PRACTICE DIARY

 

Fam Pract Manag. 2001 Mar;8(3):54.

Out of the barn

February 5

Roger was a 56-year-old new patient who had just finished his wellness exam. Outside of smoking and not getting enough exercise, he had no unfavorable health factors in his life. In fact, he was feeling pretty good. His blood work was unremarkable, but I did detect microscopic hematuria on his urinalysis. “I think this is going to end up being benign,” I said, “ but because of your age and history of smoking, we should work it up and rule out some bad characters in your kidney and bladder.” He agreed to go for a renal ultrasound and cystoscopy.

Despite my limited request, an overzealous tech scanned Roger’s entire abdomen. The report was ominous: “The liver is filled with poorly marginated, hypoechoic foci. This pattern is characteristic of metastatic disease.” I never like calling patients with adverse results, and I downplayed the findings until we could get more definitive tests. After years of delivering bad news, you get a feel for how much a patient wants to know and can handle, and Roger was not yet ready for a worst-case scenario. However, a chest, abdominal and pelvic CT corroborated the liver findings, pointed to a mediastinal hilar mass and suggested a tumor in the colon as well. A curbside with a nearby oncologist had me scheduling Roger for a colonoscopy; the greatest likelihood was a large bowel cancer that had spread to his liver and lung. Roger walked on air when the gastroenterologist told him his colon was clean, but he wasn’t out of the woods yet. Next up was a liver needle biopsy under ultrasound guidance, which confirmed our worst fears: “Metastatic, poorly differentiated carcinoma,” read the path report.

Roger’s now an oncology patient looking at his first round of chemotherapy for what is most likely an incurable affliction. And I cannot help but wonder whether we did him a favor or a disservice. Had the ultrasound tech not exceeded her authority, he’d probably not be obsessing about his disease, not worrying about nausea, vomiting and hair loss as a side effect of his chemo, and not contemplating his imminent mortality. Have we added to the quality or quantity of his years with our technology? I doubt it. Sometimes the horse belongs out of the barn.

Medical advice

February 10

“Hello, this is Clarence Chalmers. I can’t believe you charged me $40 to tell me I didn’t need a chest X-ray,” said the voice on the other end of the phone.

Clarence was a 30-something patient who had had a cough for a few weeks. He had a short visit, wherein I took a brief history of his illness, did his vital signs, listened to his lungs and told him he probably had a viral bronchitis but didn’t need antibiotics or a chest X-ray; his condition would improve with time. He felt he had been overcharged.

I find it increasingly frustrating to do the right things for patients who feel they are being shortchanged if they don’t leave with either a prescription or a requisition. I attempted to explain to Clarence that I make my living mainly by giving professional advice, not by pushing drugs or ordering tests. “Clarence,” I asked, “would you have felt you had gotten your money’s worth if I had sent you for an X-ray or prescribed an antibiotic I didn’t feel you needed?”

“Yeah,” Clarence said, “That’s what they would have done in the ER.”

“Had you gone to the ER, they probably would have done the chest film and some blood tests and given you a prescription as well, but the end result would have been the same – except for the price, which would have been several hundred dollars,” I said. “Now, that’s overcharging.”

Patients sometimes have a hard time seeing us as being in the advising business, but they don’t seem to bat an eye when they call their lawyers and the meters start running. Perhaps if our public image was more that of “health advisors” instead of “drug prescribers” it wouldn’t be so hard to send patients away with just reassurance and feel justified in charging a fair price for our services.

Legalese

February 13

A recent phone call to our office illustrated the importance of listening carefully – and always maintaining your sense of humor.

“Hello, Dr. Brown’s office,” Isabel said cheerfully, as she picked up the phone. The voice on the other end was thick, female and Southern.

“Howdy. Can Ah talk to the person who handles the penis?” said the woman.

Isabel almost fell off her chair. For a moment, she was speechless. “What did you say?” she asked.

“Ah said, can Ah talk to the person who handles the penis?”

Now Isabel was getting mad. “Who is this?”

“This is Ms. Paige.”

“Is this some kind of crank phone call?” Isabel asked.

“Ah sure don’t know what yaw talkin’ ‘bout, ma’am. Is there someone there that Ah can talk to about gettin’ some medical records?”

“Medical records? Oh,” Isabel illuminated. “You want to talk to the person who handles subpoenas!”

“That’s what Ah said,” said Ms. Paige, “the person who handles the penis.”

“That’s me,” said Isabel, “whose do you need?”

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 stories, lessons and characters family practice has to offer. No real patient names have been used.

 

Copyright © 2001 by the American Academy of Family Physicians.
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