There are things we (the providers) do to health care that are hurtful. We make protocols and rules that divide us from our patients. Protocols that sometimes make patients feel alone, distant, and disconnected from their doctors. I don’t mean algorithms of care (safe, standardized ways of how and why to treat pneumonia, for example), I mean clinic rules for helping patients schedule and get in to see doctors appropriately. Triage pathways, if you will.
I hear about these protocol-type irritations from patients all the time. Because I’m a part-time practicing pediatrician, it’s often hard for families to see me when they want. Yesterday, a patient informed me about calling one time while in route to her daughter’s appointment. She had been at a trauma hospital with a family member who was receiving care for a life-threatening condition. She was trying to make it on time to the appointment, but wanted me to know she’d be a few minutes late. She called the clinic and the receptionist said, “No, Doctor Swanson won’t see you.” Of course, this is untrue on some level. In her state of stress, I would always love to make allowances. I work in clinic to help families, precisely when life is upside down. But because of a script and protocol, she was pushed away. Of course, if we saw everyone who arrived late, we’d never be on time or reliable, ultimately rendering us less useful. Protocols do make sense. But they don’t take outliers (life) or individual patients into account.
Many things clinics do in efforts to improve care for all, hurt individuals. The utilitarian-like clinic doctrines I tend to hate. I think of these protocols as walls. Tall structures built up to protect us all from the abuse that only a few people will commit. On occasion, these walls break down the relationship that exists between doctors and patients.
Today this hit home.
Around noon, I was interrupted while writing a post about Tylenol and immunizations. O was having another self-hitting-frantic-mega-tantrum. These started about 5 days ago and can last up to an hour or more. They have become increasingly alarming to me. After today’s event, I wanted to talk with my son’s pediatrician. She’s in clinic today, but knowing that (for hundreds of reasons) it’s impossible in the year 2010 to call your doctor, I called to schedule an appointment. I’m worried about O, as is my husband. Over the last 5 days he has had a huge shift in behavior. We wonder if he’s hurting, ill, or worse. We’ve had a busy few weeks; I’ve been working late into the evenings and the boys are rising early with the sun. We’re all very tired. Hopefully I’m blowing this way out of proportion.
I call to make the appointment. The scheduler (receptionist) and I get through the name spelling, the date of birth, the doctor I want to see. She asks why I want an appointment and I say, “behavior problem.” This comes out of my mouth, I think, only because I often see patients for this exact complaint in my own clinic. She asks me to clarify, which I do. Then, I get put on hold.
The scheduler returns to ask if this is the first time O would be seen for this issue.
“Yes,” I say. Then, another hold…
She returns with the kicker, “Well, I’ll have to get a good phone number for you. I’m going to forward this to the nurse and she will call you later today to discuss.”
All I wanted to do was schedule an appointment! I wasn’t calling for advice; I wanted an appointment for my son to be examined by the pediatrician who knows him.
Some red-hot word I used (tantrum, I suspect) pushed the scheduler down a protocol. I get it. I know why this happened. But it’s not what I (as parent) and I (as doctor) feel is right. If I were a health administrator, I may feel differently. Thankfully, I’m not.
The thing is, instantly, I was more alarmed and more alone than before. Feeling pushed apart from the pediatrician, I felt more vulnerable and scared for my son. Less a part of a team that cares for him and ultimately isolated. Of course, in these moments, patients often turn to the internet. I see why. And although I have the fortune of many friends (and pediatricians) to call, I wanted to do discuss this more formally.
This may seem like a silly example. There is no imminent threat. No urgent care problem. I bring it up as yet another example of the distance we need to travel in health reform to facilitate caring for patients again. The more we centralize, standardize, and protocolize, the more space we find between doctors and patients. Really, all I wanted to do was schedule an appointment. Centralized scheduling and a protocol got in the way.
Evolving electronic medical records, “e-charts,” e-mail, and other advances will help. Yet, in health care, sometimes it really does feel like we’re trying to build businesses instead of care for patients.
As I always say to patients in clinic, when it comes to health care in America, don’t be afraid to be a squeaky wheel. Often to get what you or your children need, you may need to be loud and insistent.
