Practice Diary

 


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Fam Pract Manag. 2000 Jul-Aug;7(7):67-68.

Drivers' physicals

I have a small patient population that I see only every two years: those men and women who come in for their drivers' physicals. It seems that the state won't certify a person to drive those big rigs until it gets some questions answered, not a few of which I think are irrelevant. I can understand visual and auditory testing, but “do you have a hernia” and “do you wear a truss”? “Your heart rate two minutes after exercise”? “A positive or negative Romberg's sign”? Give me a break.

Apparently, many of my drivers consider this mini-exam a comprehensive physical. If I ask them when they last had a good going-over, they reply, “two years ago.”

“No,” I say, “I mean when was the last time you spent an hour giving a good medical history and getting a thorough, hands-on examination, complete with blood, urine and stool testing?” Many confess they've never had that experience. Next, I ask if they consider me to be their doctor. If they say “yes,” I've got them. I wave the drivers' forms in front of their faces and say, “If you're ever in the ER in the middle of the night with chest pains, do you really expect me to come and care for you with these for medical records?”

Now I have most of my drivers trained to come in for wellness physicals every two years, and I throw in the driver's physical free of charge. Financially, they're better off because their insurance usually covers the comprehensive exam while they would have to pay $65 out-of-pocket for the DMV screening. They get more bang for their buck besides, leaving not only with a driver's slip but with a “HealthTrends” chart and suggestions for better health. And if I do have to get up in the middle of the night to go attend one of them, we both can feel better about it.

Health insurance

It's getting to be a frequent occurrence that discontented patients show up in my office with their hospital bills complaining about the cost and asking me for an explanation. What I've realized is that there is a basic inequity built into the system.

Let's say there are three patients, all going to the same out-patient surgery center on the same day for hernia surgery. The center bills each patient $5,000 for the procedure, while the surgeon bills $1,650 and the anesthesiologist bills $600, for a total of $7,250.

Patient A has a policy with all the bells and whistles — a $250 deductible, 80 percent coverage to $10,000 and total coverage after that. It also includes office visits and prescription drugs. His insurance allows the whole bill, so patient A winds up paying $1,650. He also pays an $800 quarterly health insurance premium.

Patient B has a major medical catastrophic policy, with a $2,000 deductible and 80 percent up to $10,000, then full coverage, but only for hospitalizations. His insurance only allows $2,700 of the total bill, so patient B owes $2,140. His quarterly premiums are $300. (Notice that the $490 difference between what patients A and B must pay out-of-pocket is made up for by one quarterly premium!)

Patient C, who has no medical insurance, must pay the entire $7,250.

In the current medical milieu, everyone pays a different rate for the same service according to contracts negotiated between insurance companies and providers. The grossly offensive unfairness is that the uninsured, who have no bargaining power and can often least afford it, have to pay the full fee. Some 44 million Americans remain uninsured today. Perhaps they should be charged the lowest allowable fees accepted by their health care providers. This would make repayment of their medical bills a more likely outcome, while extending them a generous discount commensurate with their income.

Picking up

I have a confession to make: I like answering my office phone. I know it's heretical, but I enjoy picking up and saying, “Hello, this is Dr. Brown.” Usually, there is a long pause on the other end as the patient recovers from shock, but in our two-person office, when Isabel is busy doing an EKG or running an errand, it's either me or the answering machine. If I'm not with a patient, I can do better than, “We're sorry, but we're busy. Please call back.”

This morning, I picked up a call before Isabel arrived at work. It was a new patient, Kimberly, referred by the ER for dizzy spells. “Hello,” I said, “this is Dr. Brown.” No response. “Hello,” I said again.

“Hello?” came a dubious voice on the other end. “Is this Dr. Brown's office?”

“This is he.”

“Oh,” she said, “I didn't expect you to be answering your own phone.”

I have long ago ceased trying to explain to patients my eccentricities, so I simply said that I was the first one in and how could I help her. I spent a few minutes listening to her problem and then made her an appointment.

Kimberly later told us that she didn't much like doctors, and the only reason she made the appointment was that she was impressed I would pick up the phone and talk to a non-established patient. She proved to be compliant, intelligent, warm, friendly and fun to take care of — a definite plus for my practice. I wonder if I would have gotten her as a patient if all she had heard that first morning she called was, “This is Dr. Brown's office. Please leave a message after the beep.”

Pre-medical advising

Recently I learned that Sara, a college professor and my oldest pre-med advisee, got into three osteopathic medical schools! She made me proud. Last year, at age 45 and with low MCATs, she was rejected from all the allopathic schools to which she had applied. We changed strategy, and the allopaths' loss has become the osteopaths' gain.

All of my advisees are nontraditional; some are most unusual. Ravi, a 28-year-old Indian student, was forced to withdraw from college for personal reasons three times, never graduated and amassed a total GPA of 2.25. He wants to be a doctor, and I think he can do it. He has an IQ in the stratosphere, has achieved success in business, is a published poet and has enrolled in Columbia's School of General Studies, where he is top of his class.

Gwen, 36, is a librarian/journalist from South Dakota. She's starting from scratch, taking introductory biology and chemistry this fall. We've mapped out an ambitious three-year plan. Fortunately, the University of South Dakota Medical School only takes state residents; it had 115 applicants last year and accepted 49. Not bad odds.

And then there's Bernard, an exmarine, who commuted 150 miles three times a week to take his pre-med courses. He was accepted into the Nova Southeastern College of Osteopathic Medicine last fall.

But my most amazing pre-med may well turn out to be Jackie, who first wrote to me last month from Arizona State Prison. In an extremely well-written letter, she explained that, although she is a felon, she is attempting to complete her bachelor's degree through correspondence study and she dreams of becoming a physician.

Should a convicted felon be denied admission to medical school? I don't know; she will have, after all, paid her proverbial debt to society. Moreover, there are those of us with sterling pre-medical credentials who become felons (as well as drug addicts, alcoholics, etc.) after becoming physicians. “There but for the grace of God go I,” seems to be our attitude about our fallen brethren as we approve their rehabilitation rather than expulsion from our profession. Besides, medical schools are always clamoring for real-life experiences in their pre-meds. (Personally, I find those who agonize over whether to report their moving traffic violations so tedious.) Intrigued, I've written back to Jackie and am waiting to hear the details.

Dr. Brown is a solo family physician living in Mendocino, Calif., and a contributing editor to Family Practice Management. These excerpts from his journal illustrate the many characters, stories and lessons family practice has to offer.


 

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