Citizen of the Month

the writing and photography of Neil Kramer

Talking Health Care with Psychotoddler

doctor2.jpg 

A few weeks ago, Not So Confidential answered some of my questions about gun control. I enjoyed the format.   I doubt that he changed the minds of most of my wimpy liberal Bush-hating readers, but it was cool to hear the other side of the story.  And believe me, while I love Danny and his Huffington Post friends, I’d rather have NSC standing next to me during a bar room brawl. 

Today, I’d like to turn to another subject in the news — medical care.  This has been a big issue for several years, with very little being done.  Things in the media will only get heated up more when Michael Moore’s next movie about America’s health crisis, Sicko, comes out in theaters.

Medical care has become a personal issue lately because of Sophia.  Lately, I’ve been bitching about both doctors and hospitals, and how uncaring they can be.  But what about  the other side?   Aren’t doctors just as miserable as their patients?   Why don’t doctors and patients ever talk to each other?

Psychotoddler is a blogger, a musician, and a doctor.  He was nice enough to take some time out from (playing golf) to answer a few questions.  Feel free to grill him about any issue that is on your mind, and I’m sure he will answer you.  Just be careful not to ask him for medical advice.  He will charge you.

Neil:  Sophia’s surgeon seemed to have been over-confident in thinking that he took out her DCIS, and never wrote down the orientation of the piece, which is now requiring Sophia to get more  cut than necessary.  All doctors obviously make mistakes.  What should be our response to the error?

Psychotoddler:  Sue!  No, seriously, you have every right to discuss the issue with the surgeon and get an explanation of why the orientation was not marked.  You are correct; doctors make mistakes.  The issue is that doctors don’t like to admit mistakes because they fear litigation.  The actual truth is that doctors who discuss mistakes with patients in an open and rational manner are less likely to be sued than those who try to avoid the discussion or cover it up.  Never-the-less, there are lots of lawyers out there who would jump on an admission of error and so many physicians are uncomfortable discussing their mistakes.

On the other hand, not every bad outcome is a mistake.  Sometimes it’s a judgment call that turned out badly.

The trick is to approach your doctor in a serious but non-litigious manner.  Let him know that you appreciate the 99 things that he did right but want better understand why that one thing went wrong.  Try to avoid being adversarial.  A good doctor will respond in kind.  You and the doc should be on the same team!

Neil:  It seems that Sophia usually gets pretty good care because she is always calling and questioning her doctors (as well as shmoozing with them).  Is this the only way?

Psychotoddler:  I’d like to think that doctors provide good care to all their patients, but the truth is that we are pulled in multiple directions all day long and sometimes the simple truth is that the squeaky wheel gets the oil.  On the other hand, squeaky wheels are annoying as hell and most people try to avoid them.

Again, I prefer the team approach.  You need to let the doc know that you’re on top of things and paying attention, but also show some appreciation.  Personally, although I try to be impartial about my patients, I probably do spend more time and effort on patients whose company I actually enjoy than on those that annoy me.

Neil:  Any recommendations for making sure a person gets good care in a hospital?

Psychotoddler:  This is tricky.  I’ve seen this from both ends, as a doctor and as a family member (fortunately, not so much as a patient).  You need to be an advocate for the patient, but not get in the way of patient care.  I’ve seen families descend on hospitals, occupy rooms and hallways, question every staff member and every physician who comes in the room, all in an effort to make sure their loved one gets “good care.”  Generally, this approach does NOT work.  What happens is that the staff starts to avoid the patient’s room.  If an aid or a nurse or even a doctor knows that they’re going to get a lot of hostility or endless questions, or just feel uncomfortable with all the people in the room, they will try to go in as little as possible.  And in general, this ends up being bad for the patient.

The patient is in the hospital because they need the care that the staff provides, so every effort should be made to make the staff want to respond to calls and come into the room.  Keep visitors to a minimum.  Don’t yak on a cell phone (even if the hospital allows it—but especially if it doesn’t!), don’t feel the need to question every pill that gets dispensed.  It’s enough to let the staff know that someone cares and is paying attention.  Try to get the nurses on your side.   An overbearing family can put a patient on the nurses’ sh*t list quickly.  Be pleasant.  Smile.  Bring candy for the staff.  Let them know you respect them, not that you don’t trust them or think they’re goofing off.  In many ways, the care that the patient gets from the nurses is more important than that from the doctors.

That being said, some places are just BAD.  My mom did all those things and my dad STILL got crappy care.  Know when it’s time to bail out and transfer.

Neil:  Are nurses undertrained?

