So….I am really not one for writing angry stories……I’m really not an angry person, and certainly not an angry doctor. So if this story sounds angry, or if you don’t like to read stories that you think might sound angry, please move along — -I won’t be insulted. But I’ve realized that I have written so much about how I love my job (I am an ObGyn, and I do love my job.) but I’ve written nothing about day-to-day things that happen in my office that are upsetting to me, and it is certainly possible that patients may not know how I feel because I haven’t properly expressed myself to them. I thought I would use this space to do that. I have always told my kids (and anyone else I have wanted to give advice to) that if someone doesn’t know how you feel, then you cannot blame them if they don’t live up to your expectations. So here it is — — my rules — on:

How To Be A Good Patient (if you care):

1- IF you make an appointment in my office, I would like you to do one of two things. Either show up on time, ready for your appointment (because I will see you on time, or within 15 minutes, in almost all cases), or call us if you are not going to come in. Please do not “no-show”. I reserve 45 minutes of my time to see a new patient, 30 minutes for annual visits, and 15 minutes for things that are not likely to take much time. Not only is not showing up when we were expecting you (and when we have called, texted, emailed, and sometimes all three to remind you that you have an appointment) rude and entitled, it also tells me that my time is not valuable, and that somehow you think you did not have to keep what essentially was a contract that you made with me when you made the appointment. We are human — -and we know you are too — — we know THINGS HAPPEN….traffic, accidents, kids get sick, your mom fell, someone died, or sometimes — -you just forgot. OK — We are not insensitive to those things. But everyone has a phone. Everyone knows how to call and say “I cannot make it”, “I am sorry”, “I had to go somewhere”. Even if you call right before the appointment, or after the fact….I appreciate the fact that you thought enough of me and my time and my staff to call, to explain, to apologize. That lets me know that you understand that I have been here waiting for you, and that you still value my services. There are signs up at my office that say “If you “no-show”, there will be a $25.00 charge, and please do not expect priority for us to get you right in for another appointment”. I think $25.00 is reasonable. If people call ahead to let us know, we don’t charge them, of course, because THINGS HAPPEN. But if you don’t call, and you don’t show, can someone tell me why that should be considered ok ? Or why I should stay late or give up my lunch (which I often do to accommodate patients that need to be seen) to “fit you in”? If I am not going to be there for your appointment (after all, I DO deliver babies, and as much as I like to control things, I really have no control over babies’ arrival times), we will make every effort to call you before you have left your house to come to my office. We will also do our best to accommodate you if we have to move your appointment. I save a few days a month that I use to move patients to that have been inconvenienced by my emergencies.

2- When I see a patient, do an exam, and listen to symptoms, I often end up ordering some tests. They may be preventative tests, like mammograms, or diagnostic tests, like blood work, urine cultures or ultrasounds. I always explain why we are ordering the test(s) and patients usually walk out with a paper slip with the lab or XRay office address, and we discuss how they will get their results. We have a patient portal, through which I send many normal, or negative results, so patients can see them as soon as the results come in, and if need be, we call with any results that require explanation. We have an “alarm” system in our electronic records that tells me when, after a reasonable period of time (usually between 1 and 4 months, depending on which test) the results have not come in. My “alarm box” currently (no shit) has 438 messages in it. That means there are 438 tests that I have thought about, discussed with patients, ordered, and then these patients never went for the tests, some ordered as long as a year ago (because when a test result comes back to us, the “alarm” for that test will leave the inbox). People — — -again, I realize that things happen — but if you are not going to do a test, why should I order the test??? I get that you lost your lab slip, lost your insurance, you work too many hours, you totally forgot that I ordered it, you decided against it — and any number of reasons that you may not have gone for the test that I ordered. But I employ another person full time who goes through this inbox of “alarmed” test orders and calls people to ask IF they went (and somehow we just didn’t get the result) or, if they didn’t go, WHY they didn’t go. They make multiple calls, and sometimes we RE-order the tests, and sometimes, patients never return our calls — so we call again and again— so what would you like me to do? It of COURSE is still my liability if, say, I ordered your mammogram, you did not go, we called you back, you didn’t answer, you still did not go, and then, 8 months later, you finally go, and sadly, you are diagnosed with breast cancer. The way the American legal system works, I am still responsible because you can say “I didn’t know how important it was to go for that test”…(YES THAT IS A THING!)..It of course HELPS that I have a paper trail (really, an electronic trail) of calls and efforts that we made to call you — — but the fact remains that following these alarms, and finding patients who never went for ordered tests, usually months after the visit, is a more-than-full time job which is fraught with legal liability for me…..why not just go for the tests? Or, better yet — TELL me (so I can document) that you don’t want to, or are not going to have the test in the first place? That is totally valid, even if I don’t agree with your decision — -Take some responsibility for your decision, and say that you’re not going to do it, and relieve me and my staff of that burden?! (I guess that does sound angry…but this is one of the thorns in the side of a doctor in a private practice.)

