Wednesday, October 21, 2009

Here's A Place To Begin Reforming Health Care: A Letter To My (Former) Primary Care Physician

Dear Dr. PCP,

I called your office this morning at 9 a.m. because I realized this morning that a cold I had yesterday had triggered an asthma attack. I am currently on maintenance medications for asthma (Singulair and Zyrtec), which means I am almost never actively asthmatic. The corollary to this is that when an asthma attack commences I know that the situation is potentially serious, and I explained this to the woman who answered the telephone at your office. I asked for a prescription refill for an albuterol inhaler and an Azmacort inhaler, and told the administrator that my history of asthma, and the drugs I have been prescribed in the past (including these) could be found in my file. This is what followed:

I offered to come in to the office if a doctor wished to see me before refilling my prescriptions.

The administrator said that you were out of the office, but that there was an appointment open at 9:45 with another doctor if I wished to come in.

I said I had no need to come in, but that I was free all day (and certainly at 9:45) and she should ask whatever doctor would see me if he wanted to see me prior to prescribing (since we are all being told, because of H1N1, to stay home when we have undefined flu-like illnesses) and because you yourself advised me not to come into the office when I called with a high fever less than three weeks ago. The administrator said she would call me back and let me know whether to come in or not, and she took down all the information necessary to prescribe.

At 10:15, having heard from no one, I assumed the doctor had simply called the prescription in. I called Walgreen’s because I could tell my asthma was getting worse and I needed to begin to treat it more aggressively before it became more critical. After 15-20 minutes of being on hold at Walgreen’s I discovered that no prescriptions had been called in.

I called the office back to ask about the office visit and the prescription, and was told that because I had not been in the office for four years (which I actually do not think is true, as I have seen you at least twice since Dr. X left, but I realize I could be wrong about this) the doctor could not prescribe without me coming into the office.

At this point, I became exasperated and asked why she had not called me back and told me that so that I could have come in at 9:45. She said she had left a message on my office voice mail. In fact, she had never asked me where I could be reached; my office is in Zenith; and I was at home (sick) in Shoreline. She told me that there was an appointment at 1:50 and I could have that. I told her I was having an asthma attack now, it needed to be treated, and that wasn’t good enough. She put me on hold.

The administrator returned to the telephone to ask me if I was insured, something a look at my file would have clearly revealed (as well as the fact that she had just left a message at the job listed in the file), but which seemed more than insensitive given the circumstances.

Subsequently Dr. XY got on the phone and explained that was the best that could be done, and that if my asthma was really so bad that I could not wait three hours, I should go to the emergency room. He too reproved me for a four-year gap in visiting the office. I recounted the sequence of events in which I had attempted to come to the office earlier in the day and had not been contacted by the office, and he failed to acknowledge that this had even happened. I told him to forget it, that I would obtain an emergency prescription from my gynecologist, Dr. XX of Zenith, who makes it her business to be aware of my total medical profile; that I was inclined to find another physician because of my experience today; and that I thought I was at least due an apology for how the office had bungled this. He declined to apologize for the non-responsiveness of the office, reiterated that the responsibility lay with me for not having come to the office recently enough, and reiterated his advice about the emergency room, suggesting that I call 911 if I was truly in distress.

Now, from my perspective, what went wrong here?

I had offered to come into the office twice in the first phone call, and it would have been the work of a moment for your administrator to look in my file and discover that office procedures would prohibit the prescriptions being refilled without an office visit. I would have made the appointment and come in immediately, without asking for a callback.

The administrator might have put me on hold, talked to the doctor briefly, and asked me to come in; or just asked me to come in, as a precaution, without talking to the doctor.

Failing either of these, the administrator ought to have ascertained, at minimum, where I could be reached in person. For all she knew, when she left a message I was blacking out for lack of oxygen and unable to reach the telephone. I have never heard of a doctor’s office not asking where a patient can be reached. I have never heard of a doctor’s office simply leaving a message on a machine after having been notified of an ongoing, potentially serious, medical condition and not making an attempt to reach the patient at another number listed in the file.

No one seemed to be inclined to look at my file.

Because of errors made by your office, had I not had an attentive gynecologist who makes it her business to know the state of my health, what could have been cared for in a short office visit might have ended in an hours-long, expensive visit to the emergency room. I have never had a physician act as though seeking emergency care from Shoreline EMS and local hospitals was a reasonable way to resolve a health problem that could be at least temporarily resolved without emergency care.

I was not asking for opiates or any drug that might indicate a substance abuse problem: I was asking for asthma medications as a patient whose condition is documented at your office. They could have been prescribed at the time of my second call when it was clear that the administrator had not reached me. If Dr. XY felt he needed to see me, I would have been happy to come in at 1:50 to consult. But that was not offered as an option, and instead I was treated as though I was cruising around town trying to score asthma medications (for what reason I or any other person would do this, I am not clear.)

