Am I imagining it, or are my patients taking less and less responsibility for their healthcare, and leaving it all up to me? Here’s what happened this week, and you tell me –
Monday
Me: When was your last mammogram?
New Patient: I don’t know, isn’t it in their somewhere? (Points to computer)
Tuesday
Me: I notice that you haven’t written anything in the medication section of the interval history form. Are you taking any meds?
Patient: (Sweeps hand out in a dismissive manner) It’s all the same as last time.
Me: Okay, then, let me just confirm. (looks at computer) Prozac 40 mg?
Patient: No. My shrink changed me to Wellbutrin because my sex drive was lower.
Me: Lipitor?
Patient: Yes.
Me: Prilosec?
Patient: No, its’ Protonix now…
(You get the point…)
Wednesday
Me: You’ll need to have another sonogram next year with your mammogram. Just remind me when we order your mammogram, and I can order the sonogram up front so you don’t get called back again. That will save you the addtional visit for the sonogram.
Patient: Can’t you just write it down somewhere? I’m never going to remember that.
Thursday
Me: I’m happy to refill your Fosomax, but I’ll need a copy of your most recent bone density so I can be sure why I am prescribing it. Where was it done? We can call and get the report.
New Patient: (not stopping to think) I don’t know.
Me: Do you have a copy of it?
Patient: Somewhere.
(Pause)
Me: Would you be able to look?
Patient: I don’t know where it is.
Me: That’s all right . We can request records from your previous doctor, who probably has a copy in the chart…
Patient: (Getting annoyed) – Can’t you just order a new one?
Friday
Me: Let’s reschedule your mammogram. It looks like you missed the last one we scheduled for you.
Patient: Well, that’s because no one reminded me.
C’mon, ladies. Help me out here. This is a team effort, not a solo act.
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Next post – Team tips for new players.
Hi…you’ve been tagged and invited to play. 🙂
“This is a team effort, not a solo act.” Hear, hear!!!
I have a potential solution for you. Hire a sidekick and become Karnak the Magnificent! This way you can read the patient’s minds and entertain them at the same time.
Here is a classic Karnak quote for your enjoyment…
“A loaf of bread, a jug of wine and thou.”
Reading the contents of the envelope:
“Name three things that have yeast.”
Wow … just, wow.
Now I understand why the NP at the gynecologist’s office looked thrilled to death last week when I knew the name of my bc pill, the date of my last period, and the date of my last pap smear.
Welcome to my world.
Except I also have to find out when they last saw you. Why is it that OBGs never deign to write letters when they see my patients? It’s probably because they consider themselves “Primary Care” also. Still, two quarterbacks on one team isn’t optimal.
We must be frustrating sometimes. 🙁
So, here’s a question; when you ask when our last period was, how specific are we supposed to be?
(Is it enough to say, about two weeks ago? I said that once, and the nurse scowled.)
Fantastic post, TBTAM and so true. Love the title. It’s the medication changes that get to me. Patients: Help me help you!
To bardiac: Unless you are trying to get pregnant, “about two weeks” works for me. It’s important for the pap smear because the cells change during your cycle and knowing where you are in the cycle helps the pathologist read the smear.
I hear you loud and clear. Now mind you, this is for something that patients apparently care little about — their own general health. On the flip side of the coin, the level of patient motivation clearly has an effect on their behavior when it comes to something that they DO care about – having a baby. My motivated Type-A infertility patients come to my office armed with a list of every drug or vitamin supplement they have taken in the past year. They have a color coded chart of every time they had spotting, the amount of cervical mucus each day, their temperature, when they had intercourse and how painful their breasts felt for every day of the past year. They have collated copies of all their past medical records, a typed summary of their medical history, copies of old op reports with the pertinents parts (or what THEY believe to be pertinent) highlighted and color photos of their laparoscopic findings. This is all in addition to internet printouts of every article relating to fertility that has ever been published since the dawn of time. =)
“Me: You’ll need to have another sonogram next year with your mammogram. Just remind me when we order your mammogram, and I can order the sonogram up front so you don’t get called back again. That will save you the addtional visit for the sonogram.
