Re: new habits... TESTS, FU responsibility, noncompliance ...

May 7, 2006

This is another great thread. I am an absolute OCD maniac about tracking and returning test results. One of the first tests I ordered in my practice was a CXR on a woman with an isolated episode of hemoptysis. It showed a 6 cm MASS and I never got the results until I called them 2 weeks later and asked "WHERE'S THE RESULTS???" Nobody could explain why I did not get the results and it happened with 5 or 6 other patients at the same radiology center. Problem is now fixed BUT BOTTOM LINE is if we order the test we better have a way to track results. I have a self made EMR with a pending file that I update as tests are ordered and return. That way I can sleep at night. BTW this woman was in total denial and would have not called for her results and I would have been up a creek without my pending file. It took me months to get her to agree to go to a specialist. She had no insurance and wanted me to help her get treatment in India."No news is good news" is BAD news. Do not practice this way.I went to a malpractice seminar once where we were told by the speaker that if the airline industry were run like the health care industry we would have a major accident several times per day at the Portland Oregon airport. Can you imagine the pilot asking the guy in row 17 to look down and check to see if the landing gear went down? That what we do when we ask an ill person to call us as our only plan for returning lab/tests results.If I am particularly worried about a test or I have a worried patient (even about a minor test) I'll do what Brett suggested and have them call me after the test and I'll get the results to them right away. Sometimes I go with them to the procedure which floors the consultant doctor when the FP is standing there at 8 am in her biking attire to watch the thyroid biopsy and read the results with the pathologist and give the results in real time - no phone call, no fax. now that is service!!I even got them to match my 40% discount on the fee which was a huge relief to my uninsured patient.Noncompliant patients with testing/labs. I have no problem with patients who decline tests that I feel they need as long as they understand the risks/benefits. I notate that in the chart and continue to remind them about the needed mammogram or colonoscopy. I may become a bit of a nag but I intermittently keep checking in with them.Challenging noncompliant patients I have had recently include a woman with presumed out of control diabetes who would not go for a blood test. She finally did on her third visit and it was 399 fasting. She is now on insulin but is trying to convince me that she should be able to discontinue it. Even though she was resistant I felt I could create a trusting relationship with her EVENTUALLY and I did not feel that I should just terminate her. She has no insurance, no other place to go and dislikes allopathic medicine. Has only been to a doctor 3 times in her life and now she is 50. We have a great but challenging relationship. She honors my opinions and we can work together even with different opinions.I recently TERMINATED a NP in town for noncompliance over lab testing. This was rather interesting for me. She came for a physical 1 year ago and we ordered screening blood tests (she's over 50). She agrees to get the tests done yet her name kept coming up on my pending test file as an uncompleted test. I called her a total of 5 times to remind her and each time she promised to get the labs in January, then March. It is May now. I have over 100 people on my waiting list. I do not have time for people who do not communicate with me honestly especially multiple times. We al have our methods, limits, boundaries. These are some of mine.PamelaPamela Wible, MDFamily & Community Medicine, LLC3575 st. #220 Eugene, OR 97405roxywible@...www.idealmedicalpractice.orgOn May 6, 2006, at 6:39 AM, Brett L. Kinsler, DC wrote: Let me qualify my post prior to being flamed. I have been a lurker and infrequent poster on this list for a few months. Some of you know me from off this list and that is usually where I keep my communications. I am not an MD or a PCP but a practicing chiropractor. Nine months ago, I formed a micropractice within the ideals that have been set forth by Gorden and this group. I bounce back and forth between a larger, multi-doctor, multi-staffed office with high volume of patients to a small, one room practice with no staff depending on the day of the week. My micropractice patients have 24/7 direct access to me by cell phone and e-mail and deal with me directly to make appointments, take co-payments, etc. Certainly there are topics discussed on this list that I cannot relate to...pharmaceutical samples, certain specialized testing and procedures, etc. But the nuts and bolts of running a healthcare practice without staff, the small practice mentality, the delivery of care to patients on a highly personal level, all overlap with my own experience. I wanted to chime in on the discussion about ordering tests because I think there is a more important point than just setting up the test. When patients are sent for a radiology study or even bloodwork, they very often go home thinking, "I have cancer and I know they are going to find something terrible." Patients lose sleep for days awaiting the results of even routine tests. Many doctors don't even call their patients with negative results thinking no news is good news. For many years, my standard operation is one day after the test was scheduled (or if the patient is scheduling, I have them call me once the test is completed), I will call the radiology center or lab for a faxed copy of the results. If the results aren't ready, I will take a verbal. Almost every imaging test and many bloodwork tests can return some result within 24 hours. The patient then gets a call...positive or negative results notwithstanding. If I have referred the patient to another specialist who I know has ordered the test, I will still call for the results. Patients are amazed since they are usually told it will take "a couple of weeks" to hear about their results can know as soon as possible. Allowing your patients to sleep better at night knowing the outcome of their testing is certainly a valuable, personal service that the big practices cannot offer. Brett L. Kinsler, DC Rochester, NY

