Boutique Medicine?

24 12 2011
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“What do you think of the idea of “boutique medicine?” the medical intern asked me, as I glided my car away from the curb, into the traffic.

“Boutique – as in “specialty shop” –  medicine?  Is that what you said?” 

“Yeh.  Boutique medicine.”

“Never heard of it,” I said.

The intern was assigned for this part of his rotation to follow me around for a week, as I visited my hospice patients in their homes.  This was part of his medical training, to learn about this aspect of our healthcare delivery system.  He looked young enough to be my grandson, so I was suspicious that he really was not an intern, rather some guy hitching a ride around town.

“Well, it works kind of like this: you pay a select physician a retainer fee, and that physician agrees to be you doctor, wherever, whenever you need medical care.  He agrees to take on only a specified number of ‘retainees’”.   The intern, I’ll call him John, gave me a questioning look.  Why was he asking me, I thought?  I was a nurse.  He seemed to read my mind.  “Nurses actually see the before and during and after of healthcare, and I’m wondering, based on the patients you see, how this might go over.” 

“How expensive is this “boutique medicine”, because anything prefaced by “boutique” doesn’t sound cheap.  It sounds pretty elite, spendy to me.” 

We pulled into the driveway of my first patient, a gravel inroad, strewn with a broken down big wheel, a tire, and weeds growing up through the gravel.  The lawn, if one could call it that, was more scattered patches of weeds.  A broken-down pick-up truck rested on blocks in the middle of the lawn.  Moss grew from the roof of the rambler-style house, circa 1960-something.  As we approached the front door, we picked our way around broken concrete, which was once a sidewalk.  I wondered, idly, why dandelions and weeds and crocus grew from between these concrete cracks, and not in my lovingly tended garden. 

I pushed the doorbell, heard no sound, except that of children running and shouting mild curses at one another.  I knocked, five times, rather timidly at first.  “So, do you know these people?”  John asked.

“Nope.  First visit.”

I rapped against the door with my knuckles, harder this time.  After a minute or so, a woman came to the door, dressed in a house coat.  She appeared gaunt, her skin sallow, and her eyes drooped at the corners, emaciated. 

“I’m from hospice,” I introduced myself.  “We talked this morning?”  I introduced John briefly, and the woman stepped aside, pushing the torn screen door further open to allow us entry.  The door hung precariously from one hinge and squeaked as it open, then slammed without latching when it slapped closed behind us. 

The living room was strewn with various children’s toys.  The carpet was of an old green, shag model, but I could see it turned up in one corner, and there were several areas where the shag was thread bare.  Christine, the woman, brushed away some debris from the couch, and signalled us to sit.  The couch sagged in the middle, and had been covered with a blanket. 

I asked the routine questions of Christine, and did my initial exam.  She was a terminal cancer patient, with state insurance covering her hospice expenses, with restrictions.  Housekeeping and volunteer help had been phased out.  “Do you have any help, Christine?” 

She snorted when she laughed.  “Well, my kids, but they have school.”  She nodded her head toward the two and four-year old playing a game on the floor.  “Except for the two younger ones, I have two kids in high school.  They help a lot.”

“What about a husband?”  I asked, not being clear from the demographics I’d been given, whether or not she was married.  “He’s on disability, had a back injury a few months ago, and can’t work.”

“Does he have any long-term disability insurance that helps?”  I asked, inwardly cringing at asking such personal questions of a stranger, just after meeting her.  She seemed unphased, resigned. 

“L and I, because it happened on the job.  But it doesnt’ cover anything but his issues, and he has to go in every so many weeks, so they can make sure he’s not ‘faking it’, I guess.”  Her husband, Charles, was currently chairbound, and required a wheelchair for ambulation.  “Someone donated a specially equipped van that he can drive himself around in, but we’ve got some engine problems with it.  Don’t know where we’re going to get the money to fix that.”  The volunteer program, which once could have driven Charles to his medical appointments, had been discontinued, and I felt frustrated that I couldn’t offer that assistance. 

“OK, Christine,  I’ll visit once or twice week, and hospice will cover your meds related to your cancer.  I can order a certified nursing assistant to help you with personal care, if you’d like.  And you’ll be assigned a social worker, to help with financial issues, counselling, and to help you access any programs that you might not know about.  Social workers can be really helpful when it comes to getting through the various government systems.  They also know about charity programs, which can provide some help.”

