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Strange Things Aren’t Getting Any Better…
I had a patient nearly succeed in killing herself recently, despite my best efforts to intervene. She is a type of patient that scares every doctor: She doesn’t like medicines or ‘chemicals’ that she doesn’t understand, but she takes 20 pills a day of various supplements and herbal remedies that she doesn’t understand. She complains of an endless list of bizarre symptoms (her left eye cramps when she urinates or whatever), when the only diagnoses on her chart are fibromyalgia, irritable bowel syndrome, and anxiety. She lists 14 drug allergies, but the symptoms experienced with those drug allergies don’t make any sense. And worst of all, she says, “I know my body.” I get chills just thinking about it.
That patient is dangerous, because one of these days, she’ll actually get sick, and I’ll miss a recognizable disease in all the random background noise of her being in touch with her body. And then I’ll have to explain to the husband how his wife died of a bladder infection while under my care.
On her first visit with me last year, Karen opened the conversation: “I’ve heard a lot about you.”
Me: “Don’t believe a word of it. Those people have no idea what they’re talking about.”
Karen: “Everybody says you’re the smartest doctor in this part of the state.”
Me: “Oh, well, those people obviously know exactly what they’re talking about.”
Karen: “Good. Because my previous doctors were all a bunch of idiots.”
Over my career, I’ve learned that that’s a bad sign. Because when all her previous doctors were idiots, that means that I’m not just her new doctor, but I’m also the next idiot. If no one else can meet her needs, then what are the odds that I’ll be able to do so? So I keep my eyes open after I hear that.
She called me recently, saying that she felt terrible and that the medicines I was giving her were killing her.
Karen: “I stopped that stuff you gave me a couple of days ago. I felt just horrible.”
Me: “Which medicine did you stop?”
Karen: “I can’t remember.”
Me: * pause *
Karen: “I felt horrible. That drug just didn’t fit with my system. I know my body, and it was making me feel horrible.”
Me: “How did you feel? What exactly were you feeling?”
Karen: * spends several minutes listing every side effect she’s ever read off of any warning label for any drug *
Me: * interrupts Karen * “Ok, so you’re off whatever medicine that was now. Ok. So do you feel better?”
Karen: * pause * “Well, I just stopped it a few days ago.”
Me: “So you feel better now?”
Karen: “No. I feel horrible like I said.”
Me: “Why don’t you come into the office, so I can figure out what’s wrong?”
Karen: “I told you. It was the medicine you gave me.”
Me: “So you feel better now that you’ve stopped it?”
Karen: “No. I feel horrible.”
Me: “So why don’t you come into the office, so I can figure out what’s wrong?”
And around and around we went. I couldn’t get her to come in. She didn’t need to see me, because “I know my body.” I got her to promise to call me if she got worse. And we hung up. Both of us rolling our eyes, wondering what the other one was thinking. I went to bed that night wondering if she was actually sick this time, or if she was just in touch with her body.
I don’t sleep much.
The next morning, her husband found her on the floor of their bathroom. She was semi-conscious and didn’t know where she was, or who he was. He called me, very stressed out, as you might imagine. I had him call 911. They took her to the ER.
I called the ER doc, to give him a heads up. He asked what he should be looking for. I said, “I’m really sorry, but I have absolutely no idea.” He said “Thanks a lot” and hung up. “Happy to help,” I mumbled, as I clicked off my phone.
They scanned her head, looking for a stroke or a bleed. They did bloodwork looking for every disease under the sun. They did chest X-rays, CTs, EKGs, and God knows what else. She was extremely dehydrated. Her pulse was racing and her BP was barely detectable. So they were pushing IV fluids. She was in kidney failure, probably from the dehydration. She finally produced a little bit of urine, and they found a raging kidney infection with sepsis.
Once they figured that out, they called me to ask if she had any drug allergies. I didn’t even look at her chart and said, “Nope.” So they gave her two antibiotics (both of which, as it turns out, were on her allergy list). They worked well, and today she is recovering nicely. Thank God.
But she nearly died of a bladder infection. That I could have found in my office with a $2 urine dipstick, and fixed with maybe $5 worth of antibiotics. Except that I couldn’t have treated it, because she says she’s allergic to every antibiotic in the world.
Her hospital bill will probably be over $100k and she nearly died. She was lucky her husband found her when he did. And she was lucky the ER doc did such a nice job, so quickly. Nice save, buddy.
I would have called him to thank him, but I didn’t want to have to listen to him asking me how a patient of mine nearly died of a bladder infection.
This story may sound odd. But it’s not.