Psychotoddler:  I think nurses are better trained now than they’ve ever been.  Many function on the level of a physician’s assistant or higher, especially on specialty wards like ICUs and Cardiology floors.  The issue is that not everyone who looks like a nurse is an RN.  Nurses are expensive and hard to come by, and many hospital floors have a handful of them and then a bunch of nurse extenders, like aids, certified nursing assistants, etc, who have minimal training.  If you’re not sure about who’s giving care, don’t be afraid to ask.

Neil:  Are hospitals understaffed?

Psychotoddler:  Yes.

Neil:  If you had to go into a hospital, does saying that you are a doctor, give you special treatment?

Psychtoddler:  I am loathe to mention that I’m a physician.  I’m probably in the minority on this, though.  I hate the idea of privilege, and have no problems with waiting in line.  My mom, on the other hand, was sure to point out to everyone we encountered (the guard in the lobby, the elevator operator, the nurses and aids, the doctors and I think a few of the janitors) that I was a doctor.  I suspect that on one level it does give me more access and makes the staff take me more seriously.  On another level I think some providers are threatened by it and try to play their cards close to the vest.

Neil:  Doctors used to be thought of on par with Gods.  Now they are one notch above lawyers.  What happened?

Psychotoddler:  We let others take the reins of medicine from us.  Bureaucrats, legislators, HMO administrators.  We allowed them to take our profession and hack it up into little bits.  As a result, we surrendered our authority.  Most doctors used to be self-employed.  Now many if not most are employed by large hospital corporations.  We are like 1.5 or 2.0 FTEs, subject to the whims of middle-level administrators and can be fired at will.

I also think that the proliferation of readily available medical information, whether on the internet or through the mass media, has served to empower patients, and that power has been transferred from doctors.

Neil:  Patients are always complaining about medical care nowadays.  But I hear that being a doctor is just as bad today, especially compared to the way it was in the past?  Why is that?

Psychotoddler:  Medical care is actually much better now than it has ever been.  People are living longer, healthier, medications are better, taken less often, with fewer side effects.  We have procedures that can fix blockages in the heart and limbs, where in the past dangerous and painful surgery was the only option.  We have better diagnostic tools than ever before, almost on par with Star Trek.

But it is also more expensive than ever before.  Because it costs so much, it is much more regulated.  People complain about medical care because they have to pay so much for it and yet it seems they have less access to it.  There are many layers between the doctor and the patient, and just because something can be done doesn’t mean it will be done, if it needs to go through a maze of HMO prior authorizations.

People are also paying much more out of pocket, even as opposed to 5 years ago.  And yet for this extra expenditure, many are seeing a paradoxical decrease in service.

From the doctors’ perspective, they are getting paid less and less and working more and more.  There is more paper work than ever before.  Since the new Medicare drug plan went live, my paperwork has tripled.  Every month I have to submit new prior authorization forms for the same medications that patients have been stable on for years.  I have staff members who now spend full time on the phone with insurance companies and pharmacies trying to get my patients their pills.  All this costs money, and as a result more patients need to be seen and less time can be spent with each.

Documentation regulations are out of control as well.  Doctors at this point don’t get paid to provide care.  They get paid to produce documentation.  There are now computer programs that can spit out an entire history and physical report even before a patient is seen.  In the hands of less scrupulous providers this can lead to inaccuracy or even fraud.

Neil:  Everyone thinks doctors are fabulously wealthy.  How long does it usually take to pay off medical school expenses?

Psychotoddler:  A typical doctor pays of thousands of dollars per month in medical school loans over a ten year period.  If, like me, the doctor was not blessed with wealthy parents, he may be burdened with high-interest 30 year loans as well.  I was fortunate enough to finish paying off my loans about a month before I started taking loans out for my daughter’s college tuition.

Doctors who do a lot of procedures, ie surgeons, cardiologists, gastroenterologists, make a good living.  Those of us who rely on dispensing advice, like internists, pediatricians, family practitioners, make relatively little.  I live paycheck to paycheck.

Neil:  Why do doctors seem to care so little about their patients?  Are they seeing too many patients?

Psychotoddler:  Everybody is different.  I don’t think my patients will tell you that I care little about them.  Surgeons, by nature of their practice, are on a tight schedule and may not have a lot of time to chat, and may come off as aloof or uncaring.  Primary care doctors may have a little more time with their patients.  But not everyone is a people person.  If you really don’t feel like your doctor is there to help you, maybe it’s time for a new one.