May 7, 2006

RE Pt with 6 cm chest mass

OK, I need to know...

1) Did you send her to India.

2) In denial with chest mass-- you terminated a pt who refused to get labs for 6 months, but a pt in denial about a 6 cm chest mass took a few months?

3) Do you have another source of income besides your micro practice?

Just curious...

Re: new habits... TESTS, FU responsibility, noncompliance ...

This is another great thread. I am an absolute OCD maniac about tracking and returning test results.

One of the first tests I ordered in my practice was a CXR on a woman with an isolated episode of hemoptysis. It showed a 6 cm MASS and I never got the results until I called them 2 weeks later and asked "WHERE'S THE RESULTS???" Nobody could explain why I did not get the results and it happened with 5 or 6 other patients at the same radiology center. Problem is now fixed BUT BOTTOM LINE is if we order the test we better have a way to track results. I have a self made EMR with a pending file that I update as tests are ordered and return. That way I can sleep at night. BTW this woman was in total denial and would have not called for her results and I would have been up a creek without my pending file. It took me months to get her to agree to go to a specialist. She had no insurance and wanted me to help her get treatment in India.

"No news is good news" is BAD news. Do not practice this way.

I went to a malpractice seminar once where we were told by the speaker that if the airline industry were run like the health care industry we would have a major accident several times per day at the Portland Oregon airport. Can you imagine the pilot asking the guy in row 17 to look down and check to see if the landing gear went down? That what we do when we ask an ill person to call us as our only plan for returning lab/tests results.

If I am particularly worried about a test or I have a worried patient (even about a minor test) I'll do what Brett suggested and have them call me after the test and I'll get the results to them right away. Sometimes I go with them to the procedure which floors the consultant doctor when the FP is standing there at 8 am in her biking attire to watch the thyroid biopsy and read the results with the pathologist and give the results in real time - no phone call, no fax. now that is service!!

I even got them to match my 40% discount on the fee which was a huge relief to my uninsured patient.

Noncompliant patients with testing/labs. I have no problem with patients who decline tests that I feel they need as long as they understand the risks/benefits. I notate that in the chart and continue to remind them about the needed mammogram or colonoscopy. I may become a bit of a nag but I intermittently keep checking in with them.

Challenging noncompliant patients I have had recently include a woman with presumed out of control diabetes who would not go for a blood test. She finally did on her third visit and it was 399 fasting. She is now on insulin but is trying to convince me that she should be able to discontinue it. Even though she was resistant I felt I could create a trusting relationship with her EVENTUALLY and I did not feel that I should just terminate her. She has no insurance, no other place to go and dislikes allopathic medicine. Has only been to a doctor 3 times in her life and now she is 50. We have a great but challenging relationship. She honors my opinions and we can work together even with different opinions.

I recently TERMINATED a NP in town for noncompliance over lab testing. This was rather interesting for me. She came for a physical 1 year ago and we ordered screening blood tests (she's over 50). She agrees to get the tests done yet her name kept coming up on my pending test file as an uncompleted test. I called her a total of 5 times to remind her and each time she promised to get the labs in January, then March. It is May now. I have over 100 people on my waiting list. I do not have time for people who do not communicate with me honestly especially multiple times.

