Nov-Dec 2002 Table of Contents

PRACTICE DIARY

Chapter 40



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Fam Pract Manag. 2002 Nov-Dec;9(10):69.

Doctor's day off

It began promisingly enough. I had signed out to our new hospitalist and was anticipating a day of kicking back, walking my dogs, perhaps a bike ride, dinner out with my family and a show. But first I made a quick trip to the hospital to visit a friend, who was also my patient, who had had surgery the day before. (Isn't it fun, sometimes, to visit someone without having to round on them?) Afterward, during a detour to the office just to check my mail, I noticed a blinking red light on my answering machine. Should I or shouldn't I, I pondered. Knowing I could run but couldn't hide, I pushed the button. “Dr. Brown, this is Laura Wilson. I'm having a problem. Could you call me?” Laura, it turned out, was having paraumbilical pain that sounded like an incarcerated hernia. I advised her to go to the ER and made a note to call her back later.

I arrived home to find two more messages, this time from Alex, another patient. At 10:45, he had called to say he was having mild chest pain; 30 minutes later, he phoned to say he was experiencing some arm numbness and was headed to the hospital. I called him back and left a message that he had done the right thing. Then I left on a ride.

Although I was officially “off duty,” I couldn't help thinking about my patients. Maybe I need to get out of town to really enjoy myself, I thought, because this system clearly isn't working. After dinner, I called the hospital and discovered that Laura had had surgery for an incarcerated hernia and was doing fine and Alex had been sent home with a diagnosis of muscu-loskeletal chest pain. Just as I hung up, the phone rang. “Dr. Brown, this is Robin Adams. You probably don't remember me, but I was your patient years ago. I don't know who else to call. My six-year-old son has a swollen, tender testicle and ….” As I listened to this worried parent and gave her my advice, I thought, “Day off? It just doesn't come with the territory.”

Grounded!

Ima, my 80-year-old mother-in-law, had been hospitalized for a week with pneumonia following back-to-back excursions out of town for R&R. She simply overdid it and had gotten sick. Since she had survived sudden death the year before, we figured her life was a gift and she should enjoy what time she had left, not realizing how much work it would be to nurse her back to health.

I knew Ima was getting better when she began complaining about her hospital bills, which she couldn't keep straight but calculated to be over $3,000. I volunteered to sort things out, and she handed over her shoe box. The bills from her doctors weren't too bad. But the hospital bill was over $1,500. That can't be, I thought. There's an initial $600 to $700 deductible that Medicare doesn't cover, but why the rest of the charges? I was about to learn about Medicare's outpatient prospective payment system.

Prior to her hospitalization, Ima had undergone several cardiovascular studies and each component had its own line and code. Since they were done as outpatient procedures, Medicare hadn't paid 80 percent of their allowable, as they would have done in the office. In fact, for certain line items, they paid less than 50 percent. Ima's portion of that bill was $688. Ironically, it might have been less expensive for Ima to have gone to a cardiology group I use that discounts for cash.

After finishing my investigation, I said, “Ima, the good news is that you only owe $1,500. The bad news is that you can't go on these junkets anymore because your daughters refuse to take care of you again if you misbehave.”

“Besides,” I said, pulling my trump card, “you do want to live long enough to see your granddaughter graduate from high school, don't you?”

“I'll be good,” she promised.

Zero tolerance

It was the worst of weekends. On Saturday, I attended my son's friend's funeral. Westin, a sweet and gentle soul, had been killed by a drunk driver while driving home from the movies. He came from a loving family, was a premed student at college and was an avid dirt-bike rider. The person who killed him was high on alcohol and speed. He ignored a stop sign and, going 50 mph, broadsided Westin's car.

“What can I say?” I told his father, remembering the articles he used to write for the local paper about our sons' prowess on dirt bikes, signed by “Poppa Wheelie.” What kind of family did the young man who killed him come from, I wondered. Was he loved and adored, as Westin had been?

That night, my mother-in-law phoned to say there was a car in a ditch on our road that had smashed into a tree. No one was at the scene. “Should I call the police?” she asked. I knew the game. The inebriated driver had fled so he couldn't be arrested for a D.U.I. He would return in the morning when he was sober and claim he had skidded on the wet pavement or swerved to avoid a deer, crashed, and left to get help. “Call them,” I said.

An admonition of a man who had been at Westin's service and whose pregnant daughter had been killed by her drunk-driving husband came back to me: “Take their keys away, call 911, slash their tires if necessary –do whatever you have to do to stop them.” So this is what I'm going to do, I thought, in Westin's memory. Zero tolerance!

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. No real patient names have been used.

Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.

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