Too many patients?  You know, you can’t have it both ways.  Above I mentioned the pressures on physicians to see more patients (and by the way, employed physicians may have very strict requirements to see a certain number of patients per day).  At the same time, patients want to see their doctors in a timely manner.  A doctor could see fewer patients per day, thereby spending more time with each, but then many who want to be seen would be turned away.  And the doctor would probably not be able to keep his doors open for long without either overcharging the ones that come in or finding some alternate means of income.

There are some physicians who charge a premium, say a few thousand dollars a year, and in return limit the number of patients in their practice, enabling them to see fewer patients for longer appointments and be available quickly for them.  Obviously this would only work for a few providers out of many, as someone has to see all the other patients.  What’s interesting is that people now have to pay a premium to have the kind of interaction with a doctor that was the norm 40 years ago.

Neil:  Do you think there is too much specialization?

Psychotoddler:  Yes.  Not everyone needs to be a cardiologist.

Neil:  Do you have any specific ideas on what you would do about health care or health insurance if you were President of the World?

Psychotoddler:  Yes.  I would ensure that everyone had affordable health care coverage, that no one had to pay excessively out of pocket, and that paperwork would disappear from the face of the earth.  Also, I would make sure that we colonized the Moon by 2014 and that I could take a rocket ship ride around the rings of Saturn.  I’ve always wanted to do that.

Neil:  When I was a child, my family doctor would do all these tests, including holding my balls and making me cough.  My family doctor in LA has never seen me naked — in ten years.  Should I change doctors?

Psychotoddler:  I don’t blame him.  I don’t want to see you naked either.  Seriously, there used to be something called the “annual physical”, the purpose of this was to get you naked so your doctor could look you over and screen you for things that you didn’t know you have, because they weren’t bothering you at the time.  That’s called “preventative medicine.”  But then Medicare and many other insurers decided not to pay for it.  So it doesn’t get done.  Many of us still do this.  You may need to tell your doctor you want an annual physical, and be prepared to pay more out of pocket for what the insurance refuses to cover.  Otherwise you may only be interacting with your doc for “problem visits”, and given the time constraints we mentioned, that doesn’t leave time for the other stuff.

Neil:  A serious question — why are magazines so BAD in doctor’s waiting rooms?  Why do I want to read his old Golf magazines?  This shows the doctor as uncaring right from the start. 

Psychotoddler:  We take all the good ones home for ourselves.

Neil:  Would you want your son or daughter to be a doctor?

Psychotoddler:  From the perspective of working very hard, getting massively in debt, and then ending up in a profession that is a target of lawyers and legislators, working unbelievably long hours, for less and less prestige, the loss of privacy, constantly being a slave to the pager, etc, I’d say “no.”

From the perspective of this being a wonderful way to make a living helping people, I’d say, “yes.”  I love my patients and I love what I do.

Neil:  Are most of your friends other doctors?

Psychotoddler:  I have no friends.

Neil:  Do doctors treat patients differently according to their health plan?

Psychotoddler:  Yes, primarily in the sense that different plans limit what you can prescribe or order.  You have to factor that in when you make decisions.  It’s nice to say that you go all out for everyone, but after a few come back and complain that insurance didn’t cover their MRI or whatever, you learn to take these things into account.

Neil:  What’s the deal with all those sexy blond sales reps?  Do you go out to lunch with them?  Will they go out to lunch with me?  Have you ever bought Prozac over Wellbutrin because the salesgirl bought you a nicer lunch or had a better ass?

Psychotoddler:  I’d love to answer this, but there’s a hot drug rep waiting for me.

P.S. — Sophia has a question now that she dares Psychotoddler to answer honestly:  “Isn’t it true that doctors make more money from HMOs if these patients DON’T come in for visits?”

A Year Ago on Citizen of the MonthWatch the Road

50 Comments

  1. Enlightening, funny, a great piece. These interviews are a great format, I’d love to see more of them.

  2. Neil, That was an enjoyable entry. My youngest son may soon be going into the hospital and the one thing I think about the most is the personal care that he will receive when I am not there. Good job on this.

  3. The topic of health care in the United States makes me uneasy, angry and I won’t comment further.

    Thank you Psychotoddler for your honest answers and Neil for asking the questions and offering the entry.