We al have our methods, limits, boundaries. These are some of mine.

Pamela

Pamela Wible, MD

Family & Community Medicine, LLC

3575 st. #220

Eugene, OR 97405

roxywible@...

www.idealmedicalpractice.org

Let me qualify my post prior to being flamed. I have been a lurker and infrequent poster on this list for a few months. Some of you know me from off this list and that is usually where I keep my communications. I am not an MD or a PCP but a practicing chiropractor. Nine months ago, I formed a micropractice within the ideals that have been set forth by Gorden and this group. I bounce back and forth between a larger, multi-doctor, multi-staffed office with high volume of patients to a small, one room practice with no staff depending on the day of the week. My micropractice patients have 24/7 direct access to me by cell phone and e-mail and deal with me directly to make appointments, take co-payments, etc. Certainly there are topics discussed on this list that I cannot relate to...pharmaceutical samples, certain specialized testing and procedures, etc. But the nuts and bolts of running a healthcare practice without staff, the small practice mentality, the delivery of care to patients on a highly personal level, all overlap with my own experience.

I wanted to chime in on the discussion about ordering tests because I think there is a more important point than just setting up the test. When patients are sent for a radiology study or even bloodwork, they very often go home thinking, "I have cancer and I know they are going to find something terrible."

Patients lose sleep for days awaiting the results of even routine tests. Many doctors don't even call their patients with negative results thinking no news is good news.

For many years, my standard operation is one day after the test was scheduled (or if the patient is scheduling, I have them call me once the test is completed), I will call the radiology center or lab for a faxed copy of the results. If the results aren't ready, I will take a verbal. Almost every imaging test and many bloodwork tests can return some result within 24 hours. The patient then gets a call...positive or negative results notwithstanding.

If I have referred the patient to another specialist who I know has ordered the test, I will still call for the results. Patients are amazed since they are usually told it will take "a couple of weeks" to hear about their results can know as soon as possible.

Allowing your patients to sleep better at night knowing the outcome of their testing is certainly a valuable, personal service that the big practices cannot offer.

