Patient Care

(c) 2011 Christiana Lambert

As I’ve said before, I’m not a doctor—and I don’t even play one on TV. When you don’t visit doctors too often, it’s easy not to put much thought into what makes a good medical experience. Once upon a time I was fairly neutral about the whole seeing a doctor thing. Would prefer not to have shots or get prodded, but never responded with too much anxiety—no, I saved that for the dentist’s office where my shoddy tooth-brushing habits would catch up with me back when I was growing up. But other than my having to pay the piper, I couldn’t have been treated better by my dentist and his assistant—I mean, who now would give a young adult a free wisdom tooth extraction for college graduation?

What Doc knew instinctively was how to treat patients as if they mattered—even though he was my father’s friend, all patients really did seem to matter to Doc. Our family loved his care so much that even after we moved to a larger town with more dentists, we drove 40 minutes each way to stay with Doc and his excellent care. When carsickness caused me to throw up—on him—Doc looked little more than irritated and then knew to schedule me for the second family appointment of the day thereafter.

Even though all doctors I encountered were not Doc, I didn’t really think about them that much, but my mother did. She’s the one who later switched me from a doctor with a cold manner and minimal listening and analytical skills—the same doctor who years later would fill in for her doctor during the woman’s maternity leave and procrastinate reading Mom’s treadmill test until he decided results required an emergency flight to a cardiac center. It appears Mom was right about his lack of thoroughness.

Not until I was almost a mother did I understand the awesome responsibility of choosing a doctor for and coordinating care for loved ones. In the last weeks before our twins’ birth, I struggled to decide which pediatric practice would work best for our children. I finally made a choice based on both practical reasoning and a gut feeling. Turns out the kids were in good hands, not only for medical care and developmental tracking, but also for how they were treated from their earliest days. At my son’s 18-month appointment, he picked up a block and beaned the doctor in the head. The doctor just smiled and said, “Hey, that was overhand—that’s quite advanced for his age.”

By now, after overseeing both ordinary and more serious medical care for my kids all the way to adulthood, as well as taking over helping my mother through her final years and sitting in on some care for my in-laws, I am what could be called an “old pro” at it—if in fact I could get paid for all my experiences.

I notice when a doctor is doing more than looking at numbers from a report or relying on obvious symptoms. I can see when a doctor is listening to the story, looking for the subtle. And then, of course, it’s just so obvious when the doctor really enjoys interacting with the patient in the room. I have a doctor who delivered our babies and later performed my hysterectomy—a few years ago I realized that her focused attention in my now routine appointments is almost shocking when I compare her with other doctors I’ve visited. She is so much better at the relationship part of the doctor/patient experience than most.

I learned enough in my MBA classes to realize that most doctors aren’t just practicing medicine, but they are also managing a business. It’s a tough line to walk between keeping a practice running in a timely manner and giving each patient the individual care needed. The way providers get paid makes it imperative for them to be more efficient in delivering care—which can sometimes make a medical encounter seem rushed, especially since much of the payment comes not from the patient but from the insurance company.

That means that doctors are more often “rewarded” financially for the quantity of patients served than for the quality of the encounter with each customer. Any business encounters this classic dilemma when trying to find the right balance between quality and productivity, but service providers—especially those not paid by the true customer—have a bigger dilemma.

Nonetheless, another thing I learned in MBA classes was that simply listening to customers and providing empathy is a pretty inexpensive way to provide quality. Good doctors know this already—my guess is that wanting to do so is one reason Doc and others like him chose to study medicine in the first place.

Here in our own home we are still in search of a solution for the medical condition(s) that led to our daughter’s very disappointing ER visit. However, the doctor she met last week looked at her the whole time he examined her and paid attention to the signs of pain. Will he be able to discover what’s troubling her body? Who knows, but at least she felt heard—which is surprisingly rare for someone who has had enough encounters with medical practitioners in her short life that she could work as a quality control auditor for patient care.

Doctors who treat us as individuals with conditions and/or symptoms versus as a diagnosis code probably stand a better chance of getting the diagnosis right. Good patient care is good medicine for what ails us—even for those times when all that ails us is the fact we have to give up time and money for routine care—but especially for those times when we are in pain and afraid.

