Medical Rant #1: Doctors

The BBQ Pit
1

When are doctors going to get it - their livelihoods depend on customer service. We aren’t just patients, we are clients.

We are in the midst of a medical adventure. Honorable Son #2 (“HS2”) was born 12 days ago. He’s a premie - he was born by emergency C-Section six weeks early because he has an arrythmia and his heart rate had started to drop.

The hospital had a pediatric cardiologist on-call. In the hospital, she wasn’t the most responsive of people; on a few days, we were told by the nurses that she was coming by, only to have her not show. And there were little things; for example, we were scheduled to be discharged one day at noon. She, of course, hadn’t called in, and the nurses wanted to clear the discharge with her. She didn’t call in until 2, and then she ordered another EKG, the result of which was that we didn’t get out until around 6 that evening. Just a little bit of poor planning on her part, and we lose six hours.

But that was a minor screw-up. HS2 left the hospital connected to a heart monitor. About 24 hours after we left the hospital, the thing starts going off like crazy. We call our regular pediatrician, who says “go to the ER.” We go (the ER was in a different hospital).

We also call the cardiologist’s office. We tell the receptionist that we are going to the ER and ask for a call. We stay in the ER for about three hours - no call from the cardiologist. It turns about to be a false alarm - the ER’s heart monitor showed a better heartrate then the home monitor was showing.

Later that night, we are back at the (second) hospital. HS2’s billirubin was up, and his pediatrician wanted him admitted. We had an appointment with the cardiologist the next day, and early in the morning, I called the cardiologist’s office to cancel, saying the HS2 was in the hospital for the second time that day, and noting that we still hadn’t heard from her concerning the first ER visit.

Again, no call - indeed, we have never heard from her since.
The second hospital has its own pediatric cardiologist, as it happens one with whom we had had a consult during the pregnancy. He showed up when he said he was going to. He spent some time with us. He spoke with only the necessary amount of medicalese. When he left, we: (1) understood what was going on; (2) were reassured; and (3) had a fair idea of the prognosis - three things the first cardiologist never managed to accomplish.

We have fired the first cardiologist; the second cardiologist will be caring for HS2.

From what we understand of HS2’s condition, he is pretty much an ideal patient for a pediatric cardiologist - he is unlikely to have a crisis or have a permanent condition, but he is going to need regular check-ups and testing for about a year. That’s money in the bank for a cardiologist, and the first one threw it away because she just couldn’t be bothered to make a phone call.

Too many doctors are like this. About 1.5 years ago, I herniated a disc, and once had to go to the ER for pain management. On the way there, I called my primary care doctor and left a message. I never got a call back from him, either - and he is no longer my doctor.

The perinatologist during HS2’s pregnancy could speak (non-medical) English, and his office couldn’t start a routine appointment within 1/2 hour of the starting time, even when we were the first appointment of the day. If any of our friends need a perinatologist in the future, we will recommend against him.

Honorable Son #1’s dentist called him “undisciplined” and impugned our parenting because HS1 was scared to death, screaming and crying during his recent dentist appointment. HS1 is 2.5 years old. When it is time for HS1’s next appointment, we will be finding another dentist.

We all want the “best” doctor. But for most of us, we simply cannot know which doctors are technically more proficient - physicians’ qualifications and success rates are (largely) kept hidden from us. So the only criteria available to us is whether the doctor is responsive, punctual, and is able to communicate effectively. But so many doctors just don’t seem to care about those things.

Screw 'em. They’re not getting my business.

2

Don’t hate the playa, hate the game.

Most doctors are victims of this crazy medical mess as much as the patients. For example, being half an hour late for the first appointment of the day. It might be the first appointment at the doctor’s office - but that’s after the doctor has been to the hospital checking on in-house patients many of whom are very sick and might need more time than the sliver scheduled so that the person can cram as many patients into their day as possible.