Brett L. Kinsler, DC

Rochester, NY

May 7, 2006

1) I did not send her to India. I really had very interesting conversations with her and we worked together to find a solution that would be successful. She tried to contact the docs in India and they were unresponsive so she finally agreed to see specialists in town. Is now finishing chemo. She was primarily struggling with the fact that this would be expensive and she had no insurance so she was trying to save money, meanwhile time was ticking away (as was her life) and I had compassion for her struggle. She always communicated honestly with me (though our opinions differed at times a great deal). She came to her appointments and paid - by donation and always was transparent and fair in her interactions with me. She appreciated and vaued our relationship despite our (at times dramatic) different opinions.2) The woman with the noncompliance with labs obviously does not value my time or relationship if she can tell me on 5 different occasions that she WILL do something and never do it. She is not able to communicate with me honestly.All I ask for is appreciation and honesty. I do not need anyone to agree with me or my opinions.I have no other source of income. I do not need another source of income because (here is the key) I have almost NO EXPENSES in my business (7% overhead is VERY VERY LOW) and in my personal life (NO DEBT). I am married to a musician who makes basically no money (his highest income was less than my lowest federal withholding) I believe in the concept of voluntary simplicity. It is a pleasant way to live without the burden of extra stuff. Just living with what I need instead of all the extra stuff that people think they need. I guess I live the Ideal Microlife or the LOVE model of living.Have you ever gone to the third world where people have just enough but not too much. They usually live in little shacks but all their extended family lives in the same village. They work and play together. They do not have CPAs and financial planners and ask therapists and consultants about all their problems and how to manage their wealth. These people are having a great time just living life. They are an inspiration. When I think of my career - all I really did was apply the voluntary simplicity model to my career.Voila!!PamelaPamela Wible, MDFamily & Community Medicine, LLC3575 st. #220 Eugene, OR 97405roxywible@...www.idealmedicalpractice.orgOn May 7, 2006, at 6:59 AM, Levin wrote: RE Pt with 6 cm chest mass OK, I need to know... 1) Did you send her to India. 2) In denial with chest mass-- you terminated a pt who refused to get labs for 6 months, but a pt in denial about a 6 cm chest mass took a few months? 3) Do you have another source of income besides your micro practice? Just curious... Re: new habits... TESTS, FU responsibility, noncompliance ... This is another great thread. I am an absolute OCD maniac about tracking and returning test results. One of the first tests I ordered in my practice was a CXR on a woman with an isolated episode of hemoptysis. It showed a 6 cm MASS and I never got the results until I called them 2 weeks later and asked "WHERE'S THE RESULTS???" Nobody could explain why I did not get the results and it happened with 5 or 6 other patients at the same radiology center. Problem is now fixed BUT BOTTOM LINE is if we order the test we better have a way to track results. I have a self made EMR with a pending file that I update as tests are ordered and return. That way I can sleep at night. BTW this woman was in total denial and would have not called for her results and I would have been up a creek without my pending file. It took me months to get her to agree to go to a specialist. She had no insurance and wanted me to help her get treatment in India. "No news is good news" is BAD news. Do not practice this way. I went to a malpractice seminar once where we were told by the speaker that if the airline industry were run like the health care industry we would have a major accident several times per day at the Portland Oregon airport. Can you imagine the pilot asking the guy in row 17 to look down and check to see if the landing gear went down? That what we do when we ask an ill person to call us as our only plan for returning lab/tests results. If I am particularly worried about a test or I have a worried patient (even about a minor test) I'll do what Brett suggested and have them call me after the test and I'll get the results to them right away. Sometimes I go with them to the procedure which floors the consultant doctor when the FP is standing there at 8 am in her biking attire to watch the thyroid biopsy and read the results with the pathologist and give the results in real time - no phone call, no fax. now that is service!! I even got them to match my 40% discount on the fee which was a huge relief to my uninsured patient. Noncompliant patients with testing/labs. I have no problem with patients who decline tests that I feel they need as long as they understand the risks/benefits. I notate that in the chart and continue to remind them about the needed mammogram or colonoscopy. I may become a bit of a nag but I intermittently keep checking in with them. Challenging noncompliant patients I have had recently include a woman with presumed out of control diabetes who would not go for a blood test. She finally did on her third visit and it was 399 fasting. She is now on insulin but is trying to convince me that she should be able to discontinue it. Even though she was resistant I felt I could create a trusting relationship with her EVENTUALLY and I did not feel that I should just terminate her. She has no insurance, no other place to go and dislikes allopathic medicine. Has only been to a doctor 3 times in her life and now she is 50. We have a great but challenging relationship. She honors my opinions and we can work together even with different opinions. I recently TERMINATED a NP in town for noncompliance over lab testing. This was rather interesting for me. She came for a physical 1 year ago and we ordered screening blood tests (she's over 50). She agrees to get the tests done yet her name kept coming up on my pending test file as an uncompleted test. I called her a total of 5 times to remind her and each time she promised to get the labs in January, then March. It is May now. I have over 100 people on my waiting list. I do not have time for people who do not communicate with me honestly especially multiple times. We al have our methods, limits, boundaries. These are some of mine. Pamela Pamela Wible, MD Family & Community Medicine, LLC 3575 st. #220 Eugene, OR 97405 roxywible@... www.idealmedicalpractice.org Let me qualify my post prior to being flamed. I have been a lurker and infrequent poster on this list for a few months. Some of you know me from off this list and that is usually where I keep my communications. I am not an MD or a PCP but a practicing chiropractor. Nine months ago, I formed a micropractice within the ideals that have been set forth by Gorden and this group. I bounce back and forth between a larger, multi-doctor, multi-staffed office with high volume of patients to a small, one room practice with no staff depending on the day of the week. My micropractice patients have 24/7 direct access to me by cell phone and e-mail and deal with me directly to make appointments, take co-payments, etc. Certainly there are topics discussed on this list that I cannot relate to...pharmaceutical samples, certain specialized testing and procedures, etc. But the nuts and bolts of running a healthcare practice without staff, the small practice mentality, the delivery of care to patients on a highly personal level, all overlap with my own experience. I wanted to chime in on the discussion about ordering tests because I think there is a more important point than just setting up the test. When patients are sent for a radiology study or even bloodwork, they very often go home thinking, "I have cancer and I know they are going to find something terrible." Patients lose sleep for days awaiting the results of even routine tests. Many doctors don't even call their patients with negative results thinking no news is good news. For many years, my standard operation is one day after the test was scheduled (or if the patient is scheduling, I have them call me once the test is completed), I will call the radiology center or lab for a faxed copy of the results. If the results aren't ready, I will take a verbal. Almost every imaging test and many bloodwork tests can return some result within 24 hours. The patient then gets a call...positive or negative results notwithstanding. If I have referred the patient to another specialist who I know has ordered the test, I will still call for the results. Patients are amazed since they are usually told it will take "a couple of weeks" to hear about their results can know as soon as possible. Allowing your patients to sleep better at night knowing the outcome of their testing is certainly a valuable, personal service that the big practices cannot offer. Brett L. Kinsler, DC Rochester, NY