3- …(and I know this is a tough one which is only destined to get worse because of our current healthcare situation) — — but WHY does almost NO ONE know what their insurance covers? I totally get that the health insurance system is really complicated and confusing. There are Premiums, CoPays, CoInsurance, Deductibles, EOB’s (Explanation of Benefits), Contracted rates, Out of Network Benefits, and Out-Of-Pocket costs. And again — I have dedicated staff to deal with all of this. Believe me, I am NOT trying to rip you off. The general way that your insurance works is that I have contracts with many major insurance companies. I send them a list of all the various things that I do (office visits, biopsies, Pap smears, etc etc) and THEY tell me how much they are willing to pay for each of these services. I can “take it or leave it” with very little negotiating room. WHY do I contract with these companies, even if they do not pay me what I think I deserve for my services? So that YOU, the patient, can come to see me. Patients will usually only come to see a doctor that is on their insurance plan. And just because I am “on the plan” does not mean that you do not have to participate in payment for my services. The insurance company TELLS me how much you need to pay as a part of the total payment for the services, and that I HAVE to collect that part of the payment from you. Again, I have no leeway — -if you have signed up with BlueCross/Blue Shield, and they have decided that they will pay me “X” number of dollars for an office visit, or for a certain procedure, THEY TELL ME how much I am OBLIGATED to collect from you. And THAT is the amount we bill you for. The only exceptions are patients who do not contract with insurances that I take, or who have no insurance and pay me out of their pocket. THEN I am allowed to say how much I will charge you for a visit or a procedure and no company can tell me what to do. The insurance companies keep track, and if I do NOT collect a copay from my patients, the insurance company can drop me from that plan because I am in violation of the contract I have with them. I purchase IUDs from a company, and then I place them in patients, and bill the insurance for the reimbursement. ONE IUD costs me close to one thousand dollars, and I wait sometimes 30 days or more to get reimbursed from insurance companies. I am a small private practice and cannot buy 10 or 20 IUDs at a time. Sometimes insurance companies don’t want to reimburse me because they claim that we did not have the “approval” to place the IUD in the patient in the first place (which is untrue because, again, I have a full-time person calling insurance companies every day to verify patient benefits for these sort of things). But if the insurance company balks, the we have to “go to battle” with them to get our reimbursement. This happens more often than I would like to discuss. But all of that is MY responsibility. The part here about being a good patient has to do with when patients complain to us that they “do not have to pay this portion” because they have insurance. Your issue is with your insurance company — not with me or my staff. If your insurance company says that something I do in my office is not a covered benefit on your plan, then they are not going to pay for you to have it done in my office EVEN IF I AM A CONTRACTED PROVIDER!!! We get prior authorizations on every procedure that I do — -but if you come see me for an infertility problem, and infertility is not a covered benefit, there is little I can do about it — and you will have to pay a portion, or all of the cost of that visit. If your insurance says that they will pay 80% of the cost of a visit, then YOU owe the 20% remaining. This is all spelled out in your insurance contract — -that you signed — — so I’m sorry if it is complicated and confusing. But I am accepting what that insurance company’s contracted rates are, and if you are going to utilize that company — -you are too. Please call your insurance company’s customer service if you have a question that we cannot answer to your satisfaction, or a problem we cannot help you with. You are paying (often a lot of) money to have that plan — — -at least you should talk to them when there is an issue. Don’t just decide not to pay your bill (as some in my practice have done), or stop returning our phone calls. We are reasonable (my staff says sometimes I am too reasonable) — and I want people to have medical care. But I also feel my time and expertise are valuable, so if you do not understand how the insurance works, it really is at least partly — on you to get that figured out.