My patient may sound irrational, but she’s not. At least, not any more irrational than the rest of us.
Black Lives Matter has burned down cities for over a year protesting how many blacks are killed by white cops. While they ignore how many blacks are killed by other blacks. While ignoring the social problems that lead to such violence in their neighborhoods. While refusing to acknowledge that when a criminal resists arrest, he is engaging in a high-risk activity.
When you have a problem, it always feels better once you decide that it’s someone else’s fault. But the catch is that at that point, the problem becomes un-solvable. The first step to solving a problem is to take ownership of it. Blaming others makes that impossible. Which then makes it impossible to solve the problem.
It’s not that my patient’s illness is her fault, of course. It’s just that she needs to play a role in fixing the problem, regardless of why it happened. And if she refuses to do so, then things might get out of hand.
It’s hard to know who to blame for the problems in the black community, although it really doesn’t matter as much as we wish it did. All that really matters is improving things now, regardless of how we got here. And that will involve those in the black community playing a role in the improvements. And there are many, many people in black communities doing exactly that. God bless them.
This is why Black Lives Matter is so toxic. BLM is not just unhelpful – it is setting back progress that is hard earned by those who live in these communities and want to improve them.
When BLM encourages blacks to blame others for their problems, then progress stops (even if others are partially to blame for those problems). When BLM encourages blacks to be resentful and distrustful of whites, then it becomes more difficult for us to work together to improve anything.
Fear of others trying to help, because they might discover that perhaps your problems are at least partially your problems, is understandably met with deflection:
“It’s a Black thing. You wouldn’t understand.”
“I know my body. Your drugs are killing me.”
It’s very difficult to fix a problem that you refuse to acknowledge. It’s very difficult to accept help from someone that you don’t trust. So we take herbal supplements and we burn down cities. These responses may not seem to be completely rational.
But at least we’re doing something, right?
Strange that things aren’t getting any better…
Published in General
That’s a serious editing error.
In the title. Ouch.
Dr. Bastiat has a medical license and an artistic license. Both should be respected.
If you fix it, it will go back to the Member Feed, and the time stamps will be off kilter. I don’t know what to suggest. It’s hard to reach the editors. Maybe send a note to Scott (Blue Yeti). He might be around. He’s in California. He’s probably enjoying his morning coffee right now. It’s an easy fix.
Thanks, but it’s not that big a deal. I’ve had other errors introduced into my pieces in the editing process that upset me a great deal. I try to complain only about those. I don’t want to get on anyone’s nerves.
On the other hand, I don’t really understand editors changing my sentence structure or whatever on a social media site like this. Just make sure there’s no bad words, make sure I’m not attacking someone or whatever, and publish whatever it is.
But that’s just my view.
Not to mention he’s from Ohio. Bonus points for that…
UTI’s seem to be an ailment that can cause so many problems but often go undetected. It should not be necessary to say that many doctors are now too busy with their rant on promoting the Big Pharma pill of the month as well as the need for the flu vaccine, and more or less ignore the actual ailments the patients needs help with.
(We normal patients only get 6 to 8 mins with a nurse and doctor, so it is not a minor thing that we have to listen to four minutes of rants.)
Anyway if there was a doctor that charged the type of fee you charge for “boutique services” I’d sign up in a minute. On one of my last dr visits the dr went on for 10 minutes about how much he hated the doctor he noticed I had been seeing 3 years earlier. And that was considered to be worth $ 165 by the people at the desk on my way out.
I imagine there are doctors here in Calif who do what you are doing, but I can’t imagine any of them charging less the 5K.
If I remember correctly, my concierge physician charges $9,000 per year for a couple and $5,000 for a single and with that one gets pretty much immediate attention when needed. I think this might work for the chronically ill but not for me because so far I’m never sick. I asked her what we could do and and she said $300 for the initial visit which would include a comprehensive physical exam and talk through any health related issues. I took that and she included a short followup, at no charge, for a couple of things when we ran out of time (2 hours). She is also doing this for my son and one of my grandsons, who don’t have insurance, where it requires multiple appointments, second appointment $150 and subsequent appointments $75. They both have some minor chronic condition issues That’s working okay for me.
That is a terrific doctor to come across. I am willing to do something like that.
I am just too healthy, despite my hippy dippy lifestyle, to wanna shell out 5K a year. I take one baby aspirin a day, some Claritin and benadryl during hayfever season, and that is about it.
I have not been to the dr’s in over a year. I do miss going when I have poison oak, as it really lays me low. But it often is accompanied by a fever, so last year I soldiered on without the help prednisone would have provided. As I figured the local clinic staff would have judged me to have COVID instead of just a fever.
