Apr 2002 Table of Contents

PRACTICE DIARY

Chapter 34



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Fam Pract Manag. 2002 Apr;9(4):55.

A friend in need

I hadn’t seen Oliver, an old friend from my high school and college days, for seven years when he arrived for a visit. In our youth, he had been slim; as an adult, he had put on some weight; now, he was positively obese, weighing at least 300 pounds.

A chronic migraine sufferer, Oliver had such severe, intractable headaches that he hadn’t been able to work. The headaches had led to an obvious depression. He was on total disability. Outside of his neurologist, he hadn’t seen a physician for many years, so I convinced him to let me do a blood pressure check and some blood tests. His BP was 180/120 and his lab was notable for a fasting blood sugar of 165 and cholesterol of 275. “Oliver,” I said, “you need to take better care of yourself starting now.”

I arranged for him to see a cardiologist friend of mine in the city, started him on some Atenalol and awaited a progress report. A month later, he e-mailed me to say he found my cardiologist colleague a little stiff, but helpful. He was now on Altace as well, he was dieting and exercising, and his blood sugar was down without medication. He also noted he had a new primary care internist, was seeing an endocrinologist, nutritionist and diabetes nurse, and was using some new toys to monitor his progress. “I’m feeling much better,” he said.

“You should be,” I wrote back. “You have more doctors than my 91-year-old mother!”

Oliver ended by thanking me for the good, swift nudge. Another push and a shove in the right direction –sometimes, it’s all people require of us.

Drug money

My wife will no longer accompany me to dinners sponsored by pharmaceutical companies. Besides finding the presentations boring, she feels that these affairs contribute to the high cost of drugs. Truth be told, she has had it in for them for years, beginning when I went to an Academy meeting in the 1980s and returned to our hotel room with a telephone, a lamp and a bouquet of roses. She may have a point, although I think the more likely culprit is the increased size of their sales forces. It used to be that one rep showcased a company’s entire repertoire; now it seems there’s a rep for every drug. Can you imagine making a career out of knowing everything there is to be known about Fosamax or Singulair?

Does taking gifts influence our prescribing habits? I don’t know. I’m more influenced by what I have in my sample closet to give away. For my patients who don’t have prescription drug coverage, my sample closet is a bonanza, and I’ve kept many of them in drugs that they couldn’t have afforded for years. The quicker I empty the closet, the quicker it fills. (Drug reps abhor a vacuum.) When my closet is full, its street value is probably more than $20,000.

So are the dinners and luncheons, pens, clocks, calendars, laser pointers and notepads unprincipled or merely perks of the trade? Are they how drug companies and their representatives seek to influence us, or show us that they appreciate us and value our business? Given the way drug reps dress to the nines, patiently wait for our signatures, are thoughtful of our time and space, and make every effort to please us, it is clear that they may be the last group from which we can get some respect.

I went to dinner on Merck last year. Several months ago, in an effort to remain impartial, I attended one paid for by Pfizer. Interestingly, the same speaker spoke at both dinners for competing products. I took that to mean that there probably wasn’t a whole lot of difference between the two drugs, he too appreciated a good meal and, in this era of managed care, he could probably use the honorarium.

A service profession

It’s almost impossible to buy a bad new car these days. Although there is the occasional lemon, today’s cars are well-designed, reliable and usually covered under generous warrantees. What sells cars today is service – getting treated right by the salesperson especially.

We physicians are not too dissimilar. Often, what distinguishes us is service as well. It starts when the patient calls your office. Is your receptionist friendly or distracted? Does she attempt to get the patient into the office that same day, or does she have to put the patient off because your schedule is out of control? When your patients arrive, do they spend an hour in the waiting room, or do you see them promptly? Do you really listen to your patients, or do you have your hand on the doorknob? Do you call the next day to see how they’re doing, or do you assume no news is good news?

In my solo practice, we have added our own special touches: sending reminder and birthday cards, phoning in prescriptions so they’re filled sooner, drawing blood during the visit so the patient doesn’t have to wait at the lab, and calling with lab, X-ray and biopsy reports as soon as they are available.

Are our efforts working? We don’t see many requests for medical records anymore and our days are usually booked. I don’t think it’s because I’m a better clinician than the doctor down the street, but perhaps I care more – or at least know what’s good for business.

Send comments to fpmedit@aafp.org.

Dr. Brown, a solo family physician living in Mendocino, Calif., is a contributing editor to Family Practice Management.

Conflicts of interest: none reported.

These excerpts from his journal illustrate the many characters, stories and lessons family practice has to offer. No real patient names have been used.


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