  4. Neil and Psychotoddler, thank you so much for this interview. I too have been going through a lot with many, many doctors and it’s helpful to know their side of the story, at least from your perspective. In my near-30 years of life, I’ve only seen a doctor maybe three or four times until this year, when I’ve had to have a colonoscopy, stress echo, and thousands of blood tests. I am scared of doctors. Sometimes they tell me things I don’t want to hear. I’m scared of insurance. Sometimes they don’t pay for stuff and I don’t have much money. What’s the alternative? Die? Deal with the pain? I dunno. I do have sympathy for doctors. I tried putting myself in their shoes and the only thing I can come up with is that it’s got to be a really hard job. All around, it’s just so frustrating. I applaud you for doing it anyway. And thanks, Neil, for the insight. It’s really helpful for me to know a little bit about what’s going on on the other side during my own ordeals.

  5. Very timely post Neil…as I was just doing some research on behalf of my eldest…who’s applying to Johns Hopkins this fall. She wants to go into research…Pathology. My mom is a ICU nurse..and has held lots of hands and answered a lifetime of questions. I believe being a health care professional should be a calling. Just like being a priest, rabbi,or teacher. You must have the head for it…but without the heart, not much healing is likely to take place.

  6. You can call me, 'Sir'

    May 22, 2007 at 6:23 am

    Great interview, Neil. Great answers, Psycho. Excellent question, Sophia.

  7. Great interview, and this portion:

    >The actual truth is that doctors who discuss mistakes with patients in an open and rational manner are less likely to be sued than those who try to avoid the discussion or cover it up.

  8. One of my close friends from high school became a doctor. He eventually became a refractive surgeon so he could escape (for the most part) the insurance and payment nightmare and only have to worry about little things, like accidentally blinding a LASIK patient and being sued.

    The doctors I know are STRESSED. In the U.S., all the doctors that I started with (my ob/gyn, the kids pediatrician, my family doctor) ended up leaving clinic practices and starting private practices to gain some control over their working conditions and patient care.

    I’ve received awesome medical care here in Belgium. I’ve been here for two years and been treated and tested for heart problems as well as all the standard annual medical care and no lie, I have not filled out one form yet. The doctors don’t have receptionists, staff, or nurses–they do everything themselves because they’re not drowning in paperwork. I spent one HOUR with my cardiologist, and I wasn’t even dying! Woo hoo!

    I know social medicine is a mess in many countries but it seems to work here: happy doctors, happy patients.

  9. Thanks for this guys. Very enlightening and helpful.

    And now I must ask Psychotoddler a very important question: Have you ever had the hots for one of your patients? How did you handle it?

    Someone had to lighten the mood, didn’t they?

  10. I used to be a nursing assistant in a major teaching hospital. I had a degree in English, but I still did everything the nurses did except, give shots, but I did it for $8/hour.

    I agree with PSychoToddler on making friends with the nurses. They are the ones who really know what’s going on.

  11. I used to be a nursing assistant in a major teaching hospital. I had a degree in English, but I still did everything the nurses did except, give shots, but I did it for $8/hour.

  12. Finn — I wouldn’t be surprised if Psychotoddler went into medicine after enjoying playing “Doctor” as a youth.

    By the way, it is too bad that Psychotoddler is married because he is every Jewish girl’s McDreamy.  He is a doctor AND a sexy ROCK STAR.  (Check out his hip Hanukkah song, Sevivon, from the  The 2006 Blogger Christmahanukwanzaakah Online Holiday Concert).

  13. This was a great post, Neil. Thank you and Psychotoddler for doing us this service. When choosing a practitioner, getting back to the cheesy song theme, “You’d Better Shop Around.” As a lifelong severe asthmatic, I recently fled an allergist. He wasn’t incompetent or unpleasant, I just had a very strong, weird intuition that something wasn’t right about the practice. Much happier now.

  14. I am a tad jealous – he got better questions than I did. What? You don’t think cops get women with those cuffs and uniforms? Okay, I don’t wear a uniform but I have two sets of cuffs.

    On the serious side, it was interesting to hear what he said about physicals. If I didn’t get a very in-depth physical for my annual employee health certification I don’t think I would ever get one. All my HMO doc does is do some bloodwork and make sure I am still breathing.

  15. By the way, as “bad” as health care is in the United States, it is far, far better than almost any other nation out there. Much like our justice system – sure it is flawed, but find me a better one.

  16. Wow, thanks guys. This was fascinating!

  17. Fascinating post, thanks so much to both of you. And Neil, you’re so right about the bar room brawl—I’d be hiding behind you. Just make sure that NSC and Sophia are there to protect us!

  18. “Have you ever had the hots for one of your patients?”

    I have developed some wonderful friendships with my patients over the years, and I feel guilty when I spend time just yakking and joking with them. Because they’re paying me for medical advice, not shmoozes.