4- I know many of you think that all doctors are somehow connected by some “grand centralized electronic record system”, as if every test you ever did can be accessed though some portal that we all have instant access to. I cannot recount how many times a patient has said to me (sometimes angrily), “That should be in my records”….even if I have never seen them before. I have been in practice in this office for nearly 5 years. ANY record that exists outside of my office, even if I saw you in another office — -is not currently accessible to me with the click of a computer key. I only WISH it would be so easy. Of course the goal of all medical practices everywhere is to somehow be connected. But until that happens, the only way I can see records that were done by or ordered by, another doctor that I am NOT in practice with, is for you to either bring those records in to my office so I can see them, OR for you to tell me that you are giving me permission to access those records. In writing. Then and ONLY then can I obtain them from the other office/doctor/hospital. In fact, if I look at or access any records that you did not specifically give me permission to look at, I am in violation of HIPAA, which is the Health Insurance Portability and Accountability Act. {This is a law passed in 1992, which is United States legislation that provides data privacy and security provisions for safeguarding medical information}. Being in violation of HIPAA is a crime, which has legal and financial repercussions. If you want me to know something about your medical history, you need to tell me about it, show it to me, bring me the info, or tell me where to find it and then give me permission to access it — -otherwise, every patient is a blank slate of information. If YOU don’t know which surgery you had in which year, and which medications you are on and why you take them — -neither will I.

5- Please do not ask me to lie. I have many times been faced with patients whose insurance will cover them for one thing but not for another. Many insurance companies (except Medicare) cover patients for a yearly preventative visit without a CoPay. Nice, right? Yes, it can be. But from there it can get sticky. If your insurance company will pay for you to have a preventative visit, but will not pay for laboratory work associated with that visit, then you may have a big bill if I order tests at the time of that visit.(Again, they call the shots as far as payment — -and the insurance companies do not care if I say I think you need those tests). Sometimes, a patient comes in with no complaints, and we do an annual, or preventative type of visit. But then the patient asks me to send them for certain tests, like a cholesterol test or a blood count. I may order those tests, and then sometimes, the patient gets a large bill which the insurance company does not pay for since they only have coverage for tests that are associated with a problem visit. Sometimes patients will ask me to go back and “code the visit differently”. Now, IF there was an identifiable problem at the time of the visit, for which it makes sense to change the codes (ie, the patient did come for a preventative visit, but during that visit revealed that she was actually having heavy periods), then I can order a reasonable test, like a blood count to check for anemia, since it matches a complaint that the patient had at the time of the visit. But if the test was not something that needed to be done from the type of visit the patient had, or from any particular complaint the patient had at the time, then I will not change the test codes or the visit codes, to accommodate someone, since doing so is fraud, and not an appropriate or legal thing for me to do. Sorry. I will, however go to bat for a patient (and I have) if I think a patient absolutely needs a particular test done, and the insurance company denies it. I write letters and I spend time on the phone with insurance companies, and with medical directors and with laboratories trying to get patients the tests and care that would be vital to manage their health.

6- For good and for bad — — tell me how I am doing. If you had a good visit in my office — if my staff was nice, professional, and courteous, please feel free to acknowledge that. I want to know. I truly believe that everyone in this office and everything that goes on here is a reflection of me. I regularly meet with staff and review what the expectations are for the management and flow of patients in the office. If you have been on hold too long, if you feel someone was rude to you or if you did not have enough time to have your needs addressed I want to know about it. How can I fix it if I am not aware? I don’t (regularly) sit at the front desk, nor do I have cameras to show me what is happening in parts of the office that I am not in. My practice has grown from 3 original employees to 9 employees. I cannot see everything that happens all day long….but I would like to know. I want to know how we can best serve you. I want to know if you had a good experience here, and I want you to tell your friends. If there is a problem here — -please feel free to talk to me about it instead of loudly complaining on social media, or just telling my office staff that you will “not be coming back” without an explanation. Granted, I cannot make everyone happy all of the time. But I AM all about the customer service, and even though medical care truly is like NO other business (could you tell your plumber to “wait 90 days for payment?” Could you tell your lawyer that he’ll get paid “when someone else decides if those services were necessary”?). Some of my patients have posted amazing and flattering reviews on Google and Yelp — and for that I am truly grateful. It reminds me of why I started this thing in the first place.

So far, the positives still outweigh the negatives as far as whether I will remain in this world of solo private Ob and Gyn practice. Who knows what I will do when and if the scales start to tip in the opposite direction? Maybe whine a little more — — maybe get angry — — -and maybe keep writing narratives like this one to get it all out of my system.