Scrappy Blog

Background:  One of my colleagues left our practice a couple weeks ago.  It was a good opportunity for her – she wanted an easier commute, and she wanted to be able to arrange her work hours better around her kids’ hours.  She also is someone who doesn’t much like technology and we’re an increasingly technology-driven practice. One of her old friends (someone I trained with, actually) had more work than she could handle at her practice, so my ex-colleague (let’s call her EC) joined that practice.

Because EC’s new practice is quite a distance from us, many (most) of her old patients have decided to stay with us. So we’ve all been meeting her long-time, loyal patients, who are all sad she left. To make things worse, looks like she got a bit behind on some paperwork near the end and a couple of things got delayed, as far as communicating with patients in a reasonable timeframe.

Which brings us to my experience today.

One of her patients was undergoing pre-operative workup for elective surgery. She’d come in a couple weeks ago, and a chest Xray and EKG were ordered – but the EKG was a little atypical so she was sent on to have a stress test. There’s where things fell apart.  She had the stress test a couple days before EC left.  It was interpreted by the cardiologist and he sent a nice report about the result – which wasn’t normal – to EC’s in-box. Where it apparently got ignored.  After her final day we set things up so things being sent to EC’s box got re-routed into one of our boxes… but we’d (foolishly) assumed she left a clean box on her last day.

So several days after that, we get an irritated call from the patient.  The surgeon hasn’t gotten the clearance note for the surgery, she says, and it’s scheduled for early next week so could we please get our act together? I received this day before yesterday, take a look at her chart and see this note saying she may have early-onset heart disease and needs more evaluation of this before we put her under anesthesia. So I ask a nurse to call and get her in to see me ASAP.  We got ahold of her this AM (after two days phone tag) and she came in this afternoon.

So here’s this poor woman who is getting the terrible news that she’s probably got a faulty heart.  And learning that because of this she will have to delay the surgery which was already scheduled (as well as the vacation time off work, family support to help her recover, etc, etc). And that “we” had this info for several days and didn’t contact her until she contacted us first. She was understandably grumpy. She expressed her grumpiness (politely, but undeniably grumpily) and I did my best to explain what happened and what things I could do to try to expedite things now.  But she was clearly not pleased with me as she left.

So… a couple hours later there appears a message on my inbox.  Please call the patient, it says – doesn’t want to talk to someone else, I need to call her.  I was busy with other patients and I try to prioritize the scheduled stuff over the incoming phone stuff so I had someone call back to explain that I was in with patients, so I’d not be calling back until the end of the business day… but if she wanted to tell us her question perhaps I could have someone address it sooner?

The reply came back: Ms XXX just wanted to say that she was thinking about her behavior today in clinic and she’s afraid she wasn’t very nice to you – she wanted to apologize. She wants you to know that she usually tries to be a nicer person than that and she hopes you’ll forgive her”.

One of the biggest – could you have made this request at a more convenient time for me?  For example, last night’s example had three days of knowing about the problem, where she could have let us know the problem that needed solving, but instead she decided to call after-hours.  Another example from yesterday – a fellow who had been having headaches for two weeks, and contacts us with demands for a stat workup to be completed before he goes on vacation in two days. If you take a routine medication and your bottle is getting empty, don’t wait until you’ve used up your last pill on Saturday morning and then expect the doc to get you a refill by Saturday dinner.  If you develop the chest pain Saturday morning, call me Saturday daytime, don’t wait until 2 AM. And so on. 

And likewise I’m most friendly if you’ve used the method of communication that is easiest for me.  So if it requires immediate action from me, schedule an appointment with me so that I have time blocked off to give you that action. If it could wait a few days, send me a letter or a secure email (we have a website set up for people to do that) or a fax or leave a message on the clinic answering machine. This is far more likely to get you service with a smile.

Another big one is how life-threatening is the disease?  I understand insomnia sucks.  I got less than 3 hours of sleep last night, due to handling that situation with the 92-year-old whose blood glucose was over 500. As a result I anticipate a crappy day.  I get that you’d like to avoid that. I’m all for treating chronic insomnia.  But, one more night of poor sleep isn’t going to kill you, so wait and come see me in the daytime to start that treatment. On the other hand, when you slip and fall and hit your head and now you’re not sure if you should be going to the ER or if it’s OK to just have your family keep an eye on you for a few hours…. call me any time. I wouldn’t want you to die of the intracranial bleeding while you wait for my office to open. Sometimes its a matter of personal situation:  I want the severe asthmatic with bronchitis to call me for refills of the inhaler over the weekend; the ordinary healthy person with that same bronchitis should take some Robitussen and come see me in the office.