    But have the hots? There’s only one girl in the world for me.

    I just hope my wife doesn’t meet her.

  19. I love this post (and your blog). I am a dual citizen — USA and Israel. Guess where I get top affordable health care. Guess where I learned to be a proactive health care consumer. Nothing, no country, no system is perfect. And I know that I am blessed to have benefits/rights/responsibilities of citizenship in two democracies.
    Many Americans, Europeans, and other nationals flock to Israel for more affordable cost-effective top care (physical, dental) for which they pay, of course, out of pocket. They also flock to Mexico, for example, for affordable care in some specialties (obesity management surgery comes to mind). I know Israelis who go to Russia (yes!) for top quality (German-trained) highly cost-effective dental caregivers. While folks are flying around the continents, the airlines are doing well (and I am glad for their services, too). Meanwhile, the USA health care crisis is only worsening while the well-insured and their reps have been trying to take (not just candy, but) medicine from poor babies.

  20. Good post. Glad to see you’re keeping your sense of humor, both of you.

  21. Oy, he’s a devoted doctor, rock musician, AND funny as hell–Psychotoddler IS the real-life version of McDreamy. Which reminds me of a question I’d like to ask: Do shows like “Grey’s Anatomy” bear ANY resemblance to reality? Are doctors really that promiscuous? Are there really that many hookups between doctors and interns? Are the cases really that interesting? I spent a few hours in the Cedars-Sinai ER the other day and was disappointed at how “boring” it seemed compared to NBC’s version. How often, in the course of a week, do you have patients citing things they saw on TV or read on the Internet? We are a nation of people who think we have medical knowledge because of our pop culture offerings.

  22. Danny–the most acurate depiction of the practice of medicine I have ever seen on TV (barring maybe the first episode of ER) is Scrubs. And I am being TOTALLY serious here. The rest is a total crock.

  23. I agree that these interviews are fantastic! It’s so interesting to hear such details from bloggers … I don’t know why… I suppose I assume that everyone’s a young professional just like me! 🙂

  24. Very funny and very informative…

  25. Great interview, both of you. I really enjoyed it.

  26. Long hours on your feet with peoples lives in your hands. Too much pressure for me. I give y’all credit!

  27. I wanted to clear up a misconcepion that PT MD made regarding surgeons make a lot of money.

    This is ENTIRELY dependent on the region he or she practices.

    True, there are some geographic regions that can do this. Some areas like West LA, can say, “Oh, no. I don’t take HMO insurance. Some super specialists who have say, loads of celebrity patients, can even say, “No, I don’t take PPO or HMO. I take cash.” (I went to an orthopedic surgeon who did this. Her “proposed estimate” for a bunionectomy was 13k. I negotiated to 2x Medicare rate). Also, there are specialities such as plastic surgery, which is all cash. You want new boobs? You pay for it cash. Ironically, if you have a complication later on… say your boobs get hard due to scar tissue….your HMO or PPO will pay for the removal!

    However, in most parts of the nation, surgeons are at the very end of the contracting chain. This means that in order for them to get a patient, the patient must be referred to them. By the time the patient’s health dollar goes through the 1. Insurance company. 2. IPA bureaucracy 3. Primary care physician, it finally gets to the specialist.

    All rates are pre-contracted, which means that a physician is getting “x” number of dollars through that insurer. It could be anywhere from the low end of 70% of Medicare to 110%. Mind you, if a specialist is getting 100% of medicare, often this isn’t even enough to break even.

    And like PT MD, the surgeon I work for lives paycheck to paycheck, only gets paid after he’s paid his employees.

    The only people getting rich in this are the administrators of very large insurance companies, the owners of IPA’s and also some hospital administrators.

    My own feeling is that we will NEVER have a comprehensive system just like in Europe, Australia or the UK. Over here, we have a lot of middle men, in fact, you could say the most influential people in your life are insurance companies. They not only dictate what you pay for insurance, they also dictate what they’ll pay MDs and hospitals AND also what the MD must pay back to them in terms of Malpractice insurance.

    Why? Profits.
    All of these insurance companies are privately owned. They’re here to make money. The private sector has even moved into Medicare and Medi-CAL (known as Medicaid in the 49 other states) by acting as subcontractors –thus winnnowing down the dollars paid out even more, and also further restricting services rendered.

    We might work toward better comprehensive care, but to say we can flush all the middle men out of this, just isn’t going to happen where there’s profits to be made.

