Practice Diary

 

Fam Pract Manag. 2000 Nov-Dec;7(10):49.

Fired!

My FP buddy, Jeff, called me today about a patient I had just admitted with a deep vein thrombosis. It seems she was dissatisfied with my care and had fired me. Jeff was on medical admit and was called by the ER to assume her care. “What happened?” he asked.

“A failure to communicate,” I said. Florence was a 62-year-old, marginally intelligent, emotionally immature woman who was recently diagnosed with uterine cancer and had fired her gynecologist when he told her she'd have to go to San Francisco for treatment. She saw another doctor who told her the same thing, and she acquiesced; her surgery was scheduled for the next week. Although she had been my patient for 10 years, I hadn't seen her for many months, and when I arrived in the ER she already had her nose in the air. I knew she had to be coddled, but I really wasn't in the mood, especially after I'd learned that she'd had her symptoms for six days at home.

“Florence,” I began, “you've got a blood clot in your leg, and it could travel to your lungs. You'll need to be in the hospital on intravenous blood thinners for three to four days and then on oral meds for three months.”

“What about my surgery next week!” she demanded.

“I'm afraid that will have to be postponed,” I said.

She was visibly displeased. Before I left to write her orders, she said, “Call my husband and tell him I'm here.”

That was it. “Florence,” I said, “when you're admitted to your room you'll have a phone and can call him yourself.”

Jeff's call came an hour later.

In retrospect, I could have handled it better, done Florence's bidding, assuaged her fears and indulged her wants, but after 10 years of dealing with her, I was tired of it all. Sometimes we can't be all things to all people, and I was secretly relieved to be done with her. “Jeff,” I said, “I'm really sorry you had to get involved.”

“No problem. You've already done most of the work anyhow. Next time I have a difficult patient, you can do me a favor.”

Teresa, FNP

At first it seemed like just another resume, like the ones I've received nearly every week for as long as I can remember. But when I opened the envelope and unfolded the very professionally done resume, I liked what I saw and was interested enough to read on. Piqued, I called Teresa to talk with her personally.

Teresa is a nurse practitioner with all the bells and whistles. She has an RN, an MS in nursing and IV, BLS/ACLS and PHN certification. She's pursuing certification as an adult and family nurse practitioner and Lamaze childbirth instructor as well. I explained to her I wasn't seeking to employ an FNP (my office was too small to allow us both to work there simultaneously), but I was looking to work collaboratively in creative ways. Right off the top of my head, I said that perhaps she could develop a house-calls-type practice, use my office on Wednesdays (my day off) and consider doing a Saturday morning clinic there. She liked my ideas and asked when could she come up and meet me — would next week be too soon?

I liked Teresa immediately and so did Isabel. So far, she's visited twice and we're both trying to figure out how to make it work. I'm reluctant to make her my employee; I don't want the exploitive relationship that sometimes exists between doctors and midlevels. Instead, I would prefer that she be an independent contractor. We could bill for her services and charge her a part of the practice overhead and a fair amount for my back-up.

What do I want out of it? I want three things: 1) an in-house choice for my patients who prefer seeing a female practitioner, 2) increased service and availability, and 3) if we ever get a hospitalist up here, a chance for my second extended vacation in 25 years!

Rip off

Carolyn, a retired microbiology technician, was seeing me for her hypercholesterolemia at the same time my liquid nitrogen supplier was refilling my tank. “Say,” she commented, “I didn't know you did cryo–surgery. I would have come here instead of going out of town.” Carolyn had some pre-cancerous lesions frozen off the year before.

Curious as to what other physicians were charging for cryo, I asked. “He charged me $275, but that was including a 25 percent professional discount,” she said.

I was aghast. “How much time did he spend with you?” I asked.

“About five minutes,” she said.

“And you paid it?”

“What was I supposed to do?” she replied. “I didn't have health insurance.”

“Gosh, Carolyn,” I said, “with that kind of reimbursement I could stop using Q-Tips and buy a cryo gun.”

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

 

Copyright © 2000 by the American Academy of Family Physicians.
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