No one in the office, from the administrators I spoke to up to Dr. XY, seemed inclined to admit that I had any reason to be distressed about how the situation was being handled (which I was, very much so.) Even when I told Dr. XY that his staff person had inexplicably left a message on my office voice mail and had never asked where I could be reached he did not acknowledge that the office had made a mistake; nor did he indicate that he or I had any reason to really be concerned about my asthma short of an attack so severe that I would end up in the hospital. Rather, it was the clear inference that I was unreasonable in my demands, and he too reproved me for not having been to the office recently enough. And yet, consider the following:

When I scheduled a physical with you, Dr. PCP, after Dr. X left town, I asked if I should return yearly. You said no and were vague as to when another physical would be prudent: the clear inference was that you would be reluctant to see me unless I was actually ill. Your office has never contacted me, on the telephone or in writing, to ask me to come in for another wellness visit. My other physicians do tell me when it is time to schedule an appointment, and I see my gynecologist (at her request) once a year.

If it has been four years since my last office visit, I have called at least four times to have my asthma maintenance medications renewed for 12-month refills, and your office has complied. Although I do recall one person I talked to noting that I had not been in to the office for some time, she did not tell me that this was a significant issue for my relationship to the practice. At no point have I been told that it was necessary or desirable to come in for an office visit, even though I am clearly being treated for chronic asthma.

Several weeks ago, I had a sustained fever of 103 for several hours and called your office for an appointment, because at that point public information was that this might be an indicator of an H1N1 infection. I received a prompt return telephone call from you, in which you told me that since the fever had subsided there was no need for me to come in. Again, this would have been an opportunity to suggest I schedule a wellness appointment with the office.

Asthma is one of the underlying conditions that can cause a potential H1N1 infection, or any flu-like illness, to become deadly, even in an otherwise healthy middle-aged person.

In short, rather than being treated like a patient today, I was treated like a problem, and a person who has neglected her responsibilities towards your office – when, in fact, I have not been encouraged to visit the office, even when I call to say that I am ill or need prescription refills. Only once was this mentioned, and it was in the form of a reproof that I did not know how to interpret.

I am sure it was very unpleasant for the administrator and Dr. XY to have to talk to me today once I became upset. I would be inclined to offer an apology of my own, but for their failure at the time to acknowledge that I had reason to be distressed, or that I had a right to care short of a critical medical situation that might require attention on an emergency basis; and that today’s delay in treating a developing condition had been caused by them. Their continual insinuation that this was really all my fault for not having met a responsibility to the practice was insulting and hurtful, as was what now seems like the desire to dispose of me altogether if I turned out to be a person without insurance.

I realize that the current state of medical care is difficult for all of us, doctors and physicians: as the daughter, granddaughter and niece of physicians I am well aware that the state of play has changed in a way that benefits neither patient or physician. But that does not alter what seems to me a series of problems I have encountered with this practice since Dr X’s departure, and Dr. XY treating me as though I were a potential litigant rather than a sick person in need of assistance. I do not trust your office to deal with a routine, but serious, health matter appropriately and sensitively. Please mail a copy of my records to:

(my home)


T. Radical, Ph. D.

A copy of this letter has been mailed to Dr. PCP. Names have been changed to protect....uh, me.


Anonymous said...

You left in a name in the last paragraph; just wanted to make sure you knew it was there...

Tenured Radical said...

Good catch. Never post when ill, oxygen-deprived, or enraged.

Digger said...

Glad you got what you needed, and it didn't become something more serious. It sounds like a routine interaction with my doc, though... including the part where IF you can get someone on the phone, they suggest the Emerg "if it's that serious". Apparently suggesting the Emerg lets them off any and all hooks for what happens to you if they're not responsive. The system is very, very broken.

JackDanielsBlack said...

It seems to me that it would have been irresponsible for the doctor to send in a prescription without having seen you in four years. Things might have changed in four years. You really need to see your primary care physician more often than that, especially as you get older and especially if you have chronic medical problems.

New Kid on the Hallway said...

That is truly sucky. It makes me grateful I've never run into that (unlike your PCP person, my allergist/asthma person makes me come in once a year to get my asthma meds refilled, although it's true that there's nothing requiring me to see the PCP regularly). I especially love the way they *don't* want to see you for regular checkups, then punish you for it. When I was in grad school, TAs got health insurance, but the insurers kept changing because they'd bid low to get the contract, then raise rates at the next renewal, and the U would negotiate with someone else. Anyway, I just remember the insurers complaining they HAD to raise rates because grad students were so expensive, because we kept coming in for preventative care. Um, right, because isn't that what you're *supposed* to do? (They also said we were too expensive because we were all on bcp and anti-depressants. Because, you know, pregnant, suicidal TAs are so much more cost effective...)

Would be interested to see what response you get!

Comrade PhysioProf said...

This is a systemic problem with the health care delivery system, and not a personal failing on the part of this particular physician. Physicians and their staff are just as beat down as are patients by a ridiculous system that inures almost solely to the benefit of massive corporations: insurance companies, hospital conglomerates, and drug companies.