Patient: Can’t you just write it down somewhere? I’m never going to remember that.”
Terrible irresponsible patient here: is there something I’m missing? You’re telling me that you’re going to order a mammogram for me next year. Somehow you can plan to do that but you can’t do the same for the sonogram?
Is the flag to order me a mammogram a note in my file? In that case why not make another note in my file to order the sonogram?
Is my name on a special mammogram list somewhere? Why can’t “sonogram” be added to my name on my list?
Perhaps your statement was unclear. Perhaps you meant, “I need you to call me next year to ask me to order you both a mammogram and a sonogram, and then I need you to tell me to order them at the same time so you don’t have to come in twice.” Because it sounds like the mammogram is already taken care of and the only piece you’re asking the patient to remember is the sonogram. Which just sounds bizarre to me.
This reminds me a little of the following #1 Dinosaur rant: http://dinosaurmusings.blogspot.com/2006/12/rad-rage.html.
The PCP is annoyed that Radiology makes finding old films the responsibility of the PCP, when the PCP thinks (reasonably enough, it seems to me) that Radiology should be the owners of the films that they create and file.
Radiology disclaims any accountability for films once they have been interpreted the first time: they don’t file them, the hospital does. And the solution is to trumpet patient responsibility. The doctor doesn’t keep copies because the originals are filed at the hospital; Radiology is agnostic as to the existence of said originals, because that’s the PCPs job; and tracking down the originals is so difficult that the best solution is for patients to ask for copies of everything and to carry them around with them. (In which case, why don’t we just save everyone a lot of money and eliminate redundancy by closing down the archives and giving all originals to patients?)
In the real world, this might be true. But if #1 Dinosaur is cross about it, forgive me if I ask for some patience with the patients who don’t immediately understand the need.
I think its the trickle down effect. When the big wigs at the top of the food chain don’t have to be accountable…
Presidents, Priests, CEO’s, Investment Firms, Movie Stars, Memoirists, etc…
Then it trickles down to us little people.
Allison –
Re the mamo-sono thing. You have the perception that I have a perfect EMR that reminds me of absolutely everything so neither of us has to remember anything. (Wouldn’t that be great?)Unfortunately, howver, I don’t.
Of course I “write it down” somewhere. I write it in the patient’s chart. Along with everything else about that patient written in her chart. And flags for all sorts of things, including allergies. But there is no flag that pops up every time I order a mammogram for a certain patient that says – “Order a sonogram too”. But it doesn’t exist. Maybe you and I could design the perfect EMR and we’d become millionaires…
In the old days, I could put a sticky on the chart for things like this, but unfortunately, my current EMR has no such function. See my prior EMR post on this problem.
http://theblogthatatemanhattan.blogspot.com/2007/01/notes-to-myself_30.html
Rememember, too, that patients often schedule their own mammograms. It’s typical for the patient, who has not been in for over a year, to call the office and say -“Im here at the radiologist for my mammogram, please fax over the order.”
Finally, I have thousands of patients. Each of my patients only has one – themselves. (Well, okay, maybe their moms and their kids and their husbands, too. Still you get the point – a lot less than I have.) Is it really unreasonable of me to ask them to write down or develop a way of remembering something for their own health care? I think it is not. And truth be told, the overwhelming majoriy of my patients have no issue with this. (See today’s post) This post was just about the few who do.
Re your second comment – I have lots of sympathy for my patients. The healthcare system is a quagmire that we all ahve to work in. So I ahve absolutely no problem if they don’t always understand how things work. What I do ask for is a little willingness to work with me as we navigate it together. The situation I was describing was a patient who was getting annoyed at me for asking her to remember where she had a test done, to looks for a report she had at home and if not, to sign a request so I could get the report from her prior doc. I was actually willing to do all the leg work for her. Again, I don’t think I was being unreasonable. Or unsympathetic.
Occasionally, we docs like to bitch a little when things get difficult. Sometimes, we docs are difficult, and our patients rant about us. It’s all part of the process.
