Friday, February 08, 2008

Part II: Access

I sat and pondered my predicament. Acute lower back pain – hardly able to move – clinic all day, three cases tomorrow, call this weekend. Ennie meenie miney moe.

I called my secretary. “Peggy, I know this is last minute, but I pulled my back and can barely move. Could you look at my schedule and see if we could rearrange things so I could be seen this afternoon. I suppose I could see the first two new patients this morning – but then I’m really going to have to work on this back thing…”

“Oh honey, just take the day off – you couldn’t help it,” the Mrs says in the background.

“Oh, I bet a lot of your patients won’t mind not fighting the snow today, Dr Wes – I’m sure I can reschedule them. Are you sure you can make it in?”

“Sure, Peg, the Mrs will drive me.” I say smiling at my wife who has flames in her eyes.

“I want to you to call right away and get an appointment with a physical therapist,” the ever-reasoned Mrs says.

I hestitated. “How the hell do I do that? I mean, I’d have to call my doctor for a referral. You mean a doctor might have to see a doctor? Never!” I thought.

The look at me told me I’d better reconsider. So I dialed the phone – not knowing my doctor’s office number, I did what any self-respecting doctor should do – I called the hospital operator.

“Hello, this is Dr. Fisher, could you connect me with Dr. Smith’s office?”

“Uh, how do you spell that?” said the soft-spoken voice from the hospital.

“S-M-I-T-H.”

“Just one moment, please.” And I was placed on hold. I heard the hospital marketing jingle playing in the background – it was the lyrics from Joe Crocker:

You feeling alright?
I'm not feeling too good myself, no
Yessir, you feeling alright?
I'm not feeling that good myself, no.


I couldn’t help but smile. Just then a timid-sounding individual picked up the phone. “Hello, Dr. Smith’s office, may I help you?”

“Yes, this is Dr. Fisher, could I speak with Dr. Smith?”

“One moment please.”

You feeling alright?
I'm not feeling too good myself, no
Yessir, you feeling alright?
I'm not feeling that good myself, no.


“I’m sorry, Dr. Smith isn’t in yet. He is seeing patients today but he’s delayed by the snow.”

“Could you tell him I called regarding a referral.”

“Sure. What’s your number? “

“312-555-xxxx”

“I’ll make sure he gets the message.”

I proceed to see my now-limited clinic. Funny hobbling in to see them; my problem seemed so trivial compared to theirs. True to form, my patients were remarkably empathetic to my situation. Damn they were nice. But I was glad I persevered: one had to have his procedure tomorrow due to a series of serious circumstances. Now I'm up to four cases tomorrow, I thought. So I finished, completed the all-important electronic paperwork, and headed home. I tried calling my doctor again to see if I could get that referral – I hadn’t heard back yet. Probably busy, I thought.

“Hello, Dr. Smith’s office, how may I help you?”

“Yes this is Dr. Fisher. Could I speak with Dr. Smith please?”

“Is it about a patient?”

I hesitated. Hmmm. How to answer? I might get a faster response if I just ask to speak with him a moment, but then, I guess I am a patient right now.

“Yes.”

“And what’s their name?”

“Uh, it’s me, Dr. Wes.”

“And your date of birth?”

I gave it to them.

“Just a moment please.”

You feeling alright?
I'm not feeling too good myself, no
Yessir, you feeling alright?
I'm not feeling that good myself, no.


I waited.

You feeling alright?
I'm not feeling too good myself, no
Yessir, you feeling alright?
I'm not feeling that good myself, no.


A new voice picks up. “Whom are you waiting for?”

“Dr. Smith.”

“Just a moment.”

You feeling alright?
I'm not feeling too good myself, no
Yessir, you feeling alright?
I'm not feeling that good myself, no.


The new voice: “I’m sorry, Dr. Smith is in seeing patients. Could I get your name and number so I can have him return your call when he’s free?”

I gave it to them. Home and cell numbers. I knew this wasn’t an emergency and I thought I should try to play by the “rules.” So I succumbed.

“When can I expect a call?”

“Between patients.”

“Thank you.”