A third biggie – is this your fault?  Because if the reason you can’t get a prescription is a screwup at the pharmacy, I’m gonna be pleasant to you and then call and be mean to the pharmacy. If I failed to give you the correct number of refills to get you through to your next recommended appointment, or failed to explain to you that your diagnosis could cause this symptom, or confused you in any way – then you’ll get my quick response along with an apology.

How about this one:  should I be getting paid for the service you’re asking of me?  If it’s a routine transfer of a current prescription to a different pharmacy, where I don’t have to make any clinical decisions, then by all means call me during office hours.  If you lost your bottle of antibiotics and need me to call in a repeat prescription for the exact same thing, then calling is fine and you probably need to catch me on the weekend so you don’t miss a dose. If you want me to re-evaluate your condition and suggest different therapy:  THIS IS WHAT I DO FOR A LIVING.  I don’t want to do it for free over the phone during my dinner or sleeping hours instead.  If you need refills of the medicine that you haven’t discussed with me since I last refilled it a year ago, come in to see me – I’m not interested in guessing about whether the treatment is still appropriate.

And finally, there’s the question of what sort of person you are.  Are you one of the people who is always friendly when you come in? Have you shared your life and your family stories and your interests with me? If I was delayed in clinic with someone else’s emergency, were you pleasant to my staff and forgiving of the wait? Have you had a history of showing up on time, not missing appointments, and addressing problems in a reasonable and courteous manner in the past? Are you experiencing unusual life stresses right now – illness, divorce, bereavement, job change, etc – that might explain why you’re not thinking clearly about other peoples’ needs?  Are you demented or mentally ill? Are you mobility-impaired so that getting to the clinic is very difficult?

Now, there’s another side to this, which is:  What are my responsibilities, such that I can expect you to treat me so courteously? Here are some that come to mind:
– Make sure that I’m actually available to help you take care of problems a reasonable number of hours every week, and make sure those hours are clearly publicized.
– Offer you a number of reasonable alternatives for communicating with me and for getting the care you need.
– Being sure to listen to what you have to say, so that I don’t unwittingly cut off someone who actually had a legitimate reason to be making demands on me.
– Have competent staff and workflows so that when something needs doing, it gets done.

So.  I don’t know what it was about this particular call.  Sure, I’ve been spending the last three days beating my head against an apparently unsolvable problem, only to discover the source of the problem was a combination of a sysadmin failing to set access permissions correctly and Mac OS X inexplicably deciding that it should change the names of files when it compresses the folder they’re in (which was DESTROYING my nice object-oriented packages as they uploaded!)…

But nonetheless, I came really close to going postal on some lady just now.  She has been having insomnia for months, apparently.  She saw a doctor for it over 2 months ago; it took her three weeks to get around to getting the tests he ordered done and she hasn’t gotten around to seeing the specialist about the problems those tests revealed.  In the interim, a week ago he called in some sleep medicine for her.

She didn’t bother to go to pick up the prescription until three days ago. They told her there was some administrative problem with it that would need to be addressed by her doctor’s office.  She sat on this for three days and then tonight, after the office was closed, decided it was time to get it taken care of.

She ignored all of the non-real-time options for making her request – like the online request form, the voice mail, or a fax. Instead she had the on-call doc (me) paged. She explained to me that I need to call her pharmacist and arrange for her to have her medicine.

I politely told her that I was sure the doctor who prescribed the medicine would be happy to address that tomorrow during business hours, so could she please give them a call in the morning to explain the issue?

She then had the gall to inform me that if she had a car accident on the way to work in the morning due to her poor sleep, it would be my fault.

At this point, my hold on “polite” slipped considerably. I pointed out that it was our clinic’s policy that we don’t need to take care of administrative stuff for patients after hours. I noted that she’d been having difficulty sleeping for months, and that one more night was unlikely to make much difference one way or the other.

At which point she said “what’s the point in being a doctor if you’re not available to your patients 24 hours a day?”

I recognized at that point that my response would move out of the range of “not polite” and into the range of “unequivocally hostile”. So I simply said “I don’t know if you are interested in continuing this theoretical discussion but I should point out that nothing about this conversation is going to make me do anything about your administrative problem tonight.”

She hung up on me. That was probably the best response all around, I suppose.