“What about the other meds, like for my hypertension and congestive heart failure?  The ones I’ve been taking for years?”

I actually felt evil, as I answered, “However you’ve been paying for them before, you should continue paying for them now.  Hospice won’t cover them.”  I knew that Medicaid, the state medical program for those falling below a predetermined income level, had cut back on its coverage of medications.  Christine and her family had had to “spend down” their assets in order to become qualified for the Medicaid program.  That meant, even though they couldn’t afford it, they had to go out and buy stuff, give stuff away, spend money on things they didn’t need or want, whatever they could do to do to get rid of their total disposable assets, to bring that number below $2,000.  Money couldn’t be given to family members, because the state felt that money could be channelled back to the covered person. 

“Are you eating, well?”  I asked.  The Medicaid program, and most for-profit insurance companies had stopped paying for food supplements months ago, unless that was the only source of nutrition, as in the case of a feeding tube.  Christine didn’t qualify for this. 

“I can’t eat much without becoming nauseated,” Christine explained.  “And I have zero appetite.”  She had been buying the generic brand of liquid food supplement from a warehouse store.  “I’ve lost thirty pounds in the past month.”

“I’ll call your doctor and check on which routine medications can be discontinued,” I told her.  Christine’s face took on a look of disbelief.  John’s face mirrored hers.  “I’ll let the social worker know, and maybe there are some programs out there to provide assistance with some of those routine meds and with your food supplements.”  Christine’s eyes teared up.  She appeared defeated, humiliated, and her shoulders slumped forward, as she stared at the floor.  “When you get to the point where you are too weak to care for yourself, the social worker will get you on a waiting list for a state-approved nursing home”.  Privately paying for a nursing home or assisted living facility could easily cost $6,000 to $10,000 or more, per month.  This was clearly out of the question for Christine, and honestly, for most of the population the healthcare system “served”. 

Once John and I had concluded our visit, we got up to leave.  There was hesitation in Christine’s voice, as she asked, “So, when you say you’ll find out which of my routine medications can be discontinued ~ the ones for my heart ~ if I stop them, my heart could get worse, or fail, or I could have a stroke.”  She stared straight into my eyes as she waited for an answer. 

“I know.  And I am so, so sorry”.  Little comfort, I knew.  “But there’s always the chance that Medicaid will continue to pay for those.  I’ll find out.”

John and I climbed into my car.  I turned to him.  “So, did you get your questions answered about Boutique medicine?”

He said nothing.

“What do you want to specialize in, John?” I asked, after several minutes of silence.

John didn’t answer right away, as he watched the cars passing in both directions.  It had started to rain, and the windshield wipers seemed to taunt us.  Finally, John said, “My heart of heart desire is to go into family medicine.  I like the idea of following a patient from birth to grave, and the idea of treating entire families.”  He sounded uncertain.  “But, unfortunately, a family medicine practice pays the least of all specialties, and by the time I graduate from medical school, I’ll be hundreds of thousands of dollars in debt with school loans.”  He shook his head jerkily, his response snappy and sharp.  “So yes.  I got my questions answered about Boutique medicine.  It stinks.  In my opinion, it’s just an elitist program that makes obvious the haves and the have-nots.   And screw the have-nots.”  I blinked, not expecting such a bold assessment from the quiet medical intern.

This question of rising healthcare costs, and how to come up with a sustainable healthcare delivery system is a difficult one, but one that must be answered.  Difficult questions must be asked.  Is it ethical to have a for-profit healthcare system?  Are for-profit insurance businesses ethical?  Is it ethical to profit from a person’s illness?  When a company makes more money if the target consumers are ill, why would they want to find a cure for any particular illness?  If continuing to treat symptoms is better for the stock-holders’ bottom line, why would a business want to find a cure?  Of course, they wouldn’t.  They would want to continue to pursue more and more ways just to treat the symptoms.