I’ll calm down and I’ll get back to the Tylenol post. But I do hope to talk and see O’s pediatrician. Would like to bring the divide back together again.
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Viki says
You should have said that he might have an ear infection and wanted to have his ears checked. That’s the only way to get a short term appointment without more serious symptoms. I’m only half joking. 🙂 It gets more frustrating when you, as the parent, coordinate care between specialists. Unless there is a specific, clear medical pathology, I always call my mommy friends first. Tonight a group of us got out for a (very rare) outing and discussed picky eating over sangria. I came away with knowledge about oral-motor issues, sensory issues, power struggles, positive discipline for behavior mod, and recipes. There are times when my ped has this diverse and rich perspective. Other times, she’s another mom who stops when I mention some success story (mine or another friends), and jots it down. I think one bridge in the divide is community. So many moms become isolated from fellowship with other moms.
Melissa says
Thank you for this post! Your understanding of where your patients are coming from is so comforting. I think us moms can be very nervous as we enter the doctor’s office and in some way we are thinking that we have done something wrong. Knowing that you are a mom and can see where we are coming from makes you a great doctor. You experience the same hoops to jump through to get the help for your kids as we do for ours. Protocols are needed, but empathy and communication are needed as well. Thank for acknowledging this on your post.
Parin Stormlaughter says
You have hit upon a serious problem that I cannot find a way to overcome. I see it as similar to the triage scheduling issue because it concerns unforeseen, unavoidable events.
I’m retired on disability pension. My symptoms are fluid and I literally do not know from one hour to the next whether I’ll be able to walk or not.
I actually asked my OB/GYN last visit if she would recommend a new doctor for me who specialized in disabled people because with the problems I was having scheduling with her, she obviously did not treat disabled people. What I said mentally flattened her and she was speechless. We discussed the problem but did not reach an agreement.
Her practice demands that even long-scheduled patients wait sometimes MANY HOURS to be seen but won’t grant the courtesy of a close reschedule for a disabled person who has no control over having to cancel? Before I retired it required a sick leave request of 6 HOURS to see her. Yep, 6 hours of a day for a 15 minute appointment.
Finding a new doc wouldn’t have helped. They’re all alike around here.
I don’t know a solution to this. Do you? :/
Wendy Sue Swanson, MD says
Parin, I suggest you talk with your doctor about having notes in your chart that can be seen (and are always seen) by reception, RNs, ARNPs, MDs and staff. This is usually possible if the practice uses an electronic medical record. It could say, “Patient has a disability. If the wait is to exceed 30 minutes, they should be rescheduled.”
I’ve waited 3 hours to see my OB for a 10 minute visit. I know you’re not exaggerating. And I certainly understand the frustration.
As a doctor I hate running behind, but in pediatrics, if a child is ill and they need care, they get care from me. If the appt was scheduled in a 15 min spot and the visit takes 40 minutes (a suicidal teenager, for example) the rest of the day is ruined. But it’s a necessary evil. I do my best to apologize, My obligation to my patients (and to myself) is to be thorough and provide care. If I didn’t, I really wouldn’t like my job.
Talk with your doc about making a personalized plan. Or consider a concierge practice. I know very little about those types of practices (they don’t usually have them for children) but it may be a great solution for your situation. Many cities have them now. Seattle, I know, is one of them.
Good luck. Keep us posted on what you learn.
Viki says
Parin, we have similar troubles with specialists–especially those who perform surgeries and procedures because they can be called away. If you do not require a specialist in OB/GYN and need a regular checkup, there are two options that have worked for me: 1) See a nurse practitioner. I’ve gotten the majority of my care (incl prenatal) from a nurse practitioner. Your insurance provider may be able to connect you with a nurse practitioner who does home visits. 2) See a Family Practice doctor. Our doctor sees our whole family for all our needs. She only delivers the babies of families in her care, so her obstetrics load is relatively low. She sees the kids, does routine gyn checkups. It’s nice to cover all the bases of preventive care in one office, with one person, and (usually) at one visit. On the occasions when she was not available, there is a physicians assistant who filled in.