to me at all and I am tempted to dismiss or ignore them.

But as a physician, you have to trust your patient.  Only the really crazy patients make up symptoms.  Yes, some may exaggerate what they feel out of anxiety or out of fear that you won't hear them for lesser symptoms, but then your job is to uncover the anxiety, not ignore the complaint.  I have heard from many patients that their doctor "did not believe" their complaints because they did not make sense.  If you don't trust them, why should they trust you?

If symptoms seem contradict what I know to be possible, I often openly tell them that this seems to contradict - but I make sure I don't imply that they might not be being truthful.  A puzzle is a puzzle.  It is my job to undo a seeming contradiction.  I may not ever be able to do so, but at least I don't make them feel bad for feeling what they feel.

Rule 4:  They don't want to look stupid

r0123m I remember when I broke my shoulder - a compression fracture of the neck of the humerus bone - and went to the orthopedist office.  I always felt self-conscious about how much pain I was reporting.  A colleague had fractured his humerus the year before and had reported he was back to doing surgery within a few weeks.  Here I was, a few months out and couldn't even lay down in bed.  I felt like a wimp.  Was this other guy just tougher than me?  My orthopedist made me feel much better when he explained that my colleague had a mid-shaft fracture, while mine was right in the shoulder joint - a much slower place to heal.

This event made me realize how many patients felt when they came into my office.  People are often worried that they are over-reacting.  They wonder what I must think for a person to come to the office with that symptom.  This is especially true of parents bringing their children in.  Nobody wants to be "that mother that over-reacts to everything."  In response to this, I try to specifically say, "I am glad you came to the office for this because..." or "Yeah, I can see how that worried you because it could be...."

Rule 5: They pay for a plan

confusion What do people pay for when they come to the medical office?  They pay for opinion, yes.  They pay for knowledge as well.  But what they really pay for is a plan of action based on their circumstance.  If they have an ear infection the plan is to use antibiotic (maybe) and treat the pain.  If they have abdominal pain, the plan may be much more complex.  They want to know what is going to be done and want what is done to help.

I try and give a plan, either verbal or written, to each patient that walks out of the exam room.  What medications are given and why?  What medications are to be stopped?  What tests are ordered and what will the results mean?  When is the next appointment?  What should they call for if they have problems?  The better I can answer these questions, the more confidently the patient will walk out of the exam room.  The days of paternalistic medicine are over - no handing a prescription and just saying "take it."  Patients should know why they are putting things in their body.

Rule 6: The visit is about them

With all of the stresses in a doctor's office, I get tempted to complain about things.  Who better to complain to than someone who feels much the same way?  But patients are paying for you to take care of their problems, not the reverse.  I keep my personal gripes or frustrations to myself as much as possible.

Go to Part 2 - Patient Rules