Tuesday, October 7, 2008

I'm sorry but I need that pen back

To all patients of the medical system (in other words, everyone),

I wanted to write you this letter of apology for my lack of not continuing to put your interests first and foremost in my day. I, along with the majority of my colleagues, are sorry that we have been so engaged in the day to day care of caring for the sick, dying, distressed and helping escort newlings into the world and elderlings into their new world that we have let the system of health care get out of control. The purpose of this letter is not to provide excuses, but to help you understand where we have failed you.

I am sorry that your coughing child who cannot keep down liquids because they are gagging on their mucus and that are fussy all day because they are up all night coughing can no longer get cough medicine. See, the FDA says they don't help, and because some parents were irresponsible in giving the medicine to their children and didn't follow the bottle's directions and their kids ended up overdosing on the medicine, they blamed the FDA for allowing these medicines to be marketed to children. The FDA reviewed the studies and said that since they don't decrease the DURATION of cough, they aren't useful. So now your insurance company won't pay for prescription cough medicine for your little cougher. I'm sorry we didn't go to fight for you with the FDA to show them that studies show it decreases the AMOUNT of coughing and night-time awakenings. I'm sorry that your insurance company is glad to not cover a medicine so it can make more profit off your insurance premiums. I'm sorry that the FDA is just worried about getting sued because <0.000008642358% of kids had problems with the medicine. I'm sorry that the paperwork I spend 15 minutes filling out explaining why it was medically necessary for your child to have the medicine was determined by them to still not be medically necessary. So as my solution, to show them that it is medically necessary, I recommend that the next time your child has a severe cough and snotty nose, and they can't sleep, eat, or drink well, that you take them to the homes of the FDA officials or the CEO's of your insurance company and leave them overnight. Then, I bet, you shall have your cough medicine for your child.

I'm sorry that we have not been able to provide the medical services that we decide are needed. I called your insurance company and talked with a nurse, who told me that the test was not medically necessary. I guess I should have been a nurse so I could make the decisions needed for your health care. I'm sorry that the medical review director of the insurance company left the office at 3 pm that day so I couldn't talk to them and tell them it was medically necessary for the tests I wanted to do to get done right away. I'm sorry that you ended up in the ER at 2 am with a ruptured appendix. I'm sorry you stayed in the hospital an extra week because your appendix ruptured and you are still off work. I'm sorry your insurance company only wants to pay for 3 days of hospitalization when you were still throwing up, not eating, and requiring IV pain medication on that day. I'm sorry they wouldn't cover your medication I sent you home on.

I am sorry that your formulary with your drug company is restricted and we have to use generics. See, I demand the best for the health of my patients, and when the concentration of a drug in a generic form can vary by 20%, I believe in some cases this makes a huge difference in the outcome of your health and you need brand name medication. I write your insurance company, but they deny the reasoning, as I guess they have more knowledge of your health and the health care decisions we make together. So I'm sorry that we put you on a generic medication and it doesn't work as we had hoped, or that you had an expected side effect. I'm sorry that for those three to six months your insurance company made more money from your insurance premium by not having to pay for a medicine that we decided was right for you.

I am sorry your insurance ran out and your cash cost for medical care is exorbident. See, we have no bargaining power with large insurance companies. I can't know what another practice down the street gets for a standard office visit, because it is illegal. Because of that, the insurance company can come in a give me a low-ball contract offer of payment based on a percentage of what I charge. I can accept the low-ball offer and jack up my charge so I can actually pay my medical school loans, or I can tell them it is too low and they will go down the street to the next doctor and sell your care to them for 1/2 a percent less. I just can't take that chance, since some income is better than none. Thus, I have to increase my charges so the insurance companies will pay me a decent amount for my time, training, education, and expenses. Well, just because you pay cash doesn't mean I can give you a discount. Because I accept medicare, I have to treat all patients equally, no matter who the payor (or lack of payor) is. Thus, I can't charge cash paying patients less or else I am committing a federal crime of fraud and can go to federal prison and lose my medical license. So I am sorry our office charge is so steep for a 7 minute office visit to tell you that you have a urinary tract infection and give you a script for a med to get you better.

I am sorry I don't have samples of medicine for you to try. See, the pharmaceutical industry is cutting back in order to preserve profits because the cost of new drug development is rising and they have investors to keep happy. For me to get you samples, I have to sit in front of a computer and watch a 15 minute presentation about the drug in order to order a 30 day supply of the sample you need. I just don't have the time to do this for 3 hours a day and still see patients, deliver babies, go to the hospital for emergencies, be on call, assist in surgeries, and still eat and see my kids.

