Demystifying Medicine

The Dreaded Reply: “Please make an appointment”

December 6, 2021

Sonia Singh MD
I'm a primary care doctor who is passionate about food, writing and making healthcare less frustrating and more empowering. These are my musings. Thanks for reading!

I bet a lot of you have been in this situation:

You message your doctor about something that seems very straightforward and could be taken care of via the portal and they or their assistant responds with the dreaded reply: “Please make an appointment.”

*GROAN*

So you cancel work for the morning, schlep over to their office and deal with all the usual hassles – parking, forms, waiting, sitting next to someone who is hacking up a lung, People magazines so outdated they still have Brangelina (and possibly flu particles) on the cover.

The MA finally takes you back and asks a million seemingly irrelevant/redundant questions, you see the doctor for 5-7 minutes and they DON’T EVEN EXAMINE YOU and then do EXACTLY WHAT YOU ASKED FOR in the first place. I don’t blame any of you for thinking, WTF. What gives??

Oftentimes they ask you to come in because they DO want to examine you, check your vital signs, review your history, have a real conversation or at least lay eyes on you to confirm the diagnosis and make sure you’re okay. 

But sometimes, as in this example, the doctor doesn’t really need that additional data but still makes you come in. Why is that?

I’ve heard patients say, ‘“He/She just wants my co-pay!”

Well, not exactly. 

Your doctor probably has no idea what your copay is or if you even paid it. What your doctor really wants is designated time to address your issue AND fair compensation for that work. Here’s an example:

Earlier this year I had a lovely patient message me a few weeks after his appointment to let me know that the medication I had prescribed him worked great, but caused dry mouth. Was there an alternative he could try? There was, so I sent it in. 

A few weeks later he messaged again to say that the second medication just didn’t seem to be working like the first one – was there anything else? There was, so I sent it in. 

Another few weeks go by and the new medication worked but was causing strange dreams. He’d rather just go back to the first one. And by the way can I change the pharmacy this time and also refill his BP meds?

My patient’s requests were certainly not unreasonable. He was describing his responses/side effects in detail, and I didn’t feel like I needed to see him in person to collect more data, especially during a pandemic. I knew I was saving him time/hassle which felt like the right thing to do, but I found myself irked.

Each time he messaged me, I would skim the previous messages to remind myself of the details of the situation. Each time I prescribed a new med I reviewed his med list for interactions and explained in my reply how to take the medicine, what to expect and some of the common side effects. All prescriptions come with liability/risk of harm. The second time he messaged I also consulted a medical reference to make sure I was choosing the best alternative. The final time, I reviewed his previous testing and labs to confirm to myself that the original diagnosis was correct since he seemed to be having trouble with multiple treatment options. Even the simple act of changing the pharmacy and sending in refills takes numerous clicks in a clunky computer system.

This entire exchange required time (which is in short supply as you’ll learn below), medical decision-making (which requires 10+ years of education) and risk (to a medical license I studied and paid dearly for). 

And what did I get compensated for this? Pretty much nothing.

Most PCPs are allotted a certain number of hours each week to handle “administrative” tasks like finishing notes, reviewing results, approving refills, filling forms and answering messages.

Despite the explosion in popularity of patient portal messaging, most PCPs are given only 2-4 hours per week for the above tasks, despite the fact that studies estimate 1-2 hours of admin work for EACH full clinic day. That’s 7-14 hours per week on top of scheduled appointments. Many of us are doing this work at the crack of dawn, during our lunch breaks or in our pajamas and yet we always seem to be behind. 

Unfortunately our healthcare system doesn’t have a great way to capture these hours and reimburse us for them. (There are a few obscure codes you can bill for certain scenarios but learning them and all their required documentation and then dealing with an angry patient who was not expecting a bill is usually not worth the few dollars you might get from it.)

So what will a doctor do if you send a message that requires time, thought, energy and risk? They will ask you to make an appointment. 

Is the doctor just being “greedy?” I don’t think so. They are simply playing the “game” of insurance-based healthcare. They are trying to protect their own work-life balance. They are trying to make themselves whole in a system that consistently shortchanges them. 

Now comes the more important question: Is this right?

NO!

We have created a healthcare system that incentivizes inefficiency and waste and leaves both patients AND doctors feeling dissatisfied. Unfortunately many patients and doctors don’t realize there is a viable alternative to the traditional system.

Direct primary care practices like Juniper refuse to play this insurance game. By charging a flat monthly membership fee, we don’t have to force you to come in for an issue that can be resolved via message. We’re incentivized to take care of problems efficiently and to make sure you have a good experience. Because every single dollar is going directly to your doctor, there is minimal waste, fewer patients and more time to care for them. 

Which would you prefer?

be well,
Sonia Singh MD

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