Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Wednesday, October 18, 2006

Sigh; Just...Sigh

You know those people who make you sigh when you see their name on your schedule?

I have one (or two) of them.

I saw a lady last week with a pain -- no, it was not a pain; it was a DISCOMFORT -- in her left side; sort of in the middle, but lower down, and around to her back. She had a fullness in her lower abdomen and a sense of having to urinate (but not really urgently; or frequently; no burning with urination.)

Me: How long has this been going on?
She: I've always had this.

I finally managed to ascertain that it had been a few weeks. No nausea, vomiting, anorexia, or change in bowel habits. Her past history was significant for IBS, a TAH-BSO, no kidney stones or family history of them. Her exam was completely negative; so was her urinalysis and blood work. GYN evaluation was completely normal; a urine culture was negative. I'd ordered an ultrasound of her abdomen months ago when she came with right upper quadrant pain and nausea -- sort of -- that she still hadn't gotten around to having done. Then she called and said what she wanted was a CT scan of the lower half of her body.

This is not a clinical puzzle. This is something between somatization and hypochondriasis. That, and she calls. Often. Every day. Several times. And talks. A lot. Every time.

Somewhere in there we also had to pre-authorize Avapro for her hypertension, because according to the chart, lisinopril had made her cough. (Actually, the cough had gone away while she was still on it, because even though I gave her the Avapro and told her to stop the lisinopril when she told me about the cough, she had wanted to "finish up what she had." In fact, she'd been fine on Avapro before, but had asked for "something cheaper." Then her insurance had changed. In any event, it was easier to fill out the form for the pre-auth and fax it off.)

Today we got notice from the insurance company: they approved the Avapro. Even though they approve it all the time, this notice included a message I'd never seen before (caps theirs):
"A DECISION HAS BEEN MADE TO AUTHORIZE THIS DRUG BY ADMINISTRATIVE EXCEPTION. THIS ACTION WAS TAKEN DUE TO INTERNAL ADMINISTRATIVE/PROCEDURAL ISSUES AND IS NOT A DETERMINATION BASED ON THE SUBSTANTIVE ISSUES PRESENTED IN THIS REQUEST."

I showed it to my staff and chuckled. I joked that they probably got sick of listening to her and just said, "What the hell; just let her have it! Anything to get rid of her."

Then I called the patient to let her know about her normal CA125. I also told her the insurance company had approved her Avapro. I swear this is what she said, and I'm proud to report that I managed not to crack up until I got off the phone:

"I know. I was on the phone with them for an hour and a half yesterday."

9 Comments:

At Wed Oct 18, 10:33:00 PM, Anonymous Anonymous said...

These are the kind of patients you should fire.

Ingdirect.com, the online savings bank, fires 3% of their customers every year: those who use up too many resources. We should all do that. If the patient wants to chit-chat, she should go to a concierge M.D. or a psychiatrist.

I am sure you disagree, but there are times when it's right to look at medicine through the eyes of a businessperson.

 
At Wed Oct 18, 11:24:00 PM, Anonymous ripple of hope said...

hmmmmmm, I disagree with anonymous. have you suggested counseling?

 
At Thu Oct 19, 09:56:00 AM, Blogger Shinga said...

Barsky and Aherne report good results for their CBT package to address hypochondriasis and somatoform disorders. In the UK, the Extended Reattribution model is popular in the management of patients with medically unexplained symptoms.

I hear so many horror stories about the difficulties of negotiating insurers in the US that a little of me admires this woman's phone negotiation skills.
She should obviously give masterclasses in her method.

Regards - Shinga

 
At Thu Oct 19, 09:52:00 PM, Blogger #1 Dinosaur said...

We were joking about how we should hire her to do all our pre-authorizations.

 
At Thu Oct 19, 10:55:00 PM, Anonymous Diora said...

Does she work? A doctor's visit takes time. Tests take even longer. Most of us can barely find time for a doctor's visit when we need it, never mind going to a doctor for discomfort we had all of our lives.

Wonder if she could've convinced the insurance company to pay for things they never cover. Like Renova.

 
At Tue Nov 14, 01:00:00 PM, Blogger Dreaming again said...

I have mixed feelings reading this.

As someone with a chronic illness. My first reaction is to get angry. I know that my problems with getting taken seriously by some medical professionals is because of women like this one. (not doctors, they know I'm really sick, but ... I look ok, so some referral nurses, tech people look at me as a waste of time/resources, they don't know the whole story).

Then, another part of me feels bad for her ... what is missing in her life that is causing her to need this kind of attention? And geesh ... there is better attention to get!! ICK!

I had a doctor (pediatrician actually) that was sure that he saw me and my kids every week. He was rather rude about it. He didn't. I was in the clinic weekly ... I had to go in every 2 weeks for blood work, I had to see my doctor once a month. I took MY mother in once a month to see MY doctor (hers too) and I went to all of my husband's appointments with him. (he had polio as a child, atrial fibulation, that at the time, wasn't the best controlled, and a barrets esophogus, so she followed him every 6 weeks). Yes, I was in the clinic every week ... but not to see the pediatrician. HE saw MY face, but not me or my kids.

HE fired us for using too many resources.

Funny ... I'm still at the clinic with the same PCP ...but he's been fired from the clinic for offending too many parents ... hmmmm

 
At Tue Nov 14, 03:59:00 PM, Anonymous Kim said...

I do believe that some people live for this. This is their life. They probably work, too, but I bet they are always discussing their somatic issues at work.

I wonder if this isn't a type of OCD...or, this woman is just stubborn enough and persistent enough to get exactly what she wants, when she wants it.

If nagging an insurance company for ninety minutes is what it takes, maybe I need to be on the phone more often...

 
At Tue Nov 14, 09:34:00 PM, Blogger Interrobang said...

Got here from Grand Rounds.

Thank you for letting me know about ING Direct, Anonymous. I won't be opening a savings account with them now. I strenuously object to the practice of corporations refusing services to people strictly on the grounds that they use too many resources, as frequently, the high resource-users are poor and disenfranchised already. (The system is kind of stacked towards that, since people with means also tend to have more access than people without.)

I had known for quite a while that certain companies will go out of their way to make it unpleasant for you to use their services, on the grounds that they hope you'll go away (and thereby improve their bottom line by taking your high-resource-using self elsewhere), but to do it as a matter of corporate policy seems egregiously offensive.

Medically speaking, I'm a high resource user, as I have a disability and a handful of chronic conditions. Fortunately, I have publicly-funded healthcare, so I'm not likely to be booted off the system. I was trying to figure out a dollar figure (using the American market as an index, which isn't exactly reliable) for the total amount of medical care I've had, and the closest I can come is, using US prices, nine figures.

On the other hand, I don't assume that entitles me to waste people's time.

 
At Thu Nov 16, 11:50:00 AM, Blogger apgaRN said...

Hi Dr. Dinosaur,

Enjoyed this post immensely, and it brought a little much-needed inspiration to my own writing. As you'll see, I was on the other end of the phone for a while this week.

Thanks again!
apgaRN

 

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