Not so say there aren’t jerk, incompetent, and otherwise bad doctors - but most of the frustrations of the current medical environment aren’t their doing.

What I don’t understand is why more doctors don’t just say screw the system and start something new on their own. I’d expect to see the medical equivalent of charter schools popped up everywhere, yet they don’t seem to exist.

3

Please send a modified version of this rant to the cardiologist. If she doesn’t know why she’s being “punished” she won’t change. It’s possible you can save some other parents some of the stress she gave you.

4

Malpractice insurance is really, really expensive. If it wasn’t, there probably would be more pay-as-you-go doctor’s offices in America.

5

Sorry, that doesn’t play. The perinatologist appointments during this pregnancy were always the same - MrsSponte would have an ultrasound and a fetal non-stress test. Both were done by techs. If the doctor actually saw MrsSponte - which usually didn’t happen - he wouldn’t see her until the end of the examinations, about 45 minutes to an hour later. So the doctor’s presence was completely unnecessary to begin - it was simply an example of poor planning.

And this happens all the time, in other contexts. Yes, I am aware that physicians are often delayed at the hospital or what have you. But you almost never see the physician at the start of an appointment - you see a nurse or a tech first, who draws blood, collects urine, takes your blood pressure, whatever.

Which means that appointments should always start on time. If the doctor isn’t there, or is behind because he/she was that the hospital earlier, at least you can begin the process. Get the preliminaries out of the way, and if after that you have to wait to see the doctor, at least some time has been saved. If the doctor’s office cannot start the preliminaries in a timely manner, it means that it is overbooked or inefficient.

Sua

6

The hell with sending the rant to the cardiologist - send it to “Angie’s List” - with a cc to the cardiologist. They’re the ones trying to “rate” doctors, based on the experiences people have had with local doctors. I was contacted by AL, and asked for my ratings of the local doctors, vets, and dentists that I have had recently - and I gave them my qualitative judgment on the care I had received (mostly very good, but a few stinkers).

I haven’t (yet) used AL to look for doctors, but wish I had had the tools to do so a couple of years ago when Mr. Roo had to (quickly) find a replacement for his primary. We went with a recommendation from my (former) primary - it was a lady she went to medical school with some time ago. She was an absolute disaster - after one visit, Mr. Roo knew she wasn’t going to work out for him. (Among her other sterling qualities, she was abusive, insulting, and, as it turns out, not medically qualified for the advise that she was giving.) Checking “Angies List” for this sub-prime doctor, we can now see that her performance with us was not an “off day” (or morning, or whatever) for her; this apparently was her standard MO. Now that the opinions are out in the public, the doctor will either start acting in a medically professional manner wrt her patients, or she will not get any new patients, lose the ones she already has, and, most likely, get booted out of the medical practice group. (I hope.) (Mr. Roo got another recommendation from another doctor, and found the ideal primary - yes, we very happy now, but …)

7

Bizarrely Zagats is getting into the doctor’s rating business. Bizarre, but I love it.

Sua

8

Reception Decor: 22
Doctor Service: 14
Cost: $$$
The waiting room was “heavenly” with “tropical themed” wallpaper and a “really hot receptionist”
You may find the doctor to “smell of old tuna” but his tongue depressors are “mostly clean” with a “woody aftertaste”
“Complimentary pee cups” are a plus.
Service is limited. Reservations highly recommended.

9

Nope. I’m on the other side of this and nope. We know how many patients we have to round on and can make a pretty good guess as to how much time it will take. We start our rounding to time it accordingly. Oh sure, a day can bring surprises and you can be behind from before you start, cut some slack for a one time bad experience, or maybe twice even, but those should be the exceptions not the rule. Someone who is habitually late and habitually behind is not giving themselves enough time for what they need to do.

Yes, vote with your feet and let the doc know why you are leaving.