But now I’m left with all the seething resentment of the things that I’d LIKED to have said to her.  Like, who made her queen?  Why is she so special that I should interrupt dinner to take care of this problem, when she could have addressed it during working hours anytime in the last two days?  Is she possibly so self-centered that it didn’t occur to her that doctors are people too – people who like to spend time with their loved ones, have a quiet meal and a good night’s sleep, without disrupting all of those to do her a service that isn’t an emergency in any sense of the word? Or is she well aware that she’s out of line, but finds that making unreasonable demands and being bitchy until she gets what she wants is simply more convenient than being courteous of other peoples’ professional and personal time? Does she understand that she’s communicating the message that she has absolutely no regard for me as a human being, but nonetheless she expects me to be eager to go out of my way to help her? Why on earth would I be motivated to do that?  Does she realize that the world is full of people who are sicker, sadder, more helpless, and overall more deserving of my sympathy than she is, and if I spend my entire life working to help people every waking hour, I could fill every minute of that time helping people who are more pleasant and more deserving than she is? Does she realize that I’m so pissed off by her cavalier attitude that I’m tempted to fire her as a patient just so I’ll never have to deal with it again?

The flight down yesterday morning was entertaining, complete with an unusually charismatic flight attendant who was cracking jokes and making friends with the passengers the whole way, and a chatty seatmate with an entertaining tendency to say “agriculture” when he meant “architecture”.  The first couple of times he said it, the substitution could be construed in a way that made at least a little sense, so it wasn’t until he mentioned admiring the agriculture of Notre Dame and taking pictures of the interesting agriculture along the Seine in Paris that I felt confident that he was actually making that substitution.  SInce he seemed otherwise reasonably bright, I’m sure he’d be mortified by the error if he ever learned he made it.

I’m here because my brother and I hatched up a plot to surprise my parents with a nice, grown-up style dinner for their 45th anniversary.  Amazing.  Someday I hope to have been happily married for 45 years.  The surprise worked out – J (my brother) called and asked if “we” could take them out to dinner.  My parents assumed that “we” referred to him and his wife and kids, and the plans were set.  Yesterday I flew in, J picked me up at the airport, and we headed straight to my parents’ home.  We stopped off at the local library, where Mom was helping to set up a charity booksale; J sauntered in with me a few steps behind and said “ready to go?” as if she’d known the plan all along.  This, of course, meant she got to take us around to all her friends at the booksale, introducing us and telling everyone about the surprise.  I suspect this is the sort of thing people in her age set are mildly competitive about:  “look how much trouble MY kids go to, to make me happy!” Whatever pleases her… if being dragged around to meet strangers is all she wants, I’ve got an easy Mom.

Then home to pick up Dad, who was similarly pleased – both by my presence and by the reprieve from the expected dinner out with the grandkids.  Poor Dad never really liked kids much to begin with and has gotten more sensitive to their noise and randomness as he ages.  He tries really hard to be patient and non-critical but my nephews are all rambunctious and a bit too young to be expected to remember sedate behavior for very long. 

We took them to Pappadeaux; I felt a little guilty about taking them to a “chain” restaurant but while they’re all over the place in Houston, there’s actually not many of them outside Texas.  So in Georgia it’s a bit less ordinary.  And I was effectively selecting a restaurant from a distance, since J doesn’t get out to restaurants very much and didn’t feel confident about selecting a place.  Pappadeaux was a source of cajun/gulf coast cuisine (Mom and Dad honeymooned in New Orleans) that could be counted on to deliver tasty food at a predictable price range. And in fact it was very yummy, especially with J and I taking charge and making sure that all the treats (yummy crawfish and cheese fondeaux, tossed salad and garlic bread with the entrees, nice drinks) got ordered along with their entrees.  We each ate about 2 peoples’ worth of food.  My grilled salmon and fresh asparagus was fantastic.

Then home for a brief walk in the neighborhood and some relaxation before a long, restful sleep – J and Mom arguing a bit about who got to keep me and J agreeing that Mom could keep me as long as we promised to get up timely and head over to his place for breakfast and a day of family.

Which was also great.  My nephews are good kids, despite the above-mentioned rambunctious… my sister-in-law is a bright, interesting person who’s a little hard to get to know unless you carve out time to spend with her… my brother was obviously craving some bonding time with his little sister… and I got a bit of a kitty fix, since every time I sat down I either got to cuddle Linus the enormous purr machine or Laura the petite and shy tabby who, once she decides you’re safe people, is just as snuggly and friendly as Linus.  We put in a full day then staggered home around 8 for a bite to eat at the local Tex-Mex place (which was surprisingly good, considering we’re in north central Georgia…) and a couple hourse looking at my parents pics from their recent anniversary trip to France.