May 7, 2006

1) I did not send her to India. I really had very interesting conversations with her and we worked together to find a solution that would be successful. She tried to contact the docs in India and they were unresponsive so she finally agreed to see specialists in town. Is now finishing chemo. She was primarily struggling with the fact that this would be expensive and she had no insurance so she was trying to save money, meanwhile time was ticking away (as was her life) and I had compassion for her struggle. She always communicated honestly with me (though our opinions differed at times a great deal). She came to her appointments and paid - by donation and always was transparent and fair in her interactions with me. She appreciated and vaued our relationship despite our (at times dramatic) different opinions.2) The woman with the noncompliance with labs obviously does not value my time or relationship if she can tell me on 5 different occasions that she WILL do something and never do it. She is not able to communicate with me honestly.All I ask for is appreciation and honesty. I do not need anyone to agree with me or my opinions.I have no other source of income. I do not need another source of income because (here is the key) I have almost NO EXPENSES in my business (7% overhead is VERY VERY LOW) and in my personal life (NO DEBT). I am married to a musician who makes basically no money (his highest income was less than my lowest federal withholding) I believe in the concept of voluntary simplicity. It is a pleasant way to live without the burden of extra stuff. Just living with what I need instead of all the extra stuff that people think they need. I guess I live the Ideal Microlife or the LOVE model of living.Have you ever gone to the third world where people have just enough but not too much. They usually live in little shacks but all their extended family lives in the same village. They work and play together. They do not have CPAs and financial planners and ask therapists and consultants about all their problems and how to manage their wealth. These people are having a great time just living life. They are an inspiration. When I think of my career - all I really did was apply the voluntary simplicity model to my career.Voila!!PamelaPamela Wible, MDFamily & Community Medicine, LLC3575 st. #220 Eugene, OR 97405roxywible@...www.idealmedicalpractice.orgOn May 7, 2006, at 6:59 AM, Levin wrote: RE Pt with 6 cm chest mass OK, I need to know... 1) Did you send her to India. 2) In denial with chest mass-- you terminated a pt who refused to get labs for 6 months, but a pt in denial about a 6 cm chest mass took a few months? 3) Do you have another source of income besides your micro practice? Just curious... Re: new habits... TESTS, FU responsibility, noncompliance ... This is another great thread. I am an absolute OCD maniac about tracking and returning test results. One of the first tests I ordered in my practice was a CXR on a woman with an isolated episode of hemoptysis. It showed a 6 cm MASS and I never got the results until I called them 2 weeks later and asked "WHERE'S THE RESULTS???" Nobody could explain why I did not get the results and it happened with 5 or 6 other patients at the same radiology center. Problem is now fixed BUT BOTTOM LINE is if we order the test we better have a way to track results. I have a self made EMR with a pending file that I update as tests are ordered and return. That way I can sleep at night. BTW this woman was in total denial and would have not called for her results and I would have been up a creek without my pending file. It took me months to get her to agree to go to a specialist. She had no insurance and wanted me to help her get treatment in India. "No news is good news" is BAD news. Do not practice this way. I went to a malpractice seminar once where we were told by the speaker that if the airline industry were run like the health care industry we would have a major accident several times per day at the Portland Oregon airport. Can you imagine the pilot asking the guy in row 17 to look down and check to see if the landing gear went down? That what we do when we ask an ill person to call us as our only plan for returning lab/tests results. If I am particularly worried about a test or I have a worried patient (even about a minor test) I'll do what Brett suggested and have them call me after the test and I'll get the results to them right away. Sometimes I go with them to the procedure which floors the consultant doctor when the FP is standing there at 8 am in her biking attire to watch the