I am sorry, but I can't let you keep that pen. See, the government for some reason thinks that because a pharmaceutical company gives me a pen that I will prescribe their medicine more often. So now they have created a regulation that we can no longer receive pens, notepads, or anything with their name or the product's name on the item. So I cannot relenquish my pen to you, for I need it to take notes and write prescriptions and instructions for you - it is the second most important instrument a physician uses. Every pen now affects my bottom line, what I can take home, and with declining reimbursements from the insurance companies (we don't want to loose you to the practice down the street, so we accept a reduction in percentage of pay nearly annually even though the cost of providing care goes up), every pen and piece of paper counts. Now I will admit that some big fancy institutions did studies in university medical centers (not doctors offices) which showed that when doctors received pens and menial gifts from pharmaceutical companies, they tended to prescribe their products more often. I can tell you that I would not risk compromising your care and a possible lawsuit because of a pen or a hot pack with a drug's name on it. Could it be that while they received that pen or menial gift they were talking to the representative about the product, learning more about it, and thus became more comfortable with the product and thus were more willing to prescribe it? Could it be that a person with 11 years of post-high school training through some of the toughest curriculum and training of any profession would actually make such a logical decision? Did they study this as the possible reason for increased prescribing practices when gifts are received? Nope. They just assumed because it influenced us that it must be the object itself that was the influencer, not the information that came with it. So sorry kids, I need my pen back, and please no coloring on my notepads. And I'm sorry that even though pharmaceutical companies aren't providing as many samples and we can't let you have those pens they give us that your drug costs are not going down. You see, they have investors to make happy and super bowl ads and magazine ads to produce. Welcome to being a financer of commercial advertising!

I am sorry that I won't prescribe medications (especially antibiotics) over the phone. You see, if I do that and you have a serious reaction to the medicine or you receive the wrong treatment because we did not diagnose the condition wrong, then I am liable, can be sued, and can lose my medical license and way of livelihood. Secondly, I would not want you to get misdiagnosed and end up in the hospital with something worse going on, which is not good for you, your family, or health care costs. Third, we have an issue in this country called bacterial resistance, and if we keep prescribing antibiotics for illnesses that do not require antibiotics, eventually none of the antibiotics will work, and you will be much worse off 6 feet under than enduring a few colds through your lifetime. Fourth, I do not have psychic abilities to tell what is going on with your body over the phone or through an email. Also, I could spend all day on the phone trying to help people and I would not earn one dime because your insurance company does not pay for phone consultation time. I have to meet a bottom line, and that line requires you to come in to be seen. I respect your time and understand you may have to miss work, but in all honesty it is in your and my best interest to do so. Thanks for understanding.

To my medicare patients, I am sorry that I can't spend more than 15 minutes of time with you. I'm sorry I ask you to come back to cover items 4-10 on your list of problems. You see, medicare doesn't care how much time I spend with you, they pay me close to a flat rate per visit. If I spend too much time with one patient, I don't see enough patients in a day to pay my nurses, my front office staff, the people that help fill out and fax forms for your walker, your non-approved medication, and your handicap placard, let alone my medical school loan for that month. I know your time is important. I respect that. I know it is hard to come to the office. I know gas is expensive. But I can't bargain with medicare for better pay. They haven't increased our pay for years. That's up to Congress, and Congress doesn't negotiate, nor do they care primarily about you - they care about the bottom line and the budget and getting re-elected. We don't get a cost of living increase, but we do get more paperwork and denials for payment. I don't want to loose you as a patient because I enjoy our visits and helping you, but I have to make ends meet. Thanks for understanding.

To the veterans who come to see me, I apologize for letting the government neglect your care through the VA system. I apologize for it taking so long to get the tests you need and the specialist care you need. I apologize you are seen as a number in the system. I apologize that you have a difficult time understanding some of the foreign medical graduates that work in the VA system to get in the door of working in the United States. I am sorry that you don't have the best medical care in the area available to you through the VA system.

I am sorry that our patient-physician relationship is no longer confidential. I am sorry that what we decide is best for you in the exam room is deemed to not be so by so many other entities. I am sorry that I have allowed insurance companies, pharmacies, pharmacy benefit managers, pharmaceutical companies, medical supply companies, the government, the DEA, and the FDA (I apologize if I missed anyone who deserves credit) interfere with your health care. I am sorry that medicine is no longer becoming your choice, but is being mandated to you. I am sorry that I have let socialism force its way into a capitalistic system. I can do no more nor yell any louder. I cannot strike for you, because that wouldn't be fair to you. I cannot go to Capitol Hill to fight for you, because I can't afford to and I need to stay here and care for you. Legislators will not listen to the minority. They may, however, listen to the majority. So I encourage you to speak up! Don't let the government or any other entity regulate and dictate to you and I what is in your best interest in regards to your health! Regulation is not freedom. We have a check and balance system for doctors- its called lawsuits. They don't need to watchdog us. We are the ones who care about you and your family. Our main motivation for going into medicine was to make a difference and to help people live long, happy and healthy lives. Do they go to the same restaurants we go to? Do their kids play ball together? To they have to answer to your family if you have a major problem? So speak up and keep the government out of our relationship and healthcare (would you trust Ted Kennedy to give you medical advice? Well, he wants to via a government-run healthcare system)! If you want a good look at government-run health care, talk to a veteran who goes to the VA. They can tell you what a debachle it is and how hard it is to get the care they need.
So to my patients, I apologize. I do promise, however, to do my best to continue to provide the care you need so that you can live a long, healthy life no matter who or what interferes in my ability to do so.
With all sincerity, anger, bitterness, resignation, indignance, and sorrow.


Mumzy said...

Very articulate blog, Doc. Amen...I think it's time for something new.

Justin said...

Thank you for sharing your thoughts so eloquently. I am applying to medical school and can not understand why an effective physician's union has not yet materialized. The answer I always get is that it is like herding cats. Lets start a website - cat-herding.com (or something like that) and recruit, if the system is worth fixing and can be fixed. Just a thought.

Annlee Cakes said...

Your Blog explains alot.. ty for your honesty and forthrightness... I miss you as my Doc..