It may be that a specialist won’t care. They may be salaried by the center no matter how many patients they see. Their money may be in procedures and not in the visits and hospital consults at feeder hospitals may be something they do only because they are told they have to. They may be in enough demand for their particular expertise that their revenue stream isn’t threatened by unhappy patients. But that said most will care if they are told if for no other reason that most of us docs really do want to do a good job at what we do. Oh our egos are secure and not threatened by being told “bad boy” once or twice, but we will take a complaint about us seriously more often than not. Believe it or not I think most docs are more concerned with doing a good job than with their pay. Write the letter. Copy her Dept head. She may just be clueless.

As a doc I am also amazed by this. But I am also amazed by how patients seem to just accept being treated like that by other practices. They do not care because it does not seem to affect their business and too few complain about it.

10

Or that the dingleberry with the appointment before yours showed up 15-25 minutes into the half-hour scheduled for him, and the tech staff is tied up getting all his pre-doctor stuff done. That is the absolute top reason for our vet clinic running late. Yeah, we get the blood and stool samples, run the testing on them, temp and weigh your pet, and frequently give any injections that need to be done, with the doc only popping in toward the end to do the exam and talk about any medication changes or concerns the owner has. But there’s only so many of us, and we only have so many hands apiece, and we only have so many exam rooms to put people in, so if the first person in an appointment block shows up five minutes before the next one, it’s a domino affect that screws everything up for the rest of the day. And god help you if the third appointment shows up 20 minutes early, because you’ve gotten three patients who all need tech work within 15 minutes, when there was supposed to be an hour between them.

11

Then the simple solution would be to have there be more doctors. The number of doctors is not set by supply and demand but strictly controlled by organizations, made of of doctors themselves such as the AMA, that limit the accreditation process. They set the number of MD granting institutions and the number of incoming students each year, thereby deciding how many doctors there will be.

Obviously, there is a self interest in keeping this number relatively low. A number where the demand becomes high because of the low supply, but high enough that there is somewhat sufficient coverage.

Medical school is very hard to get into, and it should be. But, every year a whole lot of very smart people who would make fantastic doctors are turned away. Of course, increasing the number of doctors would somewhat lower the demand and therefore probably suppress salaries a bit, and being that this decision is made by the people whom it would affect, self interests get in the way.

12

Having lots of doctors out there doesn’t impact the medical school, so it’s hard for me to believe that there’s an established quota for that. However, medical school classes require laboratories - which means there are limits to how many bodies can be taught within a space due to limitations of the physical facilities. Medical schools can only teach 100 students if there are only 100 spaces in the gross anatomy lab. The only alternative would be to run 2 sections of the lab, which would mean hiring a lot more staff or enlarging the facility which would take millions of dollars.

Most places are kinda stuck with the students numbers they’ve got.

13

Question in earnest: Then why isn’t the dingleberry made to wait? Do what you can before the next appointment time, then come back to dingleberry after you’ve worked with the guy who showed up on time?

14

Having lots of doctors affects the medical doctors who run the medical schools. But the AMA (specifically the AAMC) doesn’t just determine the number of students per school, but limits the number of institutions that grant MDs by limiting accreditation. So, the physical facilities, as you put it, are also set by the AAMC.

This isn’t conspiracy theory, this is one of the roles of the AAMC

15

Clogs up the room and slows down the flow for people after that even more.

Yeah, it does sometimes seem like patients are all coming in on the same bus. The one twenty minutes late the one on time and the one coming in early all arriving at the same time. We really do try to run on time and sometimes it just isn’t going to happen. But that really should be an exception not the rule is all.

16

From my experience in the vet field, it all depends on the clinic. Some vets will still see patients as long as they show up in the time field of their appointment. Scheduled to be seen for the 10:00-10:20a appointment and show up at 10:15? Go right ahead! Doesn’t matter that we’re already insanely behind.
Other vets often will say “sorry, no dice” but this is pretty rare. They want to keep the client happy and someone who has to wait an extra 15-20 minutes is going to be less angry than someone who has to reschedule. The bottom line is, people have come to expect to wait in a doctor/vet clinic.