thyroid biopsy and read the results with the pathologist and give the results in real time - no phone call, no fax. now that is service!! I even got them to match my 40% discount on the fee which was a huge relief to my uninsured patient. Noncompliant patients with testing/labs. I have no problem with patients who decline tests that I feel they need as long as they understand the risks/benefits. I notate that in the chart and continue to remind them about the needed mammogram or colonoscopy. I may become a bit of a nag but I intermittently keep checking in with them. Challenging noncompliant patients I have had recently include a woman with presumed out of control diabetes who would not go for a blood test. She finally did on her third visit and it was 399 fasting. She is now on insulin but is trying to convince me that she should be able to discontinue it. Even though she was resistant I felt I could create a trusting relationship with her EVENTUALLY and I did not feel that I should just terminate her. She has no insurance, no other place to go and dislikes allopathic medicine. Has only been to a doctor 3 times in her life and now she is 50. We have a great but challenging relationship. She honors my opinions and we can work together even with different opinions. I recently TERMINATED a NP in town for noncompliance over lab testing. This was rather interesting for me. She came for a physical 1 year ago and we ordered screening blood tests (she's over 50). She agrees to get the tests done yet her name kept coming up on my pending test file as an uncompleted test. I called her a total of 5 times to remind her and each time she promised to get the labs in January, then March. It is May now. I have over 100 people on my waiting list. I do not have time for people who do not communicate with me honestly especially multiple times. We al have our methods, limits, boundaries. These are some of mine. Pamela Pamela Wible, MD Family & Community Medicine, LLC 3575 st. #220 Eugene, OR 97405 roxywible@... www.idealmedicalpractice.org Let me qualify my post prior to being flamed. I have been a lurker and infrequent poster on this list for a few months. Some of you know me from off this list and that is usually where I keep my communications. I am not an MD or a PCP but a practicing chiropractor. Nine months ago, I formed a micropractice within the ideals that have been set forth by Gorden and this group. I bounce back and forth between a larger, multi-doctor, multi-staffed office with high volume of patients to a small, one room practice with no staff depending on the day of the week. My micropractice patients have 24/7 direct access to me by cell phone and e-mail and deal with me directly to make appointments, take co-payments, etc. Certainly there are topics discussed on this list that I cannot relate to...pharmaceutical samples, certain specialized testing and procedures, etc. But the nuts and bolts of running a healthcare practice without staff, the small practice mentality, the delivery of care to patients on a highly personal level, all overlap with my own experience. I wanted to chime in on the discussion about ordering tests because I think there is a more important point than just setting up the test. When patients are sent for a radiology study or even bloodwork, they very often go home thinking, "I have cancer and I know they are going to find something terrible." Patients lose sleep for days awaiting the results of even routine tests. Many doctors don't even call their patients with negative results thinking no news is good news. For many years, my standard operation is one day after the test was scheduled (or if the patient is scheduling, I have them call me once the test is completed), I will call the radiology center or lab for a faxed copy of the results. If the results aren't ready, I will take a verbal. Almost every imaging test and many bloodwork tests can return some result within 24 hours. The patient then gets a call...positive or negative results notwithstanding. If I have referred the patient to another specialist who I know has ordered the test, I will still call for the results. Patients are amazed since they are usually told it will take "a couple of weeks" to hear about their results can know as soon as possible. Allowing your patients to sleep better at night knowing the outcome of their testing is certainly a valuable, personal service that the big practices cannot offer. Brett L. Kinsler, DC Rochester, NY

May 8, 2006

Glad you are able to make it work.

Different perspectives very useful and supportive.

Dr Matt Levin