  28. great interview!
    my family has been blessed with what i consider “good doctors”, we did have to deal with a surgeon at one point that had what i considered to be absolutely no bedside manner, but looking back i think i prefer knowing i had a good surgeon and look to his team for the bedside manner. i’d say it’s a tough call for what sophia should do.

  29. Sophia: The original HMOs worked on a system called capitation: meaning that the doctors or health organizations got paid a fixed amount of money per patient to provide for the patients’ needs over a year. If the group spent more money than it took in, it would lose money (ie it would spend money on the patients’ care and not be reimbursed). If it spent less money, it would keep the extra as profit. This basically shifted the burden of managing health care costs from the insurance company to the doctors. It created an incentive to provide more efficient care. So technically, a doctor could decide never to see any of the HMO patients and make a bundle. Fire all his staff and take a year long vacation. Etc. The problems with that plan are a) the patients would get pretty pissed and disenroll from that physician’s panel, b) it is actually much cheaper to KEEP people healthy than to pay for care once they are sick (stitch in time, etc). So HMOs developed all kinds of policies to keep preventative medicine up at the forefront of care. But of course a lot is still out of the doctors’ control, and once insurance companies figure out that a group is making a profit, they lower the cap for the following year (Medicare HMOs were notorious for this).

    Needless to say, most physicians don’t care for the risks involved. Did I answer your question?

    Wendy: “I believe being a health care professional should be a calling.” I couldn’t agree with you more. I’ve said as much to my own kids. Especially in today’s climate, nobody should get involved in health care unless they really really really REALLY enjoy working with and helping sick people. There are simply much easier ways to earn a buck.

    V-GRRRRL: Americans aren’t ready for socialized medicine. We don’t like to wait for things or stand in line. We want instant gratification. We don’t want to be told to wait 3 weeks to get an appointment for a sinus infection or 6 months for a gall bladder operation. We want what we want NOW.

    Dana: “something wasn’t right about the practice” Not sure what you’re referring to but, especially in the field of “allergy”, there are a lot of quacks out there peddling snake oil. Here’s a free tip: Not sure if a treatment is legit? Look it up on http://www.quackwatch.com

    Don’t say I never gave you anything.

    Tamar: Israel, as you know, has a two-tiered system. A socialized system for the masses, and a fee for service (ie cash) system for those who can afford it. I know quite a few Israelis who come to the US for care because they’re unhappy about the level of care in the Israeli system. But then again, maybe they’re just spoiled American Expatriates.

    Danny: Aside from the scrubs comment, I find most medical shows boring and insulting. I come across a few cases every week that are much more interesting than the disease of the week variety, and that’s just in my role as a primary care provider. I’m sure there are promiscuous docs out there, but I can’t say that I know any of them personally. Probably a lot more goes on than people let on to in public (or to me—then again since I walk around with a yarmulkeh, many people assume I’m religious and easily shocked). As “ER” evolved over time it became more and more fantastical. There’s no way anyone could keep up the pace they portray. Most codes aren’t frantic yelling and shouting affairs. The first pulse you take is your own. And transplants in the ER? PLEASE.

    I get fairly frequent email or clinic inquiries about the latest news from the drive-by media. Right now I’m reading up about the Avandia debacle, in anticipation of the deluge of calls from patients who are sure they will die if I don’t get them off it in the next 48 hours. I tell people that just because it’s on the internet doesn’t make it true.

  30. Holy crap… this blog is a thousand times more interesting and informative to me if I just let others write stuff! Fascinating.

  31. Yeah, Neil.
    I think you should come over to my blog and write a tomorrow’s column for me. You’ll be my “guest bloggist.”

  32. This is a great interview! I’m currently waiting for my book from Amazon called “How Doctors Think” – this is a nice glimpse that answers a few things I had been wondering about myself.

  33. Very interesting post, Neil! Thanks for giving us all something to think about. I’m personally glad I didn’t go to med school. But I’m not sure that law school was any better as an idea.

  34. Somewhere I should put in a disclaimer that the opinions expressed here are entirely my own and made up and probably wrong and may not represent the feelings of your own personal doctor.