I was beginning to feel a bit concerned that the day was withering away and I still had no rehab appointment for the afternoon. The Mrs suggested I call a rehab facility myself. I did. They could squeeze me in this afternoon, but would need a referral and my insurance card. I felt relieved. At least I could get seen today, but it would require that I make another attempt at reaching my doctor. Oh, God.

So I waited until about an hour before the appointment to permit time for a return call – sadly, none came. So I called again. I wasn’t “feelin’ so good myself” at this point.

“Hello, Dr. Smith’s office, how may I help you?”

“Yes this is Dr. Fisher. Could I speak with Dr. Smith please?”

“Is it about a patient?”

“Yes. This is about me. It is also the third call I’ve made to this office. Is doctor Smith available?”

“Just a moment please.”

You feeling alright?
I'm not feeling too good myself, no
Yessir, you feeling alright?
I'm not feeling that good myself, no.


“I’m sorry, Dr. Smith is in with patients right now.”

Well-trained I thought, but no match. I get it now.

“I’m sorry, but I want to talk with his nurse, office manager or the doctor and do not want to hang up again. This is my third call and I need a referral before 2:45 today.”

“Just a moment.”

You feeling alright?
I'm not feeling too good myself, no
Yessir, you feeling alright?
I'm not feeling that good myself, no.


“Hello, this is Ms. Office Manager. Can I help you?”

I explained by situation.

“I’m sorry, Dr. Fisher. Just a moment.”

You feeling alright?
I'm not feeling too good myself, no
Yessir, you feeling alright?
I'm not feeling that good myself, no.


“I’m not sure what’s happened, but I can’t see a record of your prior calls.”

Okay, I’m a professional. I tried to keep my anger contained. I realized I should not shoot the messenger, but boy, did I want to. Just before lunging through the phone, she continued:

“But I’ll handle this for you. I’m very sorry about your inconvenience. I checked again and Dr. Smith is still with a patient. But I’ll make sure it happens. My name is Ms. Office Manager.”

“You’re sure.”

“Yes, quite sure.”

“And you’ve entered this call on your phone log and have my name, SSN, date of birth, name of my first born, name and fax number of the rehab facility, etc., etc.”

“Yes.”

‘And it’ll be handled?”

“Yes.”

And thankfully, it was.

But the experience taught me a lot about our health care system of today. I know my doctor is a good guy. Part of this was my fault – I see him too infrequently – and I called him out of the blue for an acute problem.

But access to primary care really is a huge systemic problem. In our efforts to preserve sanity of primary care doctors with ever-increasing patient-care loads, we have created systems to permit doctors to work as efficiently as possible given the demands on their time. Specific well-intentioned shields have been erected to avoid inefficient distractions like acute medical illnesses. Phone message pools, answering systems, difficulty speaking directly with the doctor or even the nurse – all make for a horrible patient experience as we try to triage the work efficiently. Yet none really triage the problem at hand. Instead we get the obligatory "if-you-think-this-is-an-emergency-hang-up-and-dial-911" message. The inadequacy of this approach either leads to a loss of a referral by way of Walmart, a Minute Clinic, or the Emergency Room at best, or perhaps an injured patient with a more severe problem at worse.

I was lucky. I acted proactively because I know and work in this system. Importantly, I also came to realize that my own direct access is equally guarded – in part because I am often in procedures and yet more to the point – phone calls are time syncs – and time is money. So I have a nurse practioner help with these tasks.

While Medicare now reimburses some for phone calls made by physicians regarding outpatient services, they still do not pay for any calls following procedures – calls that could probably save tons of money if attended to promptly. But bureaucrats don’t see this. They see this time as covered under their 90-day post-operative “global period” – a ridiculous assumption that every ounce of effort for follow-up care to assure an expected outcome has already been paid for – and then they have the balls to reduce that fee by some 18% as of 1 January this year through trickery of billing rules.

I can't wait until BillaryCare is implemented. If we think this sucks now, we ain't seen nothin' yet. By flooding more patients into our system without addressing the shortage of capable front-line doctors, it's going to get ugly.

-Wes

Addendum via a reader tip: "Feelin' Alright" was written by Dave Mason of the band Traffic. Joe Crocker performed this as a cover song. I regret the error.

11 comments:

Anonymous said...