Thank you to the doctors out there for whom care is both noun and verb—and for whom the word patient is also an adjective that describes the type of care they provide to us when we visit them as patients.

How Did This Happen?

(c) 2010 Christiana Lambert

Keep hoping to run out of rants about our medical and/or insurance experiences, but apparently will have to save that goal for 2014—ha, ha. (That’s a gallows laugh for those of you who might have presumed I meant that at all lightheartedly.)

Late Friday night I kept asking myself, “How did this happen?”

One minute we’re having what we hope is a routine appointment for abdominal pain at the doctor’s office on a Friday afternoon at 1:30 and the next we’re on what seems like some sort of an odyssey—that wasn’t supposed to have nearly so many confrontations with all those mythical monsters of old, you know: insurances snafus, appointment scheduling problems, rude ER doctors, and the familiar vague diagnosis.

Raise your hand if you’ve ever been thrown into what could be an emergency appendectomy, but just turns out to be a lot of trauma and money for little information and little relief. Lucky for my daughter, this was her second such experience in ten years. We were all sitting there with her going, “Wait. Haven’t we been here before?” The only thing we can say that has improved was that she no longer had to drink some horrible contrast fluid for the non-diagnosis—this time she got it by IV. And for everyone who wants to blame any of this on recent changes in health care, the only major difference from 2004 is that then we had co-pays and now we have (high) deductibles—which we have had since before the outcome of the 2008 presidential election was decided.

Last time, however, the pain really did start on a weekend and require emergency care.

This time—not so much—which is especially infuriating in this era of much, much higher costs.

This time what was supposed to happen was she would get the preliminary bloodwork done (which she did) on her way home to wait for a call from radiology for information on a daytime appointment. What we didn’t expect was a phone call from the doctor’s office saying she didn’t show up covered on our insurance plan so they couldn’t get authorization. Never mind that she’s been on this particular insurance plan since July 2010 when my husband’s employer changed insurers and that she has had claims paid in this current plan year that began in July 2013. Never mind that my access into the subscriber information showed nothing amiss.

Now it became our responsibility to talk with the insurance company. First I had to attempt to bypass the phone tree gatekeeper, though. Seriously, how could I tell the computer what I was calling about in a short statement? Current subscriber denied improperly? Is that really in the artificial intelligence settings?

After my call got through to a representative—who said I was the second caller she’d had that day with a similar complaint but stated my daughter was indeed active in their records—I had to call the doctor’s office with the information from the insurance company on how they should call the insurance company. Got that? But first I had to fight to get through the doctor’s phone gatekeeper to prove that I was indeed returning an urgent call from the medical assistant.

You know what the assistant told me when he called back? Yes, she does have insurance, and, no, she didn’t need authorization in the first place.

At that point the radiology company searched all its locations and found that none would stay open long enough to get the contrast into our daughter in time for a CT scan. They could see her on Monday—except the doctor was afraid our daughter’s appendix might be ready to rupture.

Our daughter begged us not to spend the money and effort on the ER and wait for Monday. She is tired of expensive diagnoses and had little faith that this journey would be worth the urgency.

These are those health care moments where the system lets you take all the risks—your money or your life sort of decisions.

It would have been so much better if anyone had listened to us when we described why we were at the ER. No, she was not self-reporting as the paperwork says. She was there because the clock ran out on Friday afternoon—through no fault of anyone in our family. The doctor said she needed that CT scan because of where she felt the pain and how long it had been there.

The only people who really listened in that place were the nurse who brought us to the room and the admissions/financial representative who knew just how much we were going to pay for the initial snafus, even if our daughter did need an appendectomy. In fact, they were the only people who could read her name correctly.

Four-and-a-half hours later, the ER doctor pronounced her with a temporary medical condition—yes, the one listed on her paperwork from 2004—and then left us with paperwork that diagnosed her only with unspecified abdominal pain, mentioning nothing of the term he must have flung out hoping we would not remember. He wouldn’t address why something that’s supposed to last a week would still be ongoing after at least four weeks. The patient in number 19 was not an emergency appendectomy, but simply chronic, unresolved pain. Take some Tylenol and call your doctor on Monday.