In terms of cost-containment, Medicare has an administrative cost of between five and six percent.  And there is no profit margin built-in.  On the other hand, for-profit insurance companies and hospitals and clinics, build in a profit margin of somewhere between thirty and sixty percent: now think about that.  Wouldn’t that be one of the obvious causes of runaway healthcare costs?  Why do we continue to have for-profit medicine, when we know it drives up the cost of medical care, it keeps people sick, and at the same time, we continue to complain about the cost of healthcare?  It doesn’t make sense.  You can’t have it both ways.

In Europe, fees for healthcare are someone set by a government health agency; and yes, there are for-profit providers, and a few for-profit insurance companies in Europe.  But those for-profit businesses must pay a tariff on fees charged above the fees approved by the government. 

The discussion goes on to develop a sustainable healthcare system, both here are abroad.  But, in my opinion, we cannot just leave it at status quo: if you can pay for it, you get it; if you can’t, well then, maybe you’ll just have to die.  That is a death panel, whether it makes you uncomfortable or not.  I’m sure it makes those people who can’t get healthcare and are slowly dying or in chronic pain uncomfortable, too!   Much more uncomfortable that those of us who have healthcare, but must simply wrestle (or not) with the ethics of a for-profit healthcare system.

Some time ago, when for-profit healthcare came onto the scene, big-time, productivity became the word of the day.  Doctors and nurses were given productivity numbers which, if they wanted to keep their jobs, had to be met.  That meant that a given number of patients must be seen per hour, or day, and one problem per visit.  One problem per visit ensures more billable procedures or visits (just like billable hours with your attorney), and more copays for the insurance companies.  In some institutions, productivity has been worked to the minute, as in one patient per 6.521 minutes.  I am not kidding.  So, if you’ve sometimes felt rushed out the door, it wasn’t your imagination: it was productivity giving you a little shove to be on your way.  One doctor told me he had a patient come in with probable strep throat and a probable sprained ankle.  He had to ask her which she wanted treated that day; she’d have to come back tomorrow for the other.  And that isn’t the doctor’s policy.  That’s for-profit insurance policy, created by the board of directors looking for ways to make a thicker lining for their pocket books.

Ask yourself: would you want a doctor making medical decisions for you based on cost, or based on what’s medically best for you?  Would you want a doctor making medical decisions for you based on the end-of-year bonus waiting for him/her (provided by the board) if the cheaper treatment is given, or based on what’s medically best for you, what the doctor knows has the best long-term outcome for you, the patient. 

If you can afford “Boutique” medicine, go for it.  But is that the ethical thing to do?

© Janet Mitchell, December, 2011


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“Bad” Patient, “Good” Patient

12 11 2011
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First, I want to say, and emphasize, that most people who become doctors do so because they want to help people.  This is especially true, present-day, when compensation, especially for the generalist or family physician, is down.  That said, there are always a few bad apples in the medical bushel. 

In the medical world, there exists a practice that is rarely, if ever, openly discussed.  Only with a “wink and a nod” is this practice acknowledged between members of the medical community.  It is a destructive practice, one that has brought untold grief and trauma and devastation to the lives of its victim: the patient.  It is a tragic example of victimization of the victim.  It is the practice of patient labelling, as in “good patient, bad patient”.   It is a blatant violation of the physician’s oath to “First, do no harm”. 

The “good” patient is one who agrees with, and follows the recommendations of the doctor; the “bad” patient is one who has the audacity to disagree openly with the doctor.  This patient is labelled, in the medical record, as being “non-compliant”.  There are other terms that are used to communicate from one physician to another that this is a “bad” patient, such as “somatization”, or “somatically focused”.  

Being told there’s nothing wrong with you, even if you are feeling badly, having the feeling that you aren’t being listened to, or having a disconcerting feeling that you’re being rushed through your appointments, are sometimes the only indication to you that you’ve been labelled.  Listen to those feelings.  They mean something.  They mean you need to take action, and that won’t be easy.

The medical record is like the internet: it’s forever.  So, once a label has been given to a patient, it not only never goes away, it is nearly impossible to rebut, refute and correct.  Doctors who engage in this unethical practice don’t like to be wrong, and correcting an erroneous assessment and documentation requires an admission of error.  That’s why it isn’t often corrected.  But it’s your right to do so.