  35. I am proud to call myself psycho.

  36. i have to say, this is definatly more productive reading than the research that i need to be doing for my relocation…

    i have only had problems with 2 doctors – male ob/gyns.. they dared to tell me that my dibiltating cramps were in my head… um, no – that is my foot connecting w/ YOUR head…. and then i walked out of the office w/ my file

    i absolutly love every one of my doctors – well, ok, my neurologist is a bit, well… off (i am actually pretty sure he has adult aspergers) – but he listens to me and we work together to make my migraines much better…

    my pcp – i tell people she is the kind of woman that i want hang out w/ at panera and chat over a bagel, not over my medcial chart (hell, 3 people have switched to her – i am waiting for my referal commission)

    i am also lucky enough to go to the #1 ob/gyn in town AND to have been refered to the #1 mamographer in town (if you have to go to one, you might as well go to the best, right?) – both of them are they type of women who when it’s a hohum regular visit are do what they need to do.. but if ANYTHING is iffy, they are with you 100% as long as you need them

    my ENT and I rip on each other about skiing during my appts – he broke his leg at vail this year, and the year i didn’t have heath insurance, he 1) ate my annual vist fee & 2) mandated in my chart that every month the nurses give me a box of allegra samples when i picked up my allergy shot supplies since i was paying for it all out of pocket and he said that if they refused that i was to have him paged and wait for him to come out to the lobby – i did it once and well, never had an issue again (and yes, i sent him a thank you note the day my health insurance came through)

    there ARE wonderful doctors out there – and i appreciate every single one of them

    and i thank you too

  37. Thanks Neil and Psychotoddler. I’m about to spend several days in hospital while my Dad undergoes major surgery and recovery, so this is extremely timely and helpful!

  38. Edgy — I’m sorry to hear that.  Good luck and good healing.

    Next idea for an interview: with a mommyblogger!

  39. Man! (Men! You go, guys!) Even more info in the comments! Neil, I think you’ve hit a winning niche here. And PT, you weren’t sure what I meant; it boiled down to total lack of confidence. I was supremely uncomfortable in the [multiple town] offices. Thanks for the quack site. I’ve had many wonderful allergists in the past, but I moved states again and this time something went awry. (I only had two choices and the others were booked out more than three months for a consult. That should have been my tip-off, but PCP was determined to get me in somewhere immediately. My default allergist here was using conventional treatments; no surprises, no outright quackery. It was just strange because 1) patients came in in absolute standing-room-only droves and behaved like lab mice or sheep; 2) when I asked lots of intelligent specific questions they were waved off as unimportant and I was told not to worry, with no explanation; 3) they pressured me to bilk my insurance company for “anti-asthma” injections that would have cost $1000 every two weeks–I knew the company wouldn’t pay, and anyway I was ethically against supporting such a superfluous expense and lining the pockets of big pharm (I did the research and didn’t find conclusive evidence that it was effective) 4) the doctor himself never offered further information when asked, had a strange ritual of shaking the hand of every patient and smiling at them like a possessed cult member bent on converting everyone to something . . . 5) I never saw anyone come in for acute events, which allergic people typically did at my other allergists’–the immediate cases should stand out like sore thumbs; it just said “weird” to me all over. In contrast I went to the dark side–pulmonology. Much better care, obviously understandable science, more explanations, no weird handshakes, and–the biggie–all-around awesome lack of asthma attacks or even the daily usual for more than six months!

  40. i used to be a (non-hot) drug rep and feel quite jaded by the medical industry as a whole from both the insurance and drug companies.

    needless to say, it was good money but quite glad i’m not abused on a daily basis for the cash cow.

  41. Okay… a bone doctor is an osteopath.
    How come a brain doctor isn’t a phsycopath?

    When my Mother-In-Law came home from her latest hip surgery they proscribed a really expensive anticoagulant that Hubby would have to inject into her every day. As she was leaving a nurse made an offhand comment along the lines of, “I wonder why they did that”. Hubby called to talk to the doctor who had proscribed it and got a PA who was very rude and said, “well, she was JUST a nurse”. Hubby said, “I asked to talk to her doctor and you are just a PA”. When he got the doctor on the phone and it came out that she hadn’t taken any anticoagulants in the hospital, he said, “well, just have her take an asprin every day”.

  42. Docs are important. They deserve to be well compensated. I can appreciate all of the hours and hard work, but it is still not digging ditches.

  43. Really great write up Neil. I was just talking with a friend about this the other day.

  44. PT: “Halevai” that you should get so many comments on your own posts!

    Great interview questions, Neil. I like this “Get To Know Your Readers” format; hope you do it again.

  45. True, it’s not digging ditches, but let me put this into perspective.

    A consult comes into our office. She bitches when we ask for her $10.00 copay.

    Now, prior to coming in, we’ve done the following:
    -checked the referral and authorization
    -booked the initial appt. by calling the patient
    -took and input the information into our database
    -called for various test and reports that might be needed for our consultation.