Haven’t we been here before? Only this time, this particular odyssey is going to cost so much more. Let’s start with the fact that an authorization wasn’t even required even though she was insured all along and then continue with the fact that an ER is no place for someone whose condition may indeed be chronic. I don’t blame the doctor for erring on the side of caution, but I do blame the confederacy of dunces that followed—and, yet, is there any recourse for us? We could have gotten the same results at 4:00 on a Friday afternoon without all the drama and extra expense.

Somehow I don’t think we should be the only people this Monday asking, “How did this happen?”

Authorize Your Own Right to Question

(c) 2010 Christiana Lambert

I am not my mother—in so many ways. One major difference is that I do question all forms of authority—in this aspect I am the classic Baby Boomer. But when you come of age watching all sorts of experts and leaders fall, you know that everyone can’t know everything nor do everything right. Besides, we live in an era with access to so much more information that we can and should take responsibility for verifying that what we are told makes sense.

Mom loved to read and learn, but she had this maddening habit of reading one article, expert, or whatever and quoting that viewpoint for the rest of her days.

I’m no lawyer and didn’t study journalism, so I don’t always ask things three different ways or check out three different sources, but I do know you can’t just trust the first reference you find. Plus, sometimes new information becomes available or other information exists that isn’t widely known. I drive my husband crazy because I have this natural habit of continuing to ask questions—not to be ornery but because to get the true picture of a story, you sometimes have to know the back story and other associated facts.

For example, these days it’s easy to find checklists to try to discover whether or not someone has a certain health condition. But surely a diagnosis isn’t based solely on such general listings—if not we all end up thinking we have most conditions. Often a definitive diagnosis arrives from looking at the subtle information found between the lines of those listings.

And when medical personnel study in school, they must learn a staggering amount of information about a staggering amount of conditions. They can’t be experts in everything.

What we as patients are is experts in our bodies, our family traits, and our experiences. We start to see patterns and often become experts—most likely not in the biology and chemistry of the conditions we experience—but in the subtle indicators that are more personal to us. I am seldom wrong about strep in myself or the people in my home and I’m pretty good with pink eye, too—because this is our experience. And I think families such as ours who are afflicted with celiac disease often tend to know more about the subtleties of the condition than doctors who are not well-acquainted with the condition and whose medical school training happened before current protocol changes.

Medical personnel are frustrated that so many of us think we can know what’s going on based on our layman’s access to a variety of information coming from sources ranging from valid to those so invalid as to be dangerous. But that doesn’t mean our insights and questions aren’t worth considering in combination with the expert’s own knowledge.

I’m not so much of a rebel as to push back hard when I disagree with a practitioner, but I always bring up my questions and concerns in a respectful manner. In retrospect, sometimes I wonder how I could have pushed harder in certain situations. Just last month I received confirmation from a doctor my daughter was seeing for something I couldn’t get my mother’s doctor to recognize four years ago—would have liked to help Mom with that problem but no one would listen.

As patients we have to fill out copious pages listing familial connections—so often it feels as if no one reads them even though I believe most medical people believe they do matter. Maybe they don’t feel they have the time—was so glad when my daughter’s new specialist asked us about every connection listed.

When there don’t seem to be good, easy answers—the kind that would come easily if all our conditions fell into line with those checklists—then that’s when I think the professionals really ought to listen to family stories and the oddball personal information provided to them or even check into the quirky medical possibilities suggested to them.

Mom was the epitome of the hard-to-diagnose patient with her commingled conditions. Since many of my family members seem to specialize in being those people whose conditions fall into the gray areas of those checklists, we need medical authority figures who can tolerate a little questioning. Some of us don’t rebel against authority to cause trouble but to discover truth that may be hidden. Good leaders hear what team members say in order to arrive at the best possible outcome.

After all, I don’t think doctors like uncertainty any more than patients and their families do.