Physicians and their staff spend so much time and effort dealing with all this deranged corporate garbage, that they have little time, energy, or empathy left to expend on actual patient care. The fact that a subset of physicians does manage to overcome this to some extent doesn't change this causal analysis.

Beau said...

Your former PCP's office may require you to fill out a HIPAA compliant information release form to have your records released to you. Not sure if the letter will suffice.

Susan said...

TR, I wish my former PCP in Shoreline hadn't just closed her practice, 'cuz I would have recommended her... This is terrible. Talk about a practice that is too big.

Tenured Radical said...

Dear all: Thanks for your good wishes, and Jack -- one feature of this whole thing is that repeatedly, this practice has urged me not to come into the office. Upon reflection, I agree with you: it's a bad sign, and I should have known that eventually it would come a cropper. I must say, the failure to actually reach me when I urged the admin. to ask the doctor explicitly about whether I should come in (yes, inhaleable steroids are powerful drugs) was a new twist.

The anonymous poster whose snippy comment about the post being self-indulgent, and that I removed (because who needs *your* effing judgments too?)-- you know, you are right, it was self-indulgent. And yet, such a response comes from a very deep place that recognized I was being kicked to the curb for no reason other than the fact that they were covering up their incompetence. The failure of the doctor to say he was sorry strikes me as stupid, even (especially?) in the legalistic climate. Mistakes one can abide; cruelty is harder, particularly when one is frightened about being/becoming very ill.

And anyone who has spent time in an ER with an asthma attack know that for someone to lightly suggest that as a good idea is crackers. An ER is a very special kind of hell, where people walk by as though you don't even exist, as you get sicker and sicker.

Good news: the asthma is better (thanks to my gynecologist) and I have an appointment with a new PCP in the fancy-schmancy suburbs.

Anonymous said...

Dear TR,

While I don't have a dismal experience with my PCP to report, I have had numerous unpleasant interactions with unresponsive bureaucracies -- insurance companies, computer companies, airlines, hotels. Usually I am so exhausted and frustrated by the process that I lack the energy and resolve to recall and recount the entire experience and communicate to someone in authority. Thanks for an excellent exemplar of standing up for one's rights.

Anonymous said...

This is also an excellent argument for removing the insane grip the prescription pad has over our medicine. There's no reason you shouldn't be able to buy just about anything OTC. Thanks "War on (Some) Drugs"

Anonymous said...

This is what I do. I just go to the office as a walk in. About 50% of scheduled patients don't show up anyway and if you're coughing they tend to "fit you in".Asthma patients, like people having a heart attack really should be coddled as the stress makes it worse I believe. Poor you. That was probably really scary. Receptionists making decisions like this is also a problem Triage at the front.
Actually, what I do now is pay a flat joining fee of $1800 for a family of four and they know my name, I have a 24 hour phone number for the doctor and a guaranteed appointment the day I call. This as concierge service. I find it bizarre and priveleged but very very useful.

Anonymous said...

Sorry to hear it. All too common though.

As a college student I had the results of an extremely personal medical test left - in detail - on an answering machine I shared with others. Did not get an apology when I responded with (amazingly measured) deep dismay.

davidjhemmer said...

The thing is you're now classified as a complainer and that office is going to be happy to see you gone. It's a good thing you didn't threaten a lawsuit in the letter, that would have got you on the secret shit list that doctors keep and you would not have been able to find another PCP.

Goldie said...

If you can't be self-indulgent in your very own blog when you've just had a miserable encounter with the people who are supposed to be there to help you, what's the world coming to? TR, we all feel for you, and thank you for expressing our collective frustration.

I have had similar experiences with what I now refer to as the River -- as in, you can step in the river as many times as you want, but it's never the same water. 4 PCPs in as many years.

After waiting hours in pain or panic for callbacks that don't come, I have learned two things.

1. Ask what time you should expect the callback, and call at that time if you have not heard.

2. Skip the receptionist entirely, and say you need to get advice from a nurse or PA. PAs and nurses turn over as well at the River, but not quite as fast. Some still remember that they went through all that training to provide medical help, and may be more aggressive in getting you what you need, or at least telling you what you need to do to get help.

If only I could FAX you a spare inhaler . . .

Anastasia said...

OMG this makes my blood pressure go up just reading about it. I have waited more than once for that elusive call back from my PCP's office.

Anonymous said...

Did your PCP bill you for each occurrence of his cartoon picture in this posting? Even though each occurrence of his cartoon picture didn't benefit you medically? Just wondering! :-)

Anonymous said...

Do you really sign your name with ,Ph.D after? I certainly hope not!

wz said...

I'm Anastasia's Mom and feel frustrated when her providers don't respond or bumble her care, and work in a large group practice as a nurse manager. My organization works hard to train and monitor first responders but even I have had the experience of an insensitive person (most recently a nurse practitioner)making bad decisions by calling the wrong number and then not making the effort to look for any other numbers in the record. Your example of asthma flare should have caused a trained person to do better to get you in for that appointment. That was where it fell apart. The lesson for all of us is to strongly advocate for ourselves initially insisting on specifics like Goldie suggests.