17

I don’t know how useful they would be anyway. Some of the best doctors I know have the least impressive credentials on paper, and vice-versa. And my clinic’s stats on diabetes are appalling without context, but we mostly take care of the uninsured population in one of the poorest areas of the country. You just can’t compare us to a clinic with a population of rich suburban housewives.

18

Actually, I think the biggest rate limiting factor on medical education is the clinical years. Third and fourth year students have to been closely supervised on the floors, plus the patient census has to be able to support them. Supervising them takes up time from the residents (already overburdened) and attendings and takes time away from patient care - assuming they are doing a good job teaching. Similarly, patient census has to be able to support the number of students. I did a peds rotation one summer when the hospital census was low and it was terrible - I think the ratio of doctors and students to patients was 2:1 at best. The students didn’t have anything to do and didn’t learn as much as they could. I felt terrible for the third years on that rotation - what a terrible learning experience!

When I was looking at schools, I looked at some places that had recently opened more spots in their first year class. But I didn’t end up going there because I wasn’t satisfied with their answer to how they were going to equally educate everyone in third and fourth years. Schools would love to admit more students - med school tution is bloody high. But they have to consider the ability of their hospital system to absorb more students. The AMA controls some of this, but I’m not convinced that they play as big as role as is made out in this thread.

19

A lot of reasons. I run out of exam rooms, for one thing. My boss, like a lot of clinic managers in both human and vet medicine, has a thing about through-times for appointments, for another. It’s faster to get things done in one shot with no other distractions, so having dingleberry’s chart and injections and blood samples and such cluttering up my counter and lab area makes things run slower for the on-time guy and makes it a wash as far as how long he’s in the building. And around here, the dingleberries are so large a percentage of our population that if we ran all of them off making them wait around, we wouldn’t have enough clients to stay in business.

The other issue we run into a lot is when the schedule looks entirely appropriate, and we should have no issues staying on time, but what actually walks in the door bears no resemblance to the schedule. For instance, yesterday, we had a standard vaccine appointment that the owner had also mentioned her dog’s belly looked a little pinkish. The dog’s belly was blood red and had lost all the hair, he had hair thinning all over his little legs, his ears were swollen nearly shut, etc. So instead of a heartworm test, a fecal, and three vaccines, I had to pull about a gallon of blood for a metabolic panel, thyroid, and allergy testing, get hair samples for ringworm culture, scrape the skin for mites, get cytology samples from his ears, belly and feet, and take pictures to document his condition. That’s just the sample collection, that doesn’t even get into actually doing any of the testing or doing any treatment.

The same thing isn’t uncommon with human docs. Someone will schedule for a routine checkup, and then show up with a page-long med list for their 14 chronic conditions they failed to mention when scheduling the appointment. Oh, and btw, they also have this horrible pain in their knee that’s cropped up in the last week or so, and and and. In some patient populations these people are relatively rare. But in other patient populations, they’re the rule rather than the exception.

20

I work in a doctor’s office and, exactly! When patients are late, they think, “Oh, it’s no big deal- I’m only 15 or 20 minutes late, for god’s sake!” but they are putting the doctor behind. If your appointment was at 9 and you showed up at 930, you are effectively triple-booking him at 930 because he already had two patients scheduled for that time (a mere 15 minutes). Are you willing to ask the 9:45 patients if they mind being seen late because you didn’t show up on time?

Plus, if the doctor is running late, don’t blame the office staff. We have little to no control over how fast or slow he or she is running- don’t be a coward by bitching me out about it and then being all nicey-nice to the doctor. If you are bothered by him being late, speak to him about it.

Or get a doctor like mine. He is so charming and so friendly and so nice and so wonderful that even when he comes in two hours after my appointment time, my anger just melts away when he says “I’m sorry” and smiles at me. He’s so nice, he doesn’t even give you the satisfaction of being mad at him.