docmom (docmom) wrote,

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Burnt out, thy name is primary care physician

Dear specialists:

The next time I hear one of you complaining about cuts in reimbursement and the new health care reform's preference to the primary-care sphere, forgive me if I spit on your $200 shoes.

Though this is perhaps not a universal problem, it's feeling like it lately. I'd simply change my referral pattern, but I despair of finding any specialist in any field who gives a damn about my patients right now.

I have a stack of FMLA paperwork on my desk that patients are becoming frantic about, due to their fear of losing their jobs, a full 50% of which is here because "my gastroenterologist/neurologist/surgeon/orthopedist won't fill it out for me; they said I should have my PCP do it."

I have a pregnant patient with daily headaches that are impacting her sleep for the past month whose picture looks convincingly like pseudotumor cerebri, but the neuro won't do an LP because they're considering further testing, but the OB won't approve further testing because it requires contrast material.

I have a patient with abdominal pain who is clearly distended, and burping, and miserable, for whom the GI has been able to offer exactly nothing in the way of relief. She looks pregnant, she is losing sleep and weight, she is no longer eating due to pain and nausea, and she is beginning to exhibit some resulting mental fog, for which he suggested a neurologist. The first time I sent her there for eval, they sent her back to me with "see your PCP for symptom relief while we're waiting for your lab results." Now, they've stopped all the medications I tried for relief, and told her to call back in 2 weeks for additional test results, and advised her to have me send her to neurology and OB-Gyn, despite a normal CT pelvis at the time of the workup I did before I sent her to them.

And, finally, one of my favorite, darling, love-her-so-much-I'd-cry-if-she-left-my-practice patients has been removed from the liver transplant list by her transplant team for being a "difficult" patient, ostensibly because she had no right to ask why her treatment plans were being changed, no right to request that adhesives not be used on her in the hospital unless absolutely necessary due to her allergy issues, and no right to have a say in her own care. How on earth one can terminate a patient's care due to behavior when the patient's diagnoses include encephalopathy, I'll never have adequately explained to me.

I'm getting paid $50 per visit. Most of the time, patients don't come in at all when they drop off FMLA paperwork, and I take care of a huge number of things by phone. So, I get paid $50 for the 1-2 hours or more of work I do per patient encounter when counting the stuff done in between. The specialist? Requires me to send all my records before, in some cases, deciding whether or not he or she will even lower him/herself to see my patient and, if s/he decides not to, does not send my records back or offer me any suggestions for care or alternative referrals, and will often take weeks to make this determination, placing me even farther behind. When I finally find a specialist willing to see my patient, s/he spends 15-30 minutes with my patient, orders a battery of tests (bonus if it includes a several-thousand-dollar procedure s/he can perform, such as cystoscopy, colonoscopy, hysteroscopy, etc), and tells the patient s/he cannot figure out what is wrong, collects $200-$several thousand, and sends the patient back to me with no additional guidance. In fact, often, they are sent back within the week, and the specialist note is not yet dictated, I have no lab results or records to work from, and the patient has to try to convey to me what the specialist had to say, and all they're sure of is, "they said my PCP had to do that."

In short, F*** you, specialists. Start sharing your fees with me, or stop sending the patient back with instructions for me to do what should be your job.

No love,

Your burnt-out, credit-cards-maxed-out, nearly-bankrupt primary care colleague

Dear pharmacists:

Why go to school for all those years to send me requests that ask me to send in an alternative med due to the cost? Could you not, oh, I don't know, SUGGEST an alternative? Especially given that I have no way of knowing how much things cost in your pharmacy? When requesting a prior authorization or change, could you give me just a clue to the formulary I might be working with, rather than giving me a pharmacy hotline number to call for the pertinent insurance? It saves me 20 minutes on the phone if I can look up the covered alternatives and determine ahead of time whether we've already tried those, rather than sitting through a failed authorization call due to simply not knowing what was covered.

No love,

The physician down the street who can use a computer and her brain at the same time, thank you very much, maybe you should try it?
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