'Just say no' policy can be good medicine

1. DISCOUNT DOCTORING

Many patients believe that copays are too high for immediate, emergency department (ED), and specialty care and therapy visits, so they want me to manage problems I don't feel comfortable managing. Over my career, I have learned my limits. If a condition is rare in my patient population, beyond my training, or too risky-and especially if treatment options evolve faster than I can keep up-then the patient's care will be better managed by a specialist.

Chronic pain is another notable example. In the past, I only averaged half a dozen patients on Schedule II narcotics. Many new pain medications are available, and most are expensive. Pain specialists may offer better-informed treatment plans than I can.

Some PCPs enjoy the challenge of patients with bipolar disorder or chronic pain, but those of us who elect to call on consultants can't be compelled to compromise because clients complain of costly copays.

A related worry involves the patient who wants to skip a follow-up appointment with a specialist to discuss test results. I've had patients who wanted me to interpret thyroid pathology test results to avoid another copay with the doctor who performed the biopsy, patients with cardiovascular disease who wanted to save money by having me print out the results the cardiologist sent to me, and even a few who wanted me to order and interpret radiologist-performed breast biopsies to avoid involving a surgeon.

I'm hardly an expert on breast pathology, prognostic cancer biomarkers, resection and reconstruction options, or radiation and chemotherapy. If patients insist that I release results, I insist on meeting them face-to-face to review the results based on my knowledge as a generalist.

My favorite follow-up queries from patients are, "Why did Dr. So-and-so order this test? What did he (or she) plan to do next?" I explain that I'm terrible at reading other doctors' minds and reiterate that they really do need the expertise of the specialist-which is why I referred the patient in the first place.

The situations that exhaust me the most involve patients who dump a problem in my lap to fix magically, accompanied by an ultimatum: "I can't afford the specialist, so you need to fix me." A recent patient with advanced osteoarthritis wouldn't pay copays for physical therapy or orthopedic follow-up. She has returned to me, and we're back where we started. I have no other tricks up my sleeve. I feel bad that she has financial challenges, but I don't perform arthroscopy or joint replacements.

Speaking of ultimatums, they remind me of the classic thief's line from the movies: "Your money or your life." Some patients want their money and their lives, at our expense. They'd love our offices to be open 7 days a week, 15 hours a day, to evade an immediate-care fee.

In my two-doctor practice, we're available 3 nights a week and Saturdays. We can't juggle more and still be on speaking terms with our families.

I've had requests for phone management of life-threatening conditions. I receive several calls each year from folks who say they can't afford an ED copay for chest pain. A cardiologist friend of mine has a ready rejoinder: "Have you checked the cost of funerals lately?"