Peace,
TBTAM
Oh, I certainly understand ranting about Thursday!
And I know how frustrating it is to explain the same thing over and over and over and over again to thousands and thousands of Wednesdays… and how it’s hard to avoid feeling frustrated at having to explain it yet again, even though you’re explaining it to different Wednesdays each time.
And I know you don’t have a pie-in-the-sky EMR, and even if you did you would still need to double-check with your patients. My point was simply that your patients don’t know that. It doesn’t seem remotely unreasonable to me that you should have the option of scheduling me for either a ‘mammogram’ or a ‘mammogram + sonogram.’ If real life is just not like that, if you can have your own tickler on ‘mammogram’ but the only tickler for ‘sonogram’ that can exist is me, ok, explain that to me… but don’t be surprised if I’m surprised. The default assumption is that this sort of thing should be possible. There’s nothing wrong with a patient thinking you should be able to do it. The problem is that you can’t, and that you have to keep explaining that fact to people. Blaming the patient for expectations that are completely in line with real-world functioning in other areas feels a little unfair.
RE Friday: I get reminded for dentist appointments and leg-waxing appointments. Basically anything that gets scheduled more than a week in advance, the provider takes the initiative to remind me because otherwise they lose money and everyone is annoyed. Ok, so your radiology clinic doesn’t do that and so your patient is either lazy or disorganised. Fine. Patients shouldn’t be lazy or disorganised… and radiology clinics should remind people of their appointments. It’s quite standard.
And yes, please rant! Especially as you are gracious enough to let people rant back. On your blog.
Allison –
Appointment reminders are standard, because, as your waxer knows, they are good business. But they do not abdicate the patient of any responsiblity to remember their appointments.
As for the mammo-sono, you got it. Sometimes, there is a mismatch between my reality and my patient’s expectations. That’s the whole fodder for the post.
Thanks for reading (and for commenting!)
You’d think somebody that had some problem that required a sonogram along with their mammogram would stay on top of that.
The gals I know would be badgering you about why they couldn’t have a breast MRI, and which mammo place does digital!
You know, we laymen often don’t know what types of questions you’re going to ask us, and how specific you need us to be. I suppose I could carry around copies of all my medical records with me, so I can look up the dates of various things, but you also have a copy somewhere in your office. Maybe you could hand it to me and I could look it up for you?
I care about my health, but there’s no way I can memorize everything you might be interested in in order to save you five minutes of digging. I dissociate under stress, so therefore anytime I get really ill or have some anxiety-inducing medical procedure, my brain “helps” me by trying to block the memories out. If I know in advance what kind of data I will need, I will print it all out. But often the questions come out of the blue.
You’d think an emergency appendectomy would be pretty memorable, right? Wrong. It’s a haze of pain and illness and morphine. I can guess the month and the year based on some other events that happened around the same time. I’d have to go through my medical records to get you an exact date.
Getting my period is so mundane that I don’t notice when it starts and when it stops. I don’t carry around my BCP with me, so I can’t even pull out the packet and extrapolate. However, when I’m going to see a gynecologist, I do remember to extrapolate the date beforehand.
I also bring lists of current medications to doctor visits. But anything else? Search me! You’ll have to look it up or go with my best guess.
Just a view from the side of the patient who gamely struggles to remember.
Anonymous –
See my post from 4/16 for what to bring to the visit and what it’s helpful to remember.
Sounds to me like you’re doing fine in terms of this – Ballpark dates on normal menses, prior surgeries and such are fine. Record requests will fill in the blanks for the rest.
No way are you expected to remember it all – but a willingness to try and help me gather the info from old records and reports is all I ask.
Have a great day, and thanks for reading.
TBTAM
I do my best to have copies of all my bloodwork, radiology reports, radiology films if possible, and prior reports from doctors. I can see when I go to appointments that doctors do appreciate getting anything I can bring.
