Sunday, January 10, 2016

Why My Patient Left the Office

A patient came to the office and refused to see me, although I was quite willing to see him.  I’ll present the scenario followed by the patient’s reason he took an abrupt U-turn.   Then, if you are inclined, you may offer your own advice and comment.

I performed a colonoscopy on this patient and found a large polyp in the upper part of the large intestine, or colon.  The upper part of the colon, or right side of the colon, has been receiving a lot of press in gastroenterology in recent years.  Medical studies have observed that cancers in this region are more easily missed for reasons that don’t need to be explained here.  For this reason, gastroenterologists are particularly vigilant when examining this region.

The polyp was large and somewhat hidden behind a fold of tissue.  I suspected that this was a benign lesion.  I removed the polyp using one of the gadgets in our bag of tricks, but knew at the time that I had left some polyp tissue behind.  I was unable to remove the entire lesion because of its tricky location.  In addition, because the polyp seemed to be embedded in the wall of the colon, I wasn’t certain that I could safely remove the remaining fragment without causing a complication.  First, do no harm.

The Large Intestine - Where Polyps Hang Out

I advised the patient to return to the office in 3 weeks so that we could review the options.   In the meantime, the pathology report from the specimens confirmed that the polyp was benign, but pre-cancerous.  The remaining polyp tissue would have to be removed.   Our practice has a No Polyp Left Behind policy.

There are 2 options that make sense.
  • Have a surgeon remove the R side of the colon, which would guarantee safe and complete removal of residual polyp in one session.
  • Refer the patient to an expert colonoscopist at one of our nearby teaching institutions.  There are advanced techniques and skills that could complete the task that I left unfinished without surgery.  This is certainly easier to go through than an operation, but there is a lower probability that all of the polyp will be removed in one session.  Therefore, future colonoscopies would be needed to reexamine the site to verify that it is clean.  Colonoscopies have risk and inconvenience.   This approach, in my view, affects quality of life as for a long period of time, the patient has concern about polyp tissue left behind.

Discussing these two options, with their respective risks and benefits, is a long conversation.  I would anticipate many questions from the patient and any family member who might be present.

The patient came to the office at the appointed time, but then balked when he was asked for his $40 co-payment, as required by his insurance company.   Of course, we have nothing to do with setting co-payment rates.  While I have respect for the sum of $40, I think it can be argued that this is not excessive for receiving a full presentation of medical options from a physician on how best this patient can prevent colon cancer from developing.    

He left the office.  How should I react?  Should I call him and provide a ‘free office visit’ on the phone for 15 minutes so he doesn’t have to fork over the forty?   I make dozens of phone calls to patients every week, but these are generally to resolve simple issues.  If during one of these calls, I decide that a phone call is not appropriate for resolving the issue, then I ask the patient to make an appointment.   While a patient might think, for example, that I can diagnose and treat diverticulitis on the phone, I prefer a hands on approach here.

Should I write to my PPP (petulant polyp patient) and advise him that he needs to see me face to face as the issue is more than a phone call can handle?  What if I do so and he doesn’t show up.   If a few years from now, the lesion turns malignant, then will this be my fault?  When does my responsibility end and his begins?  

13 comments:

Carole said...

Write the letter, if it's only 40 dollars for him and you question what's the big deal, then it's only 40 dollars to you as well! Better to be safe than sorry! Plus I'm sure you care more about him than that 40 bucks, right? You honestly have no idea why he didn't pay that 40, if you write him, I bet you 40 bucks you ask him why and he'll tell you why, you'll probably end up feeling badly thinking the worse of him.
I'm serious about the bet !!! I will pay up....

Carole said...

MD Whistleblower
So I did see, you do reply now and then. I'm guessing you, never replying to me is personal- can't imagine why, though? I've never been rude or disrespectful, in fact quite the opposite. Not only do I read your blog, but I've read your postings on another popular blog. Now there, I've read some pretty rough comments, (I didn't like or agree with towards you) which I'm guessing by now you enjoy more than the compliments and respect I've shown you. Also believe at this point it's because I'm not one of your own, so I'm a nobody! Truth is I am somebody, and I count and I do matter- but I get it, no biggie- still like you and what you write about in spite of feeling less than worthy of your valuable time, I won't bother you any longer.
About this post, I feel you should call or write that patient, I'll be more than willing to pay that 40 on his behalf. You can e-mail me privately, and let me know where to send the payment, will want a receipt though!!!! :)

Michael Kirsch, M.D. said...

