More than one problem? Make another appointment

So I’m currently rotating through an outpatient medical clinic, and despite all the hand-holding, kumbaya-ing, and “the patient is a person” mentality, beneath the surface an insidious beast lurks. This “beast” is the closely held belief that the patient is only allowed one complaint for each scheduled appointment. You made your appointment to get your blood-pressure meds refilled but you also have seasonal allergy concerns? Too bad, make another appointment so we can discuss the issue on a separate occasion.

Just recently I was (politely) scolded by my resident because I presented a 7-week-old baby whose mother had 3 concerns – the child had been throwing up his milk at each feeding for the past few weeks, he had a rash across his entire body for the same amount of time, and she was concerned that he might also have an umbilical hernia. “Try to keep them to one complaint” my resident told me. But the rash and difficulty feeding were likely related (milk-allergy), and the hernia concern arose because she was a new mother and didn’t realize kids usually outgrow those things – it took 2 seconds to say “oh, that’s normal and he’ll probably outgrow it. don’t worry.”

I have difficultly understanding where this idea, that we can only allow the patient one problem per visit, comes from. I understand that the appointments are booked closely together, generally with 15-20 minutes per patient (which includes the time it takes to fill out any necessary paperwork), but have these doctors lost their minds? Do they not realize that people who come into their clinics must take off work to get there, rearrange child-care schedules, etc? Even if they are retired or stay at home to take care of their children, they still have lives and would prefer not to spend most of it at the doctors office waiting in boring stimulus-free rooms.

I have to believe that if we actually had a free-market health care system many of these problems wouldn’t exist. Our society is accustomed to getting it all done at once – this is why stores such as WalMart or Target have achieved their level of success – you can get your grocery shopping done and stock up on anything else you need in one trip. People expect the same thing from their doctors, and I’m siding with the patients on this one. There is no reason why our system couldn’t adjust to accommodate the person who has a couple different medical problems going on. A more market-based approach would simply charge a bit more for the larger amount of doctor’s time the visit uses. As it sits right now the system is too rigid to adjust to these demands – everything must fit neatly into a 4-5 digit “code” for what the visit accomplished, and the doctor is paid according to that code. I understand doctors don’t like it when a visit they thought would take 15 minutes all of a sudden takes 45 because the patient has a lot of issues to bring up, but if you took your car to the mechanic to get the oil changed and they found a problem with your engine, wouldn’t they offer to fix it on the spot while you waited? Wouldn’t you be pissed if the mechanic told you to make another appointment (which would be at least 2-4 weeks from now) to get your engine fixed, and that in the meantime you would just need to deal with it and keep your fingers crossed while hoping that your car doesn’t break down? I would be pissed. No wonder people don’t like going to the doctor.

~ Lily

3rd year medical student extraordinaire (at least in my mind)


Ethics in medicine – real life experiences

I haven’t been posting very regularly on this blog since starting my third year of medical school because I’ve been a bit busy adjusting to the new routine of seeing patients every day. I must say that although the hours required during the clinical years of med school are worse than the classroom years (overnight calls, long shifts of standing, etc), it is also much more interesting seeing patients every day and applying everything we’ve learned up to this point (hello steep learning curve!). With this intense clinical exposure comes a lot of scrutiny of my future colleagues – I look at each of the doctors I work with and see traits I would like to possess, and also those I do not. While I can say that most of the doctor’s I’ve worked with have been fantastic both with their patients and with their interest in teaching us students, a few have been downright awful and possibly unethical. Here is a sample of the worst that I’ve encountered these past few months:

The first is a doctor that takes no interest in the students and barely listens to what we have to say after we interview her patient and give a report before she examines them. I have to wonder why someone like this doc is working for a teaching hospital if she obviously despises the students. To make matters worse, a few of the students who have worked with her more frequently have commented on how she treats patients differently depending on their race. While I haven’t witnessed this first-hand (I’ve only been with her on a few occasions), I can’t say it would come as much surprise…I understand everyone has personal biases, but when you care for such a diverse patient population as ours it is necessary to work extra hard not to let your biases influence care. I hope I don’t turn out like her.

The second involved a primary care physician who was treating a morbidly obese patient with osteoarthritis of both knees. This patient’s insurance would not cover a particular injection the doctor wanted to give to alleviate the pain/inflammation of her joints, so the doctor was in the process of setting up a situation where she would order the injection for another patient whose insurance would pay for it, but give it to the first patient. I’m pretty sure that counts as some form of insurance fraud, but my guess is a lot of people would look the other way because of the general public perception of the “evil insurance company.” While I certainly sympathized with the pain this patient must be going through with her knees and the impact it has on her quality of life, I couldn’t help but think that if she would lose even a little weight she would feel a lot better all around. Perhaps the insurance company wouldn’t cover the shot because it likely wouldn’t make much difference given the severity of her obesity and arthritis. But what do I know?

The third doctor was a specialist performing an endoscopy-type procedure on a middle-aged woman. If you’re not familiar with how those procedures work, you are basically putting the patient under partial anesthesia so that they are awake but heavily sedated. Most people don’t remember much afterwards, though their eyes are open and they can talk a bit throughout the entire thing. This doc was chatting with his fellow nurses and technicians when politics came up. I was always raised never to bring up “religion and politics” while at work, but I figured since these people worked together for so long they must be comfortable discussing their views. The doctor was a republican, while most of his coworkers in the room were democrats…to be honest I think they were all a bit stupid when it came to understanding federal policy, as none of them sounded very educated on the issues (but I digress…). Of course Barack Obama comes up, to which the doctor makes some remark about how “Obama’s a muslim, and I just don’t think it’s right to have a muslim in office with terrorism being such a issue” etc. I’m probably wording things a bit more eloquently than what came out of this guy’s mouth. I am not an Obama fan for various reasons, but I couldn’t stand by quietly while this doc was spouting lies. I made some comment about how Obama is actually a christian, but how some keep trying to spread the rumor that he is a muslim because they think it will deter people from voting for him. Then the doc starts rambling about muslims, saying what essentially amounts to “muslim = terrorist”. Suddenly he becomes aware of what he’s saying, and he looks down at the patient and asks, “are you a muslim, ma’am?”. This poor woman, in her drugged state shakes her head “yes” and says something unintelligible. The doc’s face loses a bit of color, and then he turns to one of his nurses and asks if she would please administer more of the drug that produces amnesia (so the patient won’t be able to remember the offensive things he said). The nurse looks at him thinking he’s joking, but the doc is entirely serious, so she administers more of the drug. Would the extra dose of this drug harm the patient? Probably not, though it is still plausible that it might have. I guess “first do no harm” goes out the window for this guy when you say something offensive to your patient who is completely incapacitated. It made me really sick to my stomach to witness the entire thing, and I hope I’m never paired with this doctor in the future.

I still think most doctors are good people, and this has been confirmed numerous times for me in the past couple of months as I’ve worked with a variety of different practitioners, but it’s hard to look at them the same way when there are a few rotten apples spoiling the perception. I may not know what kind of doctor I want to be at this point, but I’m starting to get a good idea of what kind I don’t want to be. From your perspective, what are traits that make a doctor good or bad? Any comments are appreciated!