And it takes a monumental effort to collect all this material. The main obstacle to this effort is the staff at doctor offices and radiology labs. My experience has been that 50% of the time, staff will look at you like you are speaking Greek when you request a copy of anything in your medical file. They will then tell you that you can’t have it, or you have to ask an office manager, or you have to fill out a form and wait for someone to review it, or you have to have your doctor request a copy for you, or you need to submit a written request to some other office along with a $10 check, or that they only give out copies on Tuesdays and Fridays after 11:00.
This was my experience getting a copy of a breast ultrasound to take with me to an appointment with a surgeon: Called the radiology lab on a Monday to ask for a copy, was told copy would be ready on Tuesday. Go to lab on Wed., was told that I would have to sign in at the clerks desk, and then I had to wait until a clerk came out to get me (just like patients waiting to have studies done). After 30 minutes, my name gets called. I tell the clerk I’m there to pick up the ultrasound. She goes looking, can’t find it. Another clerk can’t find it, either. They decide finally that a copy had never been made. They tell me that it will only take a few minutes to print out a copy.
ONE HOUR LATER, I’m finally handed a copy of a printout from a computer, which must have taken all of 10 minutes to make. For this I wasted an hour and a half, even with giving them a request two days before showing up at the lab.
This is why patients don’t bother to have copies of their own studies or tests. It’s not that they don’t care about their health. It’s that it is made abundantly clear by office staff to any patient that it is not important to THE STAFF if you get your records or not. And subsequently, patients get the message that collecting their records is insignificant.
I honestly believe that doctors have no idea how difficult it is for patients to have access to their own medical records. For doctors, its easy – just a quick phone call, and the records are faxed over. For patients, it can be a phone call plus a two day wait plus another hour and a half spent in a waiting room, just to get a computer printout.
Dr. TBTAM, what instructions do you give your office staff when a patient requests a copy of something in their file?
BTW, I do enjoy your blog.
Anonymous –
I feel yout pain. And you are absolutely right, getting hold of old films and records can be incredibly difficult. And yes, it is much easier for us. Which is why we do eveything we can to help the patien, including sending the relase ourselves to the prior doc, calling the radiologist ourselves for the report, etc.
What I don’t do, though, is collect old films for the patient to bring to the new radiologist. That makes no sense for the radiologist to send the films to me and then for me to send them to the patient. (Thats two chances for things to get lost, and believe me, that happens.) For this, I do leave the patient to do the legwork on their own.
If a patient wants records from us, all we ask is for a signed release. (That’s the law). No charge.
Take care and thanks for reading!
I’m glad to know that you don’t give your patients any problems with getting copies of anything in their medical files.
I’ve often wondered what instructions office staff are given in various places that I’ve been to. Are they unaware that it is against the law to withhold information in a patient’s file? Still, I’ve seen this scenario too often. I have also had a doctor tell me that one reason a patient can’t get copies of test results or reports is because of doctor’s fears of lawsuits, and the fear that medical records will fall into the hands of a lawyer, via a patient. Which is why it is so much easier if a doctor requests the information directly from another doctor, rather than via a patient.
BTW, I do understand your point about patients getting the radiology films, that these have to be directly picked up by the patient. Oddly, it’s been radiology films that I’ve had the most difficulty getting (see above story about ultrasound study).
However, I have used the ‘doctor requests the information’ gambit to work around the access problems. If I see a clerk getting difficult, I counter with a carefully placed remark of ‘Dr. S has requested that I bring my most recent studies with me, for my initial consultation with him/her tomorrow. My family doctor Dr. T has also told me to bring them to the specialist’s appointment.
This usually does the trick. Once a clerk hears that even a mythical doctor wants those results, the barriers come tumbling down. Yes, I’ve lied to clerks, and made up stories about Dr. S and Dr. T.
Now, I’m not proud to be doing this, but like you say, a patient has to be proactive, and it’s not in his/her best interests to let a surly, ill-trained clerk hold one’s health hostage.
Thanks again for the good writing.
Empower your patients – make them take responsibility, rather than thrusting it upon you.
I’ve found that sometimes even slightly OTT exclamations about something little they’ve done to help themselves goes a long way!