This is a very interesting post. I am an American who lives in Germany and I can say that in such a case, you can call a doctor and get an appointment on the same day. I'm not a 'private' patient, but we do pay a lot for insurance into what is essentially a single payer system. However, it does work because we do have the right to pick our insurance and our doctors. It is not a perfect system, but when there is an acute problem you will be able to get in touch with your doctor immediately. None the less, my vote in the primary did not go to Hillary. You can't force a single payer system down people's throats if they really don't stand behind it. It's too bad Americans don't take a good look at the rest of the western world to see how national health insurance can function and here I am decidely not talking about Great Britain.

Dr. Val said...

I have the utmost sympathy for your low back pain, by the way. It's amazing how incapacitating it can be - and how there's no way to visualize any of the pathology on any test known to man. :)

Eric, AKA The Pragmatic Caregiver said...

I won't get off into a rant on the various competing healthcare finance proposals floating around out there. Hillary is *NOT* pitching single-payer this time around. Universal coverage != single payer.

In any event;

First, Dr. Wes, my deepest sympathies. Acute back pain bites. I'll have a stiff naproxen-and-water in your honor.

Second, welcome to the world mere patients live in. My general perception is that well-intentioned busy providers think that phone messaging and triage functions can be handled by any high school graduate with a pen. The physicians reinforce to these people of limited capacity how busy they are and how important it is that they're able to work efficiently, and the Buffy with limited critical thinking skills and zero medical knowledge digs in and builds a fort. Repel all callers! Protect the doctor! The doctors NEVER FIND OUT about it, because patients know what side their bread is buttered on, and know if they rat out the receptionist, they'll never get an appointment again. Doctor is happy (no nuisance interruptions), receptionist thinks they're doing a great job (nobody complains to the doctor!), the cycle ramps up.

Dealing with two sick people in my life, one of the BIGGEST sources of frustration is the competence level of some of the ancillary staff of the various highly talented doctors we deal with. Case in point...

Cal takes one CII control. Drugs in this category are the only option for treating his condition - there's nothing else on the market with this mechanism of action. For those who aren't prescribing physicians, this means that every month, a new paper Rx was required. No phone calls, no faxes, no refills. (this has recently changed). Running out of this stuff will result in withdrawal symptoms and possibly psychosis. It's potent stuff. It works wonders.

Dr Z, an immensely talented psychiatrist of vast pharmaceutical knowledge was the prescriber. We see her about every three months for a med check and strategic optimizations. She's a gem. Couldn't do it without her. We shower her office with homemade baked goods in appreciation.

Sadly, she used to hire the dumbest people on the planet for her outpatient office support. Knowing this, we managed the experience. A week before we need the Rx, I'd call asking for a new Rx. If I didn't get a human, I'd send a fax (with a transmission log), asking for a call when the Rx will be ready for pickup. If I hadn't got the call in three days, I'd call back. Lather, rinse, repeat.

It was like pulling teeth. Never once did I get a call that the Rx was ready. Never once did it just get dropped in the mail as the doctor said she liked to do. I *have* that doctor's pager, cell and hospital office numbers, but I'd sooner DIE than use them for an Rx issue.

Excuses flew. "Oh, we never got a message." "Oh, we never got that fax". "Oh, the doctor's been so busy she hasn't had time to authorize refills", and the best of ALL TIME..."Oh, he can wait until his next appointment for the new Rx". . . six weeks away.

Fortunately, Dr. Z has found a highly competent midcareer professional to take over for the useless pair of Buffys.

I have NO problem telling physicians that they're highly competent but their office staff couldn't last a day working the register at McFattyBurger.

There are solutions:

1) Reachable triage service.

2) Educating these largely-new-to-the-professional-workplace call handlers about the sacred trust people put in their doctors, and the need for efficient handling and accountability for phone calls and faxes.

3) Service evaluation. You can't manage what you can't measure. The Miracle Whip Clinic uses mystery shoppers to evaluate their central appointment desk. Callers are provided with a specific set of symptoms, but no script, and complete an extensive evaluation of the call handling, and management can identify their calls in the system to document the triage protocols that were used and the appropriateness of the offered appointment. You can do the same thing on a smaller scale. Ask patients directly if they are getting good telephone handling. If someone comes in for an acute problem, ask them "How many calls did it take to get an appointment time offered?". "Are you satisfied with getting your questions answered?"

