A Doctor's Dilemma

A woman has cancer. She wasn't supposed to have cancer; I was treating her for something else for many years, but then she developed cancer. Not just any cancer, but one that I know will prove fatal. Soon!

I treat a lot of patients with bladder and prostate cancer, so to a certain extent, I'm used to it. But they come to me because they already have cancer and I'm supposed to make them well. I do that pretty well and I'm confident that I can help. But this is different. This is a patient I already know. I know her husband. I know her family. I want to help -- to offer her hope, maybe even cure, but at the very least some more quality time. But that's not what I do; I'm a surgeon. I cut out cancer, but hers is too far gone. It can't be cut out. It needs chemotherapy, but I don't do that. And even if I did, it won't cure her; it may not even make her better it all. It may make her worse; it may kill her.

So, I referred her to an oncologist. He's is warm, caring and optimistic. He returns her calls and he treats her the best way he knows how. But she, her husband and her family want my opinion. They call me a lot and I call them back and I do the best I can. She's not feeling very well and coming into the office is a burden for her and I have nothing to do anyway but answer their questions. They thank me for my time.

My time. Phone calls. First I spoke with her oncologist, then her internist. I spoke to the patient, then her husband. I arranged lab tests. I filled out numerous forms so that she can have some procedures done that I don't perform, but oversee. I tried to speak to the doctor who actually does the procedure to tell him that she does not need anesthesia (which she is scheduled for). That doctor doesn't call me back despite repeated calls. I wrote a medical summary so she may obtain a second opinion.

All told, over two hours were spent providing assistance to her care.

Here's the dilemma . My fee? $0. No insurance company pays for this stuff anyway. I don't do this for the money (Duh), but almost all of the time spent was, by necessity, during office hours. It was all unscheduled, so it took up time that was supposed to be spent with other patients. Some complained about waiting. Some complained that I didn't spend enough time with them. That's not good for my practice. I can earn more if I don't get involved with patients like this. After all, I'm not even actually treating her. But when she calls, I feel compelled to do what needs to be done. That's not good for business.

The Patient's Plight

The patient's plight. She's scared. Terrified. Her husband is scared and angry. She knows that her treatment is not working. She sees and feels herself getting worse. She doesn't want to die. She doesn't want to suffer. She doesn't want to get all the complications that she is already getting from chemotherapy, so she wants another opinion. She wants some hope.

But her immediate concern is the procedure. She knows she doesn't need the anesthesia and all the tests they want her to get before the procedure. She just wants it done, but when she calls to tell them that, she can never get to speak to the doctor that does the procedure, only a nameless person who answers the telephone and tells her that they will discuss it just before they do the procedure. But first, there are the blood tests, filling out the same kind of forms she's filled out so many times before and the fact that they will not schedule the procedure until they receive the form requesting that the procedure be done.

Why haven't they received the form? Because I need to speak with the doctor first to warn him about certain things that I know about (but are not on the form) and assure him that she does not need anesthesia. I also need to tell him that he has already done this procedure before on the same patient and all that he is doing is changing something (His office said they have no record of that). It's very simple. I could easily do it in the office if I had the equipment.

The patient knows all this and to add to her discomfort and apprehension, she is frustrated.

The problem in a nutshell. Individual doctors need to be able to spend more time taking care of individual patients. Nothing in any of the current legislation really addresses that central thesis. All of the current 'solutions' deal with the delivery of health care to the 'population.' The solutions deal with cost cutting, regulations, algorithms, cutting back on waste and inefficiencies (did you ever see anything as efficient as the bureaucracies that run government and health care insurance companies)?

All well and good, but individual doctors spending more time with patients individually means that each doctor sees fewer patients (or works more hours). So we need more doctors and we need to pay them well enough for their time so that it is worth their time to talk to patients (and worth their time to be doctors in the first place). That?s not going to drive down the cost of health care, but that's the way it is.