Birthday cards

Dec. 27

Every Dec. 27, I get a birthday card from Rich, my insurance agent. Besides wishing me a happy birthday, the card usually contains a coupon for a truffle or an ice cream cone at the local ice cream parlor. I look forward to it every year.

Last year, it occurred to me that I might do the same thing for my patients. Our software allows us to create a birthday list for a range of dates, so twice a month I print out a list and highlight the names of our active patients. Isabel, my office manager, then addresses the cards — and draws a smiley face on each one. We don't send sweets, but we do wish them a healthy birthday.

The response has been one of surprise and appreciation. One patient told me that when her son opened the card he remarked, “Hey, look what Dr. Brown sent me. He's OK.” Another patient said she showed it to her coworkers and bragged, “Can you believe what I got from my doctor? Does your doctor send birthday cards?”

I especially like to send the cards to patients who otherwise might not receive any — shut-ins, widows, widowers, people estranged from their families, people without families. They always appreciate being remembered. And if they happen to come in on their birthdays, we can usually find them a cupcake with a candle and embarrass them with a rendition of “Happy Birthday to You,” just like they do in the restaurants.

Ankle sprains

Jan. 7

My 14-year-old daughter, Margot, recently experienced her first sports injury. After spending three injury-free years playing competitive volleyball and basketball and running 10 miles a week, she hurt her ankle during a light volleyball practice. Her lateral malleolus was swollen and tender but not ecchymotic, and an X-ray was negative for fracture.

Did I want to treat my own daughter's sprain? Not one bit. I sent her to Dave, the orthopedic grinch, and he put her in a walking cast for two weeks, which he had to negotiate with Margot. When it came off, he put her into a stiff boot, and then she advanced to a lace-up brace with stays. Within a couple of days she was scrimmaging with the junior varsity girls, and a week later she was off to a tournament.

It occurred to me that specialists have a lot to teach us with regard to even seemingly simple injuries. My approach to sprains has at times been minimalist: ice, crutches, splints and a bandage. Last year, a star player on the girl's varsity suffered a severe ankle sprain and received the same treatment at our ER. She didn't play again for six weeks, and it still isn't right. “Immobility is key,” Dave says. “You have to give the torn ligaments a chance to form a scar and heal.”

In fact, he casts almost all sprains because, although the boot works, almost no one keeps it on all the time. He tells his patients, “I can be a nice guy or a good doctor,” and if they try to tell him that “so-and-so's doctor didn't cast them when they had a sprain,” Dave tells them to go there. He says he's taken too many of these cases to the operating room when they weren't treated properly and left the patient with residual weakness and pain.

In lieu of throwing fiberglass, I've resolved to get my local medical supply to carry the boot so I don't have to refer my next sprain to Dave. And if my patient refuses to wear the thing all the time, I'll say, “No more Mr. Nice Guy. If you can't keep it on, I know a doctor who will either cast you or operate on you. Choose.”

The letter service

Jan. 12

My collection agency offers me an invaluable option for my over due accounts. It will send my patients a letter giving them 10 days to begin paying our office before they officially go to collection. The letter looks formal enough, doesn't threaten patients' credit ratings and serves as a wake-up call. Plus, if the patient pays us, we owe the agency nothing. After the 10 days, they take a percentage of whatever they collect on the unpaid bill.

We now request this service on all our accounts that are at least 90 days past due, once insurance has paid its share. In addition, we send our own letter with patients' final statements. It reads: “Because you have not fulfilled your financial obligation to this office, after repeated billings and phone calls, we have no choice but to turn your account over to our letter service. You will have 10 days after receiving notification from the service to pay your debt, either in full or in part, to this office. After this time you may only pay the collection agency. … If you do not take care of your account prior to it going to collection, we will not be able to continue to keep you as our patient.”

Most of our patients have responded to this approach. Those who don't get a letter asking them where, within the next 30 days, they would like their medical records sent. I sign the letter “Regretfully.”

Some might consider this a hard-nosed approach, but when you see your patients with large unpaid balances eating dinner out at the table next to yours, then you want to be the one who decides who does and does not receive charity care in your practice.