    THE DAY OF
    -checked in the patient. reviewed the records. ascertained it was all correct.
    -took patient history. spoke to patient before doctor came in. wrote down history. input history into computer.
    -examined patient. talked to and advised patient. answered any questions.
    -ordered labs. wrote prescriptions.
    AFTER PATIENT HAS LEFT:
    -dictated or wrote patient history. gave diagnosis about current condition. made recommendations.
    -sent copy of consultation to the referring doctor.
    -copied all relevant documents and sent to biller.

    If the patient needs surgery, we will spend extra time seeking an authorization from the insurer. Once we get it, we have to spend time scheduling it and then sending further instructions to the patient.

    In all we’ve spent an easy 2 hours on each patient….. and that’s without scheduling surgery yet! Add another 2 hours just for that! If they decide to cancel, we have to do it all over again.

    Factor into this that the patient has seen or talked to at least 3 different office personnel. They’ve spoken to the doctor, who has at at least 12 years of education.

    Our pay? Because it’s an HMO, we’ll get anywhere from $25 (Medi-CAL)to $70 for an office visit. That’s it.

    Break it down hour by hour, and it comes close to making less than a clerk at Costco.

    This is why medical school enrollments are down. Quite frankly, in the future you’ll have a better chance of finding a veterinarian than you will a specialist in many areas of the US.

    But then this could be convenient. Just take your dog in and ask the doc to have a look at what’s ailing you too.

  46. Psychomom: Psychos of the world, UNITE!

    Edgy Mama: Good luck with your dad. This interview came about largely through commiseration with Neil regarding care our parents received at various hospitals. I blogged extensively about my dad’s illness and death (http://psychotoddler.blogspot.com/2006/01/dads-status.html) but you may want to stay away from that right now.

    Dana: Ok, that’s something else. You’re just not confident that they’re doing their jobs correctly or listening to what you have to say. As my wife likes to say, “Click ‘Next’”.

    Gorillabuns: Drug Repping is one job I know I would be lousy at…

    Jack: …and digging ditches is another. Trust me. You DON’T want me digging your ditches. I’m happy to stick my finger up your butt, but leave the ditch digging to the professionals. Did I ever mention that I shoveled dog crap for the summer prior to medical school?

    Marilyn: NOT PRACTICING MEDICINE HERE but it is common to prescribe blood thinners like Lovenox (probably what you’re talking about) after hip surgery to decrease the chance of blood clots in the legs or lungs. Yes, they’re uncommon, but I see a few every year (I’ve got one in hospital right now) and trust me, it’s better to prevent them than get them. Aspirin is not that great at preventing them. Usually they use warfarin, which is a cheap pill, to prevent the clots. Some doctors will use the injectables until the blood test for the warfarin is therapeutic. BTW don’t underestimate the thoroughness of either the nurses or the PAs: they really are keeping it all together.

    Pearl: Was that a shot? Are you taking a shot at me?

    Kanani: I think a lot of people don’t really understand that a “copay” is not an extra little fee dinged on by the clinic or insurance company to keep nuisance patients away, but is actually part of the payment for the doctor visit. I have patients whose insurance requires a $25 copay. What that really means is that the insurance has cut its reimbursement to me by $25 and now expects me to collect that directly from the patient. So if my visit fee is $50, and I don’t collect the copay, I’m only getting paid half.

  47. FD and I have a bunch of kids. NONE of them went into medicine or mental health. We got a d-i-l who’ll become a PsyD when she graduates. At some point the kids watched us and said to themselves, too much work, too little pay, too little respect, let’s try something OTM (other than medicine). Too bad.

  48. Break it down hour by hour, and it comes close to making less than a clerk at Costco.
    Kanani,

    Sorry, I still don’t feel much pain. There are a lot of professions in which people spend hours before and after without any guarantee of being paid.

    Most of the docs I know do not work for free and are not handling a lot of the administrative duties.

    If people cannot pay they get shuffled out to county or some other low income clinic.

    Don’t get me wrong, I think that docs deserve to be well compensated. But I have a hard time accepting some of the cries I hear from my doc friends. It is not as bad as they like to say.

  49. A while back, on DovBear’s blog, there was an interesting post about how difficult it is to be trained as and become a physician while remaining an observant Jew. On that subject, how do you handle the conflict between a patient’s right to privacy and the prohibition against yichud (roughly, a male and female not married to one another being alone in a room together)?

  50. I have a don’t ask/don’t tell policy. I don’t ask a rabbi and I don’t tell him what I do.

    But seriously, the only issue with yichud is when I do a pelvic, and then I have a nurse in the room, as do all male physicians.

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