The disgruntled patient

No matter how much your patients appreciate you, all it takes is one patient who doesn't to ruin your day. They're easy to spot. They fidget, don't make eye contact and are quick to express dissatisfaction. I had one just today. His feet had swollen after I increased his dose of Adalat, and he was particularly upset that I had sent him for a colonoscopy after finding some blood during his prostate exam. The colonoscopy showed internal hemorrhoids and sigmoid diverticula but not much else. “Hell,” he said, “I could have told you it was just hemorrhoids. Now I've got to pay a lot of money to that other doctor, who said I didn't need to have it done in the first place.”

“He said that?” I asked, incredulously.

“Hell, yes, he did,” my patient said.

Where do I go from here, I thought. Let's not get into what the consultant did or did not say; I wasn't there and I'll let him know later what my patient heard him say. And this clearly wasn't the time for long explanations of standards of care.

“Look, Lyle,” I said, “because of your age, I had to prove that you didn't have colon cancer. You don't, and that's good news. I'm sorry the procedure seems expensive, but if we hadn't done it and you had colon cancer, then we'd both be sorry.”

He thought for a moment. “I'm not going to take any more of that blood pressure medicine either,” he said. He hadn't yet said he was going to find another doctor, and I resisted the urge to suggest it. Besides, I thought, Lyle doesn't even like doctors. Why would he want a new one?

“How's this sound?” I finally asked. “Why don't you come back when you need to see me, and we'll leave it like that?”

On his way out, Isabel asked him if he needed a follow-up appointment. “No way,” he said. “I'll call you.”

Staying visible

A patient came in early today and chanced to see me by Isabel's desk reading my mail. “I'm impressed,” she said. “Most doctors stay in their exam rooms and almost never come out where their patients can see them. You're a very visible presence in your office.”

I thanked her for the compliment and thought, do I really do things differently? It's my style to walk into the waiting room and call for and escort each patient into my consultation room. Rarely does a patient go into the exam room before we sit down and talk. I like to meet my patients before I have them disrobe; it levels the playing field and puts them at ease. I take chart notes, obtain the pertinent history, then suggest the kind of exam I feel would be appropriate. I draw their blood myself and have ECGs, urinalyses and stool guaiacs done in house — one-stop shopping. When our visit is done, I bring the patient to Isabel, who arranges for follow-up and ties up all the loose ends. Then, I see my next patient. Maybe I'm just old fashioned. Or maybe this is the only way a one-doctor office without a nurse can work.

No-shows

We have long struggled with what to do about no-shows. I can understand a patient not appearing for a 15-minute follow-up, but when someone misses an hour-long physical without calling to cancel, I fume. Some time ago we began calling all our patients to remind them about their appointment times. We also tell patients that, if they cannot make it to an appointment, they must cancel 24 hours in advance. Still, we have no-shows and patients who cancel at the last minute saying things like “I just don't feel like it today.”

Such patients, I've concluded, do not value my time, as I value theirs. So we now charge them for the missed visit. If they pay the fee, they are back in our good graces. If not, they are looking for another doctor. Most people are apologetic and pay the bill; the others we are better off without. A little consideration for my time and labor goes a long way toward making me feel good about getting up in the middle of the night to attend to that patient's needs.

An ED alternative

A logging contractor I know recently sent one of his workers to the emergency department (ED) after a 3-inch diameter tree limb struck the worker in the shoulder and chest. He had his wind knocked out but was otherwise OK. In the ED, he had chest and shoulder x-rays and an abdominal CT for occult hematuria. Everything was negative, including cash flow to the employer, who was billed $1,400. The employee came to see me a few days later for a work release. He was concerned about being told there was blood in his urine, and I explained that was not unusual in anyone with flank bruising. A repeat urinalysis was negative, and the patient left reassured.

For family physicians, this represents a great opportunity: seeing employees with minor injuries in lieu of their using the ED. It's an arrangement that offers reduced costs for employers and health plans and more appropriate care for patients, without making them wait four hours to be seen.