Carole, of course I value your input. Keep in mind that it is barely 24 hours after you offered your intitial response. Do you think this is not a reasonable interval? The issue of whether to write a letter or insist upon an office visit can be tricky. What if every patient expected that their office visits would be converted to physician letters or emails? Is it reasonable that physicians would offer complex and nuanced medical advice for free? Moreover, it really possible to put in a letter the advantages and drawbacks of purusing an operation or some other medical approach? Wouldn't you expect that the patient has many questions? Does the physican incur liability exposure because the letter was inadequate in explaining all of the nuances of the patient's situation? Does the patient have a responsbility to follow reasonable medical advice, which may include coming to the office for a discussion? While I have touched upon the economics of a letter, my primary point is that an office visit provides the proper level of medical quality.

Carole said...


Dr. Kirsch, thanks for acknowledging my comment and replying. In my defense (again- no biggie) It's the first and only time- and its sincerely appreciated. That patient absolutely should of followed through, why 40 dollars stopped him makes no sense and has me curious and yes a little concerned, since he went through the whole process and procedure. You made some very valid points on both scenarios. Exactly why I feel it's better to be safe than sorry later- (for both of your sakes) At this point in time "now" though- I believe a phone call would be better, asking him if he's going to follow up "suggesting" the results he must want and surely has questions, which are important to you to answer. How amazing that would make you- trust me!!!! If he says no be direct and ask him why not and if it's about the 40 dollar co-pay, clear that up and then let it go, he can't say you didn't try or care! I personally believe the follow up appointment from procedures is important and a must, and worth every single cent. And you DO deserve to get paid for your time and expertise...








Melody said...

From my side of the desk, (if I were the patient) the calculus would be this. I paid for an "original" visit, be it due to a troublesome symptom or a routine annual exam. I then scheduled and went through a colonoscopy. Again, both my time and money were expended. Now, I'm being told I need to make yet another payment to hear the results/recommendations. How many times do you want to be paid . . . how deep are my pockets, and at what point do I look at you and see that YOU are looking back at me as merely a continuing money stream? Does patient 'skin-in-game' require us to ascertain what ALL the costs will be, from consultation to resolution? Are we savvy enough, as mere non-medical flotsam, to ask for a "package" deal? Or do we just keep turning the other cheek and opening our wallets every time we interface with you?

Carole said...

Dr. Kirsch
Melody has made a good point about the co-pay, big time! which when I first read your post, I thought to myself he's PO'd about that co-pay,
And probably rightfully so because he had already paid out (?) and didn't follow through (not because he didn't want to) but walking away frustrated basing it on the principle of "unfairness". I just know there has to be more to this story, and facts not known or left out. Thats exactly why I'm curious!! It just doesn't make good common sense, unless that's the true reason- principle of unfairness, over amount owed.
I really wish he had the results, and I don't mind paying the 40 for him to be called back in to get them. Then again maybe he just didn't
have it then or now!?!

Michael Kirsch, M.D. said...

Melody, thanks for commenting. Folks have a right to be paid fairly for the work they do. I understand a patient may be frustrated at receiving several bills for what they may incorrectly perceive to be a single service. If a patient undergoes a colonoscopy, which is normal, the patient will be charged accordingly. If the colonoscopy is abnormal, and biopsies are taken, would you expect that a subsequent office visit when biopsy results are discussed and treatment options are presented, shouldn't result in an additional charge?

Keep in mind that physicians have absolutely nothing to do with any of this. We don't set any prices or copays, etc. They are all mandates from insurance co's and the gov.

Fred Gandolfo, MD said...

This is a great topic. I left a more extensive comment on KevinMD. It actually ties into an upcoming post I have written regarding what to do with these big polyps if you can't remove them in one shot.

Just wanted to say I enjoy your blog and writing style. Keep doing what you do!

Fred

Michael Kirsch, M.D. said...

Thanks for the kind words, Frank. Hope you'll be back. MK

BPladybug said...

Yes, you need to write him! And send it certified and return receipt for your protection. But you can also offer to waive the copay.