4) Track the data. I can tell you the name and number, time and date of the call and if they left a message, for virtually everyone who has called our firm for the last several years. Adding the technology to track the disposition of that call is trivial. And I'm not dealing with sick people at work, ya know. I jus' sell widgets.

It's frustrating. I try to be a good patient/patient representative. I leave concise phone messages with what's going on, what I need, and good contact information. I tend to fax, because I know it gets read and charted, and it can be dealt with asynchronously. I'm incredibly respectful of physician's time and the competing demands for their attention.

At the same time, I'm a paying customer. I get shat on by the system the same way you did, and I'm doing it for me, my mom and Cal. I feel helpless, trapped in abyss, and it makes caring for them a much harder job than it has to be, mostly because there's no feedback channel to constructively complain about the service in a way that doesn't threaten my future access. I'm over a barrel here.

The assumption from these phone bimbos and bimbas (there are a few guys in these positions) is *UNIVERSALLY* that they know more about healthcare and running a business than me, from their year of answering phones . I might not know how to direct a drug rep to the conference room to set up a lunch, or how to water houseplants, but I know darn tootin' well how to run a seven-digit business with customer contact. I know that when someone who even expresses the slightest interest in one of our instruments calls me and wants to speak with me specifically, I'm going to know about it, I'm going to know what they want and how they've told me to reach them and that they've been offered other resources to answer their questions. It's totally asinine that people prepared to spend a lot more money are so poorly treated when they're in need of medical attention.

I'd kick my lawyer, my accountant, my banker or my barber to the curb in a heartbeat if their communications service levels dipped twice to the level I routinely experience from the staff of the most highly educated, highly intelligent professionals I routinely deal with.

Best wishes for a speedy recovery. I find Thermacare heatwraps the best source of comfort and joy when my back decides it needs a day off.

Eric

DrWes said...

"Lather, rinse, repeat."

Eric -

Wow, sounds like you've experienced exactly what I encountered, and your comments and recommendations are right on target. I sent a feedback note to my internist via e-mail and he responded - seems corrective actions are in the works.

I found myself sounding like the stereotypic irrate patient, yet I now understand why they get that way sometimes. It's not that they're bad people necessarily, it's usually because we could do things better. "Just-live-in-my-shoes-for-one-day" moments like mine should be an experience every doctor goes through - we'd all have a new appreciation of what our patients are asked to endure for the sake of healthcare.

Eric, AKA The Pragmatic Caregiver said...

Endure is such the right word. No other purchase you make or service you contract for has such a lousy part-you-from-your-money experience. Motel 6 has better reservations than the average outpatient MRI facility.

And your experience was *with* the MD after your name.

Deb said...

Fantastic post, Dr. Wes. And I totally agree with you.

Kb said...

I don't think you have anything to worry about when it come to universal healthcare.
The Dims are a little nutty if they think they can pullout of the middle east and still have a nation to need healthcare for. (I say that being a registered Dem myself.) IMHO!

R. W. Donnell said...

I trust you're feeling better by now. You probably wouldn't be expressing yourself so well if you weren't. As I recently found out, acute pain can bring blogging to a grinding halt. Great posts. Stay well.

Felix Kasza said...

Anomymous in Germany:

I lived most of my life in German-speaking Europe (came to the US in 2004), including six years in Germany itself, from 1992 to 1998.

The German system is going broke, and it's taking the taxpayers and doctors with it. Shortly before I left, Germany instituted a Medicare-like system to cap drug costs: Physicians prescribe away, and at the end of the trimester, the drug expenses are added up and divided into the budgeted money. A shortfall is deducted from doctor's payments.

If Dr. A's colleagues Drs. B and C "over-prescribe", Dr. A gets a pay cut .... wonderful system.

And then, of course, there still is the old adage about the level of care provided by Germany's socialised healthcare system: "Too little to live, too much to die."

Cheers,
Felix.

Anonymous said...

We see more patient so we can hire more people so we can see more patients. Dumb, isn't it ?

drytears said...

Just be happy that the only mistake you experienced was that your calls weren't logged. For me the nurse carried the wrong message to my dr and it resulted in me getting a occipital nerve block!