The Bigger Picture: You vs. Your Patients

So there I was, sitting in my doctor’s waiting room, trying not to let on that I was listening in on an argument between staff concerning another patient and me.

The other patient and I had already had our scheduled exams but our doctors wanted both of us to get ultrasounds - and only one open slot remained that day.

To one staffer, it seemed obvious that I should be the lucky one. After all, the other patient had already left the office, whereas I was right there. But her colleague explained that the other patient’s insurance had expired that day. For her, the ultrasound was today or never.

Yes, I know that it’s an atrocious violation of HIPAA laws, to say nothing of simple courtesy, for these staffers to be having this conversation within earshot of patients. But I admit that that’s not what I was thinking about at the time. I was thinking: It sounds like one of us is not getting in. And these staff members are going to decide which of us is going to be disappointed.

And boom: Just like that, your office is suddenly your patient’s adversary. Conversations like this are happening in big and small practices every day, including yours. Consider that each staffer at my doctor’s office was advocating not only on one patient’s behalf, but also against the other patient’s best interest. Which patient would conveniently receive a service her physician said was necessary? And which would not?

This is one of the lesser-discussed consequences of our broken healthcare system: Physicians and staff are now forced to be the referees in conflicts between patients, insurers, and the realities of supply and demand.

For example, you might get paid more under pay-for-performance if your patient’s diabetes is better controlled, and, sure, it’s better for the patient, too. But getting the diabetes under control means another confrontation with the patient over his diet and how well he monitors his glucose levels.

Yes, this confrontation may happen without pay-for-performance anyway, but now it’s your money on the line when the patient won’t, say, lose weight. If he doesn’t care to change his lifestyle, the system now makes that an issue for you. It holds you individually responsible for someone else’s behavior. It will surely change the nature of physician-patient interactions when the doctor’s concern is not merely for her patient’s physical health, but for her own financial well-being.

Say a patient comes in insisting on a CAT scan for her lower back pain. Clinical guidelines might not recommend the scan off the bat, and payers and specialty societies alike want you to adhere to practices based on evidence, not patient opinion. Now you are fighting with your patient.

A long-time patient owes you $2,000. Do you dismiss her?

A primary-care physician I know noted in a chart his concern that a patient might be bipolar. He referred the patient to a psychologist. The patient never followed up. However, at the patient’s request, the practice sent the chart to a disability insurer as part of the patient’s application for coverage. No surprise, the carrier refused to cover him. And the patient came back to the office yelling bloody murder.

Doctors used to see patients as minions. Then, as something closer to partners. Now, they are more like combatants.

OK, not all the time, certainly, but it happens. And then what do you do?

It sure helps to be clear in your own mind about what the right thing is to do for your patients and to keep your practice open for all your patients. Regardless of managed-care pressures and payment, if you resist extra procedures and focus on preventive services and recommending healthy lifestyle choices, that’s good for patients.

Some will still get mad, but at least you are arguing from an ethical, somewhat removed perspective. That’s better than making choices (right or wrong) because someone - an HMO, the government, your manager - makes you.

Pamela Moore is editorial director for Physicians Practice. She can be reached at pmoore@physicianspractice.com.

This article originally appeared in the September 2008 issue of Physicians Practice.