The Name Game

(c) 2012 Trina Lambert

Disclaimer: This post was not inspired by yesterday’s post about receiving a life insurance payout in the wrong name. No, I originally wrote it in March 2012, but did not post it at the time; however, after receiving that payout check, I revisited this rant. As I said, I’ve been experiencing difficulties with people getting my name wrong since I was born half a century ago. Consequently I’ve had many opportunities to think about this problem. I’ve decided that as important as it is for financial institutions to use correct names, it’s even more important for medical practices to use patients’ correct names—whether or not I am the patient.

If yours is a typical or common name, you might think I’m being petty. You might also think that I am taking one minor detail and making it more important than it should be. Of course, you have a right to do so, but maybe that’s because you aren’t often in my shoes or the shoes of my daughter—or weren’t in my mother’s shoes.

Because if a physician’s office can’t get our names right—whether it’s the receptionist, health assistant, nurse, and/or doctor—despite our reminding you every time you say our names incorrectly—we’re going to start to question whether yours is the right practice for us.

It’s not that we don’t understand misreading our names—as I’ve said, people in general have done that all our lives. But once or twice, OK? We don’t mind if you stop and ask if you don’t really know how to say our names—that shows that you are reading what’s written. Just know that I, personally, will correct you every single time you say it wrong, even if you do so for sixteen years. Please don’t act annoyed by that. I imagine you do want to call patients by the correct name, but you’re busy and mistakes can happen when you have too many things to do at once.

How about adding a phonetic spelling to our charts so that any staff member who picks up our chart has an extra clue as to how to get it right the first time? In a paper-centric world, you can put it on a sticky note and add it to the folder. On the other hand, if you only use computers and your programs don’t allow that, then you really should ask the service providers to look into providing a way to add notes to the name section with their next update.

And your attempts at empathy by saying that you hate it when someone gets your name wrong? Make sure you really do have a unique name. There’s a big difference in assigning the wrong nickname or misspelling a name—as in “My name’s Michelle and people call me Shelly” or “I’m Kathy with a ‘K’ and everyone assumes my name begins with a ‘C’ instead”—versus getting the name wrong. I’ve said it before and I’ll say it as long as I know our names: my name’s Patrina, not Patricia, my daughter’s name is Christiana, not Christina, and my mother’s name was Elda, not Edna.

You see, getting names right is a good sign that you care about each patient as an individual. Names are central to who we are. No matter what Shakespeare said, if I call a rose a thistle, it does not seem as sweet. Even if I call a rose a daisy, it’s still just incorrect. When you consistently call people by the wrong names, then that raises concerns about how well you are paying attention to patients’ unique problems.

We start to wonder if you are listening to what we are saying. Or do you have problems recording information accurately? Something so small as starting our visits by calling us back by the wrong names could introduce doubt into how well we feel you do everything else in your office.

No, the customer/patient isn’t always right, but we are right to expect you to show us respect by attempting to get our names right.

Just in Their Time

Richard "Dick" Lange, circa late 1950s

Let me state upfront that my father was a pharmacist and so was my father-in-law. These two men took their jobs very seriously and had incredible attention-to-detail. They weren’t afraid to call doctors if they thought a mistake had been made or make sure their own assistants had verified all information. My father’s been gone these past ten years, but my father-in-law is still around. His insurance company keeps wanting him to switch to mail order prescriptions, but since he does not trust those organizations, that won’t happen any time soon.

Wish I could say that my experiences with our mail order prescription company have proven him wrong.

Even if the company had never made a mistake—which is not true—just their turnaround time alone hardly seems acceptable. I realize my father lived in a different era, but he made sure that the patients got the prescriptions before he went home. My father-in-law even worked Easter, for goodness’ sake. Two weeks after the company receives a prescription, they get the medication into our home? Just in their time, not ours, right?

Slow service seems bad enough, yet that’s not our only problem with them. Apparently their system isn’t set up well to reconcile prescription order forms with on-file records. Because our kids have been in college, their mailing addresses have changed a few times. And some glitch in their system keeps old addresses available on their end even after we’ve removed them on our end.