The advantage of a decent GP in charge of things is I would not be so paranoid when in a situation like the above.
I guess $400/month (plus what amounts to co-pays) is considered “low cost” health insurance these days, but it’s way beyond what I could afford.
I’d like catastrophic insurance for the rare hospitalizations and otherwise to pay $3 to $5 per minute for walk-in office visits. A prominently displayed 6″ stop-clock on the desk would be nice, too. (This doesn’t include tests or blood work.)
I’ve long advocated per-minute charging because I know it’ll be a quick visit, and for those who know their bodies, an hour-long visit with socializing should be no problem for the doctor.
$5 per minute works out to only $300 per hour, they would charge a lot more than that.
That’s the whole point, they don’t have to. No coders or billers. Just a receptionist, and nurse or MA and the doc. That’s gross 600K a year, that’s enough for a good living for all three, plus rent and utilities, insurance, and supplies.
It’s more complicated than that, of course. Just for starters, even without insurance there would be records to keep and stuff.
It’s a cash business. All records are done in two minutes on paper.
I was referring more to medical records, not financial ones.
That’s what I’m talking about, too. If you don’t bill third party, you don’t have to use EMRs.
My concierge physician also has a yoga class she runs and I’m not even sure what else.
That’s fine, but I’m not talking about concierge medicine. That is generally paying a flat rate for essentially unlimited care. I’m talking about charging an hourly fee for service. And the fee can be broken down into 1-minute increments. Also, it generally is a cash service which obviates an EMR. Patients with insurance can get a xerox copy of their visit notes, and bill their insurance companies directly themselves.
In the end, it allows patients who want a long and leisurely visit to have one and pay for it, and patients that want a quick in and out to get one and pay less for it, and it allows the doctor to be paid for his time without setting maximum appointment times.
The reason I mention that is with the political shenanigans going on I tell my children and grandchildren to develop several sources of income so that when one gets hit they still have income.
Let me also say, last year I went to a doctor that takes $100 cash for a visit, which is very low. He also takes medicaid and medicare, but most of his patients are medicaid who want to be seen same-day, and that is difficult to get, so they pay cash. He does a very brisk business. I think vaguely that he saw more than a dozen patients in less than an hour while I was waiting: $1500 per hour. Not bad.
He spent probably 120 minutes with me, but that was 90% struggling with his EMR and prescription system. Even at $3 per minute I would have been happy to pay.
That’s great. A yoga class has to be very low overhead.
What happens to the waiting room?
Also, who is going to know exactly how much time they need, in advance, and what happens if they get to the end of the pre-scheduled time but it turns out not to have been enough? For that matter, if someone schedules 10 minutes but their problem is resolved in 5, they’re likely to resent paying for an extra 5 minutes they didn’t need, but the doctor wouldn’t have pre-arranged for anyone else to pay for that time…
They have the de rigueur large screen TV, in this case playing an animated movie about car racing snails.
It is, as is very common in many clinics, a mix of appointments and walk-ins. Appointments are more or less adhered to, and walk-ins wait. As it was I had an appointment and was kept waiting, and I didn’t mind. This waiting is, in my experience, the same as visiting my surgeon’s, or my internist’s, or a neurologist’s or a dentist’s office, all of which only see scheduled appointments.
And I have never seen an appointment end early anywhere without a patient ready and waiting to be seen.
there is this thing called overhead- and it costs-you know rent, heat, paying staff ( they get huffy if you don’t pay them every once in a while). So your Doc charging $5/min grosses ~ 600K isn’t gonna do it unless he is in a remote rural location with cheap real estate & some really desperate to work staff (meth head husbands or such). Malpractice will run you more than pocket change. And even without third party payers you will need something more sophisticated than an abacus to get lab results- and PCs and Microsoft ain’t free. Maybe you could illegally reuse much of your medical supplies- you recall the old joke: “you know you have a cheap HMO when the tongue depressors taste faintly of fudgesicle”.
addendum- and $600K assumes 2,000 hours of direct patient time- hard to do- your turn over time would have be fast. That is one of the reasons your doc is doing his electronic charting in front of you-he can’t afford the time to do it later and with the clunky piece of crap most electronic record systems are he needs to do it right away so that if it freezes he doesn’t have to remember everything. And most EHRs are garbage.
I’m sure you know it’s done every state. Cash payment, billed by the minute. The doctor’s who’ve been interviewed liked it a lot.
Does BLM make NAACP obsolete now?
Or UNCF (United Negro College Fund)?