Your Voice: Balancing rules empathy and apologies

Thank you for the James Sweeney article “Balancing egos and errors” (November 10, 2016). These are critical skills for physicians to maintain their objectivity and humility in treating patients. Patients reveal their utmost secrets that nobody else may know, to their physician and their staff, with high expectations, and even some that are unrealistic.  

It is important to have some guidelines and rules by which to operate. Here are some general ideas I present as standard physician equipment: 

If it is an office policy or generally excepted issue, let the staff handle it matter-of-factly. The physician or clinical staff will only get embroiled, frustrated and accomplish nothing.  

If it is a financial issue, let the staff handle it in a matter-of-fact way. Use collections judiciously after multiple failed attempts to communicate and receive payment. You can catch more flies with honey than with vinegar. A patient will generally stick with you if you empathize and work with them. 

For minor clerical issues, office staff can hear the patient out, empathize, apologize (if there is an office error) and get to the bottom line for the patient. 

For clinical issues, the physician must understand both sides of the story from the staff and patient before proceeding.

If there is a clinical error, such as patient getting the wrong medication or child getting wrong immunization: 

1. The physician must hear the patient or parent out to allow them to get it off their chest. 

2. Respectfully empathize with the patient or parent. 

3. Apologize if wrongdoing and potential harm may have taken place. 

4. Discuss what health risks to the patient may have occurred, if any. 

5. Don’t forget to discuss any financial risks if the patient or insurance company may have paid inappropriately for a product or service. You will likely have to “eat” the cost of the service and any other care that stems from it. Be magnanimous and offer to fix it on the spot. 

6. Create and describe a new process that you will institute to prevent the problem from happening to the patient or any patient in similar circumstance. 

7. Lastly, make sure that the patient or parent understands all of the above and that you care. 

If you follow these rules, patients will generally endure the bumps and bruises of an every day relationship with a physician and medical practice. If they get easily frustrated, inappropriate or abusive, let them go elsewhere.

Craig M. Wax, DO
Mullica Hill, New Jersey

Next: Direct primary care could create brighter days

Direct primary care could create brighter days

In response to “Is DPC a viable way to MACRA-proof your practice?” (MedicalEconomics.com, December 10, 2016), at age 59 and not ready to financially or emotionally retire, I think that if I were to stay in primary care I would go the direct-pay route.

Instead, I have chosen to semi-retire and do ER work 20 to 30 hours a week, and make much more than full-time practice under the current system. I believe that the future will see patients paying cash to see a physician, or else see a midlevel under their insurance.  

Sad days ahead if we continue to let things like MACRA and MIPS rule the world.

Online comment

CMS payment methodology is a joke

Finally, someone taking the bull by the horns! Thank you for your piece by Keith L. Martin (“CMS must stop manipulating small practices,” September 10, 2016).

CMS is, in my opinion, clueless to the problems of small practices and their bureaucratic alphabet soup. Not a day goes by that I contemplate giving up my solo practice simply because of the mountain of new regulations and “games” that CMS is thrusting upon me. 

If I am not providing good care, my patient would simply seek out other providers. Try telling an 80-year-old Medicare patient that they need to sign up to access their records online and send me direct messages about their healthcare needs-maybe in the next generation.  

This new “payment methodology” [via MACRA] is just another nail in the coffin for solo/small practices unless CMS changes its thinking. 

Keep up the good work.

Paul Williams, DO
Harrisburg, Pennsylvania 

Next: Trump must deal with medical liability

Trump must deal with medical liability

In “An open letter to the next president” (October 10, 2016), Keith L. Martin … would have the next president look at rising drug costs, narrowing physician networks, and the uncertain future of small and solo practices. He mentioned other concerns as well.

But he did not mention the need to change how we deal with medical liability. Most physicians believe that the system is shamelessly adversarial and opportunistic. This makes many doctors over-order tests and consultations to show that everything had been done, in case a suit is filed. 

Called “defensive medicine,“ this raises the cost of care and health insurance for everyone and at the same time does not improve patient care.

This state of affairs has prevailed for decades and little has been done to eliminate the questionable methods that drive the system.

But there are other ways of dealing with the problem. The best that I know are health courts run by judges with special training in medical liability.

Health courts can eliminate the hostilities and misunderstanding and anger that drive the system now, but also can get compensation when appropriate to patients quicker.

Moreover, court and attorney fees are greatly reduced because settlements are arrived at in months and spared the three-to-five-year wait that it usually takes for suit to be settled.

As medicine becomes more complicated, so do medical complications and patients’ expectations.  In all but the most obvious case of negligence, it is natural for patients suffering bad outcomes to accuse physicians of malpractice.

Some good physicians who acted competently and who acted in their patients’ best interests have been sued without cause in the past. And some good physicians acting competently and in the best interests of their patients in the future are just as much at risk of being sued without cause in the future.

Health courts may not completely eliminate the untrustworthiness of the medical liability system that makes physicians lack confidence that they will be treated fairly but it would be unreasonable not to study them.

Health courts ought to at the top of the next president’s agenda.  The committed and persevering and united voice of physicians, however, is needed to assure that it gets on the agenda and gets the fair hearing it deserves.

Edward Volpintesta, MD
Bethel, Connecticut

Next: Medical mix-ups common with hospitalists

Medical mix-ups common with hospitalists

Regarding “Transitional care: The unintended consequence of hospitalists’ rise” (July 10, 2016), I entirely agree with Dr. Bauman’s view regarding the unintended consequences of the hospitalist program. 

Even the transition of care is no substitute for your own doctor caring for you when you are in a hospital. The lack of communication between the hospitalist and the PCP, as well as the inability for EHRs to talk to each other, has resulted in unnecessary tests being done while hospitalized as the hospitalist does not know what was done so far. 

Then, after discharge, the PCP does not get a complete account and more often than not the meds are changed to the preferred substitute in the hospital (e.g. Lipitor for all statins and Lisinopril for all ACE inhibitors) and the patient gets a new prescription for the other drug and they already have the old meds at home and then they are really confused. Some end up taking both and run into trouble.

Kiran R. Modi MD
Titusville, Florida