Twice in the last six months the company has sent our prescription orders to the wrong location, despite having received the proper mailing address on the mailing form. The company employed no heroic methods to get us the prescription at the correct address, even after admitting the errors came on their end. Whenever there has been a problem, I could rely on spending around an hour on the phone discussing the problem before the company took any steps to resolve the problem.

I’m not going to bore you with the details, but I think it’s unacceptable that this company mails prescriptions to the wrong addresses. And, that they don’t seem to have a plan devised for hurrying corrections through their system.

You don’t have to be a pharmacist to read the addresses on an order form, but the pharmacists I knew would be upset that their hard work wasn’t enough to take care of the customers’ health care needs in a timely manner. Does it make sense that I can order a comforter for my bed and rely on receiving it faster than I can get a prescription?

Health care reform needs to start by making sure all providers still care about their patients’ health, whether or not they see them face to face. Tell me we’re not out of time to fix that part of the system—just in time shouldn’t have to be a term reserved for a nostalgic period when providers busted their butts so that patients could begin treatments in a timely manner.

A Tale of Two Medical Visits

(c) 2011 Sherman Lambert

Might an empathetic bedside manner trump news delivered, softening blows because the patient feels heard?

Visit one, not requested by us but strongly suggested by the medical staff, started off in what is a typical way in our family: they got my daughter’s name wrong. Hey, I realize I named her a unique name, but after sixteen years at a practice, why is it so few of the staff get her name right? Is it possible they have a habit of not reading with attention?

Then the staff member proceeded to ask us why we were there—and then argue with us about our answers. We did not ask to come back so soon, but were told it was necessary for a specific reason—which had not been recorded the same way in the visit notes. Before we left without doing anything medically, three staff members were in the exam area, none willing to agree with the reason we said we were there while turning the conversation to what my daughter was not doing right—through information that had never been discussed at the previous appointment.

First of all they discounted what they had done and then turned the finger of blame on us. We were supposed to feel appeased with platitudes that it wasn’t a waste of time because they got to check out something else. Believe me, it isn’t whether they think something is a waste of time that matters—it’s what we, the patients—customers, if you will—think.

And maybe we would have felt the visit had not wasted our time if they had even offered one sincere apology for the miscommunication. Perhaps they really do think we got it all wrong, but this is not the first time we have encountered such confusion at this practice after we had the apparent misfortune to see two different providers at two visits—either office politics or medical philosophy discrepancies are involved or the staff does not write good notes in the charts—or all of the above.

In fact, with all my years of watching over my mother’s and my kids’ care, I can tell you that this is not an area I get wrong often, if at all. I know when the appointments are and I know why they say we are supposed to be there. The more I deal with medical appointments and procedures, the more I realize that good patient care is about more than the medical aspect—it’s also about good listening and record-keeping.

So I can tell you that my daughter was very unhappy to go to an appointment elsewhere an hour later. Since we haven’t figured out who should be her primary care doctor now that she is nineteen, when she has an urgent general concern when she is at home, she still has to go the pediatric practice where she’s been seen her entire life.

First of all, they called her by her given name. Then the PA asked questions that showed she had read the most recent sections of her medical chart. And, get this, she didn’t question how she said she felt, but discussed it with an empathetic tone. Of course, then she sent me out after a few questions so she could treat my daughter like the adult she is. By the time the appointment had ended, this PA had suggested something that could explain so much about all these constant physical problems that have been so hard on my daughter’s emotional well-being. Not a one of the specialists had ever mentioned such a possibility but so often they didn’t appear to have read her medical history and/or did not listen enough to our explanations to ask such thorough questions.

The daughter who entered that practice ready to shutdown on the next medical person who discounted her experiences left peaceful, despite hearing that there might be an explanation for her health problems that would mean even more medical treatment.

I am convinced she calmed down all because she felt she had encountered a provider who tried to understand all she had experienced, by simply reading good notes and asking related questions to draw out more possible information as well as by listening to the answers.

In other words, she felt heard. And that may make all the difference in getting a good enough diagnosis so that true healing may begin.