When Your Doctor Is More Invested Than You Are

The first patient I made cry ended up leaving my practice and moving on to a colleague of mine. Unfortunately for the patient, switching providers did nothing to make her change her own ways and she ended up with an amputation, the outcome I was trying hard to prevent.

What did I say to cause the tears? I had looked her in the eye and simply said

Right now I care more about your foot than you do. How is that possible? If you lose your leg it will affect every aspect of your life and mine not at all. Yet I am more invested in this outcome than you are. Make a change or lose the foot, the choice is yours.

It was the truth. A hard truth that unfortunately made no difference and while this was an extreme case, it happens with nearly every patient in varying degrees.

The dirty little secret about doctors is that most of the time they do not heal anyone. The best we can do is provide you with the tools you need to treat yourself at least in the cases of chronic, long term conditions. Sure I can cure your wart, surgically correct your bunion or eliminate your ingrown nail. But when it comes to longer term problems, it has more to do with what you are doing than anything I can achieve for you.

Your endocrinologist can’t follow you around all day making healthy eating choices for you, reminding you to check your blood sugar and to take your insulin on time in the proper dose.

Your internist can’t wake up inside your home and remind you to take that blood pressure pill and put the salt shaker away.

Your cardiologist can’t force you to take that 10 minute walk every day they recommended for heart health.

And I couldn’t follow this patient around reminding her to wear the offloading boot, keep the dressing on and stay out of the pool. The best I could do was explain clearly what needed done, why it needed done and what would happen if she didn’t.

Maybe some doctors do not care about their patients. Maybe some only want to get through the day. There are a lot that do care though. That worry and stress and wrack their brains, digging deep into their training, to come up with ways to make you better. Doctors that you lie to when you look them in the eye and swear you’ve been doing everything they prescribed and yet are no better. Doctors that worry they missed something. Doctors like me that lay awake at night trying to come up with a solution.

If I care more about your outcome than you do, there is a big issue and it isn’t the treatment plan. You are responsible for your own health. It is your body, your life. If your doctor comes up with a treatment plan and you know it will not happen, speak up. Explain what your concerns are. Ask questions. Do not sit there and nod and walk out of the room knowing full well you have no intentions of following through.

The only time I get angry with a patient is when they come back to me and aggressively demand to know why they are not cured. Why do I still hurt? Why haven’t you fixed me yet? Do you even know what you are doing? My wound has not improved in months! My heel still hurts!

I’m not a shy doctor. I have no qualms explaining to you very clearly why you still hurt, why your wound is not healed.

It’s because of you.

It’s because you are not stretching, wearing proper shoes, using ice massage. It’s because you ignored my instructions to elevate to reduce swelling, wear the special shoe to reduce pressure and not get the foot wet. I’ll do all in my power to set you up for success but the 15 minutes I see you a week are but a drop in the bucket.

You must care more about your outcome than I do. Trust me, I care. A lot. It’s a high bar to set for my patients. I lay awake at night wondering what I’ve missed, what I should do next. I text colleagues and ask for advice. All assuming that you are following my instructions. If I learn that you aren’t , that you in fact don’t care about this outcome more than I do, then I too will stop caring.

When both the patient and the doctor stop caring about the outcome, it gets dangerous. So please, step up to the plate. Become more involved in your own care. It’s your health on the line. Ask questions. Speak up when you know something isn’t possible for you. Ask for an alternative. Be polite about it and don’t lie. I want you to get better. Trust me I really do.

Your Anger is Misdirected

Nothing is more frustrating than a delay in care. Here you are in pain, possibly scared but at least a little anxious about your condition and future, and you have to wait to receive treatment. You want a fix and you want it now, but you are told you have to wait. A test is needed to confirm the diagnosis so a proper treatment plan can be rendered. Trust me, it is far better to receive treatment for the proper problem than to start unguided and get it wrong.

The doctor, highly educated and trained in her specialty, has ordered a MRI to look at the soft tissues in your foot that are creating your pain. You are informed that the imaging center will call you to schedule.

You wait. The days start to go by and you have received no call to schedule. Your anxiety grows as your pain goes untreated. More time passes. Eventually all that anxiety turns to anger induced by fear of the unknown. You call the doctor who prescribed the MRI and yell at the receptionist, the medical assistant, the nurse, the physician’s assistant, the doctor. Everyone who will listen.

Why haven’t you been contacted to schedule the MRI? Why are you still in pain with no diagnosis and no treatment? The doctor must have forgotten you, made a mistake or worse yet, doesn’t care or believe you.

What you do not know is that the doctor has been working in the background on your behalf all this time and has been doing so in between other patients and for free.

After the MRI prescription was generated, the imaging center contacted the physician’s office to inform them that your insurance plan requires a prior authorization or will not cover the test. The physician had to print out and submit all your medical records to prove medical necessity. Never mind that the physician is a specialist in the field with years of study and training. Protocol demands medical records.

