Monday, August 10, 2015
Of PCPs and THC
The drug test came back abnormal. There was THC present. I walked back to Mrs. Johnson and raised my eyebrows.
“What's wrong?” she asked, not used to whatever kind of look I was giving her.
“Uh, you forgot to mention to me that you smoke weed.”
She blushed and then smirked. ”Well, yes, I guess I forgot to put that down on the sheet. I don't do it real often, but sometimes it takes mind off of things. I just get real anxious about my kids, my husband … and my heart problems. I only smoke 1 or 2 a night”
She's not your usual picture of a pot-head. She's in her sixties, has coronary heart disease, irritable bowel, hypertension, is on Medicaid, and is the essential caricature of the poor white folk who live in the deep south. And she smokes weed.
I was doing drug testing on her as part of my office policy. Mrs. Johnson gets 30 Percocet per month, and so clearly poses a high risk of drug trafficking, escalation to PCP, crystal meth, and LSD, and ending up behind bars for the rest of her life. That's why I had to test her. And now I caught her in a lie, trying to cover-up her use of illegal drugs.
My old practice had a policy of discharging such people immediately from the practice. Some of our physicians had the belief that any departure from the rules should be dealt with swiftly and harshly. It's part of the reason I couldn't stay in the practice. They had taken a large step away from the most important part of the doctor-patient relationship: trust. They saw any evidence of dishonesty on the part of the patient as a reason for discharge from the practice, even if a very good explanation existed. I was just “too soft” in their thinking.
While I do find value in regular drug testing of patients using controlled drugs, the way in which it is often enforced in many practices is with an air of suspicion. It's just one more factor in the decay of trust on both sides. Yes, people who abuse the system to get drugs to abuse or sell and doctors who dole out drugs like candy are the ones to blame. Mrs. Johnson is not part of the problem.
Physician mistrust goes far deeper than drug testing. My patients often seem embarrassed when they have symptoms that don't make sense because, it turns out, they are disbelieved by other doctors. I have had many patients comment that it is “nice to have a doctor who actually listens to me and what I actually say.” This is sad. How can anyone give care to patients if they aren't listening to the patient and taking what they say seriously? It's as if the only thing holding the doctor back from making a proper diagnosis is the patient's ability to give their history.
The problem of mistrust works the other way as well; people don't trust their doctors. Just today I had a woman complain to me about the doctor she had been seeing “for the past 10 years” who made her “come in and pay $120 just to get a prescription filled!” She went on to complain about how so many doctors are “just in it for the money.”
Her view of the motivation of doctors comes from the central dilemma our payment system puts doctors under: choosing between the business and the patient. The ideal business scenario for doctors is to have very sick patients who require multiple procedures, yet who take as little time as possible. This is what is good for business, as doctors can have a higher code/hour submission rate. This, of course, is the absolute worst thing for patients, who want to be healthy, avoid unnecessary or excessive care, and have doctors who spend time with them. On top of that, this best business scenario will invariably lead to lower value care (lower quality at a higher cost).
Doctors are forced to either give up income to do what is right for patients and for society, or to stuff their consciences securely in the overhead compartment and run the business well. Some doctors seem to comfortably lock their consciences away, but most find a compromise on the spectrum between high income/bad medicine and low income/good medicine. It's the main thing that drives doctors to burn out. It's why I left.
So the patient is left wondering if the reason the doctor can “only handle one problem at each visit” is because it makes more money. The patient wonders if the doctor doesn't talk to them on the phone because they only make money when they come to the office. The abbreviated care most doctors provide further undermines any belief that the doctor has the patient's best interest in mind. This care is abbreviated even more by the onerous demands of coding, defensive documentation, and data submission for “quality measures.” How can good care occur when what little time the doctor spends with the patient is dominated by the doctor-computer relationship? Those of us who are bothered by such things are the ones who go home feeling terrible about the poor care we are giving.
One of the main reasons I don't charge a copay for office visits in my current practice is that I wanted nothing to undermine my patients' trust. The reality is that charging a copay would do little to increase my income, but a patient could question my motivation for requiring an office visit. Some doctors, criticizing my approach, recapitulate the mistrust of patients wondering if some patients would “take advantage of this and want to be seen all the time.” I have over 600 patients now and that has never happened. Why would someone want to go to the doctor all the time? It simply doesn't happen. I think it's because people feel fortunate to have me as their doctor and don't want to abuse the system. They seem more apologetic about coming in and “bothering me” than ready to gorge themselves at the all-you-can-eat Dr. Rob buffet.
I see an enormous difference in the trust between me and my patients since starting the new (sort-of new) practice. I tell them that my business model works best when they are healthy, happy, have their questions answered, and paying their monthly fee. I explain that the re-alignment of my business success to coincide with what they want for themselves (and what works best for the healthcare system), and they like it. They want me to succeed. Some have even offered to pay me extra when they were particularly complicated.
It takes a while for people to actually be in a position of trust with their doctor. They look for some catch or some way in which I am going to short-change them. Yet I have every motivation to keep them happy and healthy. Once they realize this, they seem to relish our relationship, not wanting to jeopardize it by being “too demanding.” I think it's remarkable to both sides: I am amazed that my patients want me to be wildly successful in my business, and my patients are amazed that I want them to be incredibly healthy, off of medications, and only needing me infrequently.
So when Mrs. Johnson's drug test came back, I wasn't inclined to kick her out of my practice or even lecture her about telling the complete truth. After all, isn't smoking a little weed better than taking daily Valium or Xanax? Isn't it better than drinking moonshine, or asking me for more Percocet to “calm her nerves?”
Instead, I laughed. The craziness of this “country bumpkin” doing her best Cheech and Chong imitation just seemed funny.
“Just don't smoke too much, Mrs. Johnson,” I said. ”And be careful getting that stuff. I don't treat people who are in jail!”
She laughed, and gave me a hug before she left. On her blouse I noted a faint but familiar smell from my high school days. Yes, the test was right.
After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.
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Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
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Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
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