Letters

Lions and tigers and elephants?
To the Editor:

Over the years, we physicians have put up with a progression of bureaucratic rats, cats, and even a few dogs in our exam rooms. But the insurance and governmental intruders have finally grown too big to work around effectively. On Jan. 1, an elephant was placed in the exam room of every family physician. That elephant is the new Medicare documentation guidelines put forth by HCFA.

What is the effect of an "elephant" in the exam room?

1. Elephants are messy. Sadly, we will now be spending more time and concentration cleaning up after the elephant, checking our count of systems examined, making sure our documentation indicates a complex problem -- the constant mental gymnastics that siphon our time and fatigue our cognitive energies.

2. Elephants crush people. We may say, "I refuse to be constrained by this beast. I will do as I think best in my exam room, document what is necessary and bill what I think fair." But elephants have a nasty habit of crushing people who don't watch out for them. We have been warned that if we make errors in our judgment (or counting), we may face a Medicare audit, fines and penalties.

If we are to keep high-quality, focused patient care in the exam room, this elephant must be chased out, or at least shrunk down to size! I'm hoping someone out there knows how.

Andrew L. Smith, MD
Boca Raton, Fla.

When the 'customer' isn't right for your practice
To the Editor:

The Staff Management article "Remember Even Angry Customers Are Always Right" (September 1997) offered some excellent advice but left out one of the doctor's responsibilities: discharging the disruptive patient. Sometimes the patient problem is a problem patient.

Treating patients with empathy, understanding and respect is certainly important; TLC can stand for Tactics to Lessen Confrontation. We must recognize, however, that some patients demand so much that they simply cannot rein in their rage, reason or recognize good care. We can do less to control the anger an irate patient spouts than we can to build the trust and praise our satisfied patients spread amongst their friends. Likewise, it is more difficult to find and more important to keep devoted personnel than demanding patients.

Patients are not customers in the customary sense. I hope family practice does not become just another service industry in our consumer culture.

The customer may always be right, but the doctor is always responsible. Our drive to solve problems and our desire to be all things to all patients sometimes shades our judgment. Part of our professional duty is to set limits. Some patients are best served by insisting that they find a practice where they can share reasonable respect.

William R. Phillips, MD, MPH
Seattle

For the web surfers
To the Editor:

All family physicians who face the everyday struggle of dealing with mismanaged care should put the following web site on their must-read list: http://home.earthlink.net/~austintxmd. It is a very helpful site if you want to know which plans are deceitfully cutting payments to physicians (or "providers" if you prefer) and limiting services to patients (or "lives"). Being a physician, not a corporate lawyer, you may not be aware of many of these payment reductions, which may or may not be in the small print of "negotiated" contracts. The web information can help us as physicians decide which plans we should consider "discharging."

Additionally, the web site offers information that is a real eye opener for patients. Its discussion of what physicians do relative to other professions has given my patients a better understanding of my frustrations and obstacles in today's health care system.

Neal D. Johnson, MD
Austin, Texas

We want to hear from you. Letters is an open forum for our readers. Write to Letters Editor, Family Practice Management, 8880 Ward Parkway, Kansas City, MO 64114-2797. If you prefer, fax your letter to 816-333-0303. You may also contact FPM by E-mail at fpmlet@aafp.org. Include your address, daytime phone number and fax number, if any. Letters may be edited for length and style. All letters sent to the editors of FPM are presumed to be intended for publication unless otherwise specified in the text of the letter.

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