The insurance company took their time to respond to the new information. The outcome? Denied. A peer-to-peer review is required.

Let me tell you something here. The peer-to-peer process is a joke. An insurance employed physician of any specialty reviews the case. The ordered physician is given a contact number and a time to call and speak with this person. In all my years of practice, I have never once spoken to a fellow podiatrist or orthopedic surgeon in regards to my medical decision making of foot complaints. I have spoken with a nephrologist (kidney specialist), a pathologist (looks at specimens in the lab) and a pediatrician though.

It has to be completed though. While you are at home lamenting to all that can hear that your physician is not providing you any care at all, said physician is squeezing in time between other patients with their own needs to sit on hold with your insurance company. An hour later, they are connected to their “peer” who reads the script in front of them and informs them that a MRI will not be approved until a radiograph is taken and 6 weeks of conservative care has been failed.

The physician explains that this is not an osseous problem and a radiograph that shows only bone will be a waste of time, radiation exposure and insurance dollars. Furthermore, conservative therapy is vastly different in the scenario of an inflamed tendon (physical therapy can be used to reduce the inflammation and pain and has a faster return to full function) versus a torn tendon (physical therapy can worsen the condition and cause substantial harm) and waiting 6 weeks will only delay the care the patient needs.

The authorization is declined.

Now the patient must waste time and money getting a radiograph which is read as negative as expected. Six weeks goes by, the patient remains in pain and remains angry that the physician is doing nothing for them and finally the physician can once again attempt to get the MRI approved.

Think this never happens? It happens all the time. I once had a MRI declined for a soft tissue mass being told by my “peer”, a nephrologist, that it is likely a ganglionic cyst anyway and every one is the same, just treat it like that. I took the patient to surgery to remove the mass and it came back as a malignant tumor with a high rate of spread and metastasis. Treat them all the same, huh?

And while you were at home getting angrier at your physician, keep in mind that all the time writing letters of medical necessity to your insurance, waiting on hold, speaking with the “peer” and charting every single communication was all performed outside of your appointment time. This means that not only was it squeezed in between other appointments, but they have zero compensation for any of the work. Hours spent trying to get you the care you need, all behind the scenes, and without pay.

Next time you become angry that your care is being delayed, contact your office and ask the status in a polite way. I’m sure paperwork gets lost and tasks get forgotten from time to time, but the vast majority of time your care is being delayed due to your insurance company and has nothing to do with the doctor trying to get you better. Better yet, the next time you find yourself angry that your care is being delayed, call and ask the office what you can do to advocate for your own care. Can you call your insurance company yourself and plead your case? Can you provide additional information? remember, your doctor is your teammate in your care, your coach even, but is not the sole person responsible for your health.

Welcome

Becoming a physician is a calling. A calling to heal others. To get dirty in the minds and bodies of fellow human beings. To put others first on a quest to keep those around you healthy, active and alive.

Most will enter this world with an inherent and protective sense of naivete. With eyes wide, they flood into the classroom expecting to learn, to grow, and to come out the other side entering a world that has open arms awaiting them.

Unfortunately, the rose colored glasses get removed, quickly. Those who manage to make it through the arduous hours spent studying, end up blinking at the lights overhead in the hospital hallway, half awake and stunned by the reality of residency. If they thought the hours spent in the lecture hall, anatomy lab and at home reading books and memorizing notes were long, they are in for a treat.

Residency comes to an end too though. After years of struggling to decide if sleeping or eating is more important in the rare 20 minute break, the new physician is sent off into the world in a haze of excitement. Finally they will get to do what all those years ago they dreamed of doing. They get to be healers.

You would think then that once they were full fledged physicians, all the turmoil and hardship would be behind them. The pervasive stereotype in America is the slightly rotund, middle aged male physician with so much money lining his pockets he doesn’t even know what to spend it all on. A handsome salary for an easy day job. Walk in late to a patient room, stare at a computer, barely make eye contact, hastily diagnose, throw a treatment at the person and walk out the door in time to make tee time at the local golf course.

Maybe in the hey day of medicine, the 80s and 90s, that was true. I can’t say for certain as I graduated in 2010 from school and 2013 from my residency. I can, without a doubt, tell you that that isn’t true today in 2019 and hasn’t been true for a long while.

The life of a physician in the US in 2019 is much different than the average person believes. I read an article recently that stated that 90% of those who work in medicine will suffer physical and/or verbal abuse by a patient in their career. I laughed. I suffer verbal abuse on the daily at the hands of my patients. I do not know a single provider who hasn’t.

This blog is being written to help everyone understand and navigate the complex world on healthcare in the US. It isn’t the same as it was before and I am sure it will change again. My hope in writing this blog is to help those who consume the goods provided will have more empathy for their providers, more power in their own care, and a better knowledge base to arm to arm themselves with the next time they find themselves or a loved one sick, scared and in pain.