I see two possibilities. One is your patient cannot afford to pay the $4o. In which case isn't he lucky the the ACA covered his Colonoscopy at 100% for preventive. These next procedures will not be Preventive and he will need to pay the deductible if he has not already done so and then the coinsurance. If he can't pay $40 he certainly will not be able to pay those thousands of out of pocket costs for surgeries or several additional procedures.

The second possibility he that it was not the money but rather a total lack of understanding of his insurance and how it works. Perhaps just a resentful belligerence
toward insurance, the high expense of our medical system, and a lack of understanding of the ACA.

The plan he is on, whether picked by his employer or his wife covers his Preventive Care at 100%. That is such a great change. And there have been copays for years and years unless you worked someplace like Microsoft.

Another point is that he might by frightened of cancer and wanted an excuse to run away from you and not hear the news you needed to share.

I did enjoy reading your blog. I hope you found resolution for this difficult patient situation.

yours truly, An Independent Insurance Agent

Michael Kirsch, M.D. said...

@Bladybug, I didn't realize that independent insurance agents still existed, outside of museums! Thanks for your comment and I look forward to future visits by you.

Anonymous said...

I saw your post through KevinMD & it actually prompted me to sign up with Disqus, so thank you. The basic truth is your patient had most likely perceived the initial appointment & procedure cost to include a follow up. It's usually not more nefarious than that. This is what I commented at KevinMD site:
The good news is you thought about the patient's case & wanted to meet with them. The bad news is you lost a patient because they perceived you trying to scam them out of money by seeing them for something they perceived could be done by phone.
The patient certainly could have spoken up at appointment or w/your staff but that would require clear policies on the matter & your staff trained to explain them. I'd really recommend for your specialty that you develop policies in writing that explain in say normal colonoscopies a call is acceptable but should the procedure yield data requiring further steps a regular scheduled appointment is required and not included in initial pricing.

As a patient & practitioner, I think you've made an error but certainly not intended harm.

Your appointment would have ultimately only resulted in a referral to another physician thus for the patient to spend 3 weeks & money only to be told they must see someone else feels (whether you get this or not) disrespectful to the patient. When one has a problem, time becomes so critical and disrespect of that time even with best intentions does not result in good relations. Going forward I recommend increasing your policy communication but I really recommend when a procedure results in another step, particularly a referral which takes time, have your staff call the patient (an RN or PA), explain that results warrant further evaluation & treatment & offer that the patient be given the opportunity to schedule with other doctors (two in your example)and provide those doctors with an update on patient so THEY can explain circumstances. Always have staff remind patient that they can come in to discuss further & reassure the patient that you are interested in overseeing their care if they desire. Otherwise take steps to insure their GP is fully aware of findings and recommendations.

It's not "your fault" they don't want to see you but if you are really honest you'll acknowledge that who they really need to see is someone else. Be respectful of that and you are unlikely to have this response again.

Fondly, Cheryl Prevor Psy.D.

Anonymous said...

The good news is you thought about the patient's case & wanted to meet with them. The bad news is you lost a patient because they perceived you trying to scam them out of money by seeing them for something they perceived could be done by phone.
The patient certainly could have spoken up at appointment or w/your staff but that would require clear policies on the matter & your staff trained to explain them. I'd really recommend for your specialty that you develop policies in writing that explain in say normal colonoscopies a call is acceptable but should the procedure yield data requiring further steps a regular scheduled appointment is required and not included in initial pricing.

As a patient & practitioner, I think you've made an error but certainly not an intended one. Your appointment would have ultimately only resulted in a referral to another physician thus for the patient to spend 3 weeks & money only to be told they must see someone else feels (whether you get this or not) disrespectful to the patient. When one has a problem, time becomes so critical and disrespect of that time even with best intentions does not result in good relations. Going forward I recommend increasing your policy communication but I really recommend when a procedure results in another step, particularly a referral which takes time, have your staff call the patient (an RN or PA), explain that results warrant further evaluation & treatment & offer that the patient be given the opportunity to schedule with other doctors (two in your example)and provide those doctors with an update on patient so THEY can explain circumstances. Always have staff remind patient that they can come in to discuss further & reassure the patient that you are interested in overseeing their care if they desire. Otherwise take steps to insure their GP is fully aware of findings and recommendations.

It's not "your fault" they don't want to see you but if you are really honest you'll acknowledge that who they really need to see is someone else. Be respectful of that and you are unlikely to have this response again.

Cheryl Prevor Psy.D

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