Countless patients, eventually diagnosed with fibromyalgia, chronic fatigue syndrome, chronic pain syndrome, and many more difficult-to-diagnose and hard-to-treat diagnoses, have first been labelled “bad” patient.  They’ve been referred for psychological evaluations and given psychiatric diagnoses.  They’ve been from doctor to doctor to doctor, before finding one fine, curious, and determined physician who will listen and stick with the patient long enough to find a diagnosis and hopefully, a helpful treatment.  At last, the labelling can be mitigated.  But, sadly, it will never be completely erased.

First, let me share what’s basically (or should be) involved in a visit with your doctor:

* A review of medical history, past and current

* Patient’s perspective of their illness/problem with opportunity to update the doctor on changes since the last medical visit

* Clarification of the patient’s focus of concern

* Assessment of pertinent systems, such as blood pressure, temperature, oxygen level, pulse, lungs, pain level.  Pain is now considered “the fifth vital sign” to be assessed at every visit; this is a law in some states.

* Review current medications and allergies

* Review labs/other diagnostic studies, give patient opportunity to ask questions, explain meaning of test results

* Update social/family concerns that may be affecting patient’s health (based on patient’s own assessment)

* Plan for treatment, discussed and agreed upon by patient and physician.  The physician has an obligation to give you an opportunity to ask questions and provide clarification regarding your medical situation.  The Joint Commission on the Accreditation of Hospital Organizations has made patient-centered care a primary focus at this time.  That means, you should play the central role in addressing your medical situation.  That means, Dr. Welby is no longer omniscient, and only you are qualified to say what you are feeling. 

So what can you do if you suspect you’ve been labeled, or that your medical record is inaccurate?  First, you can request a copy of your medical record.  By law, this must be made available to you, upon request, with some limited exceptions.  You may be charged a small fee for this, but most organizations will provide a limited number of pages, free-of-charge.  You can also request a copy of a specific visit, as in the case of being seen by a doctor for a second opinion, a one-time only visit, or lab and other test results. 

Unless you read your medical record, you cannot know what’s in it.  If you find inaccurate information, put a request for corrections in writing and give it to your doctor.  Ask your doctor to make the needed corrections, or at the very least, to put your original written request for corrections into your medical record.  You can also submit a written rebuttal, if you feel a physician has mislabeled you, and request the rebuttal be added to your medical record.  Don’t expect the doctor to admit to an error or to add an addendum to your record to amend his/her original assessment. 

Secondly, you can take someone with you when you visit a doctor with whom you are unfamiliar, or haven’t yet established a solid relationship.  It’s not a bad idea to have a witness, and it can make the doctor think twice about sticking you with an unwarranted label.  We’ve all been taught that our doctor is someone we can trust; this is usually the case, but unfortunately, not always the case.  Currently, a study is being done asking the question: “How much do we really know about what goes on and is said during a patient/doctor visit?”  For the most part, we know only what the doctor documents.   

One recommendation that I have is to require that, before entering a visit note into a patient’s medical chart, the patient must be given the opportunity to read, then initial or sign the note, acknowledging that what is contained in the documentation was/wasn’t discussed during the visit and that an opportunity was/wasn’t given for the patient to ask questions.  If the patient has concerns about the accuracy of the documentation, s/he would be given the opportunity to execute a separate addendum to the visit note, detailing specific concerns.  Only after the patient has had the opportunity to “authenticate” the visit note, as described above, can it become an official part of the medical record.  The patient would always have the right to waive this “authentication” process simply by initializing/signing a statement, so indicating.

If you’ve had the unfortunate experience of being mislabeled, don’t do nothing.  But stay rational, as angry or devastated or frustrated as you might feel.  Keep it professional.  Don’t lose your temper and “give your doctor a piece of your mind”: that will only make things worse.  Put requests in writing, and keep copies of all requests and reports.  If you have a good, established relationship with another physician, especially if it’s a primary care physician, ask if s/he would be willing to write a rebuttal opinion or response to the doctor whom you feel has mislabeled you.  A legal confrontation can be expensive and emotionally exhausting, but if all else fails, and you feel strongly about the situation, if you feel the mislabelling is closing in on being libelous, that is also your option. 

Patient labelling has to stop.  Until it does, hang on tight, and don’t give up.  And most of all, remember: there’s no such thing as a “bad” patient.  Only a few unethical, perhaps cavalier, doctors.

©Janet Mitchell, November 2011

 

 


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