Larry Greenbaum, MD

Jane (not her real name) is an 83-year-old woman with rheumatoid arthritis. She was doing well on a combination of methotrexate and a biologic, but at her last visit she was aghast over the price of her biologic treatments. She is one of those old-fashioned types that worry about her bills, even though the government is picking up the tab. After she told me that her out-of-pocket expense was zero, I reassured her that she (unlike the government) was doing well and closed the topic.

She came back 6 months later and reported occasional problems with her arthritis, but overall, she was still doing well. Her anxiety over the cost of her biologic prescription, however, was not improving. At this point she wanted me to review a stack of her explanations of Medicare benefits (EOMB). The cost of the drug was $6,092 in June 2012, $15,846 in July 2012, and $16,583 in August 2012. She asked if I had changed her biologic dose, but I had not. Six months earlier, her treatments had been about $15,000 each, so the $6,092 bill for June was unusually low. The July and August bills were in line with the previous costs, although the prices were creeping up.

My frustrated patient called the hospital to find out why the charges for her biologic therapy were so high and so variable, but she didn’t get any satisfaction from her inquiries. She was told that the billing for her treatments had been outsourced. When she asked for a phone number where she could find an answer to her questions, the number wasn’t available. She asked the hospital employees if they would be able to locate the phone number if they needed it to recover a lost paycheck. That seemed like a wonderful question, but the hospital employees didn’t appreciate her insightful line of inquiry.

The hospital couldn’t or wouldn’t answer my patient’s valid questions, and I couldn’t either. Her arthritis continued to do well, but her drug combination had an expensive price tag to match its effectiveness. I ordered some labs, reassured her that she was still doing well, and asked her to return to see me in another 6 months.

Our health care system is in a muddle. Everyone is spending other people’s money in a system that doesn’t seem to have any checks or balances. My patient deserved answers regarding the cost of her treatment, but she had run into a brick wall. In an effort to distract an anxious patient to whom I’m giving an injection, I sometimes quip, "This won’t hurt me a bit." Regarding health care costs, my old gag could be reworded to, "This won’t cost me a bit." I probably won’t be able to explain her EOMB when she returns in 6 months, but hey, it’s somebody else’s money.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

Jane (not her real name) is an 83-year-old woman with rheumatoid arthritis. She was doing well on a combination of methotrexate and a biologic, but at her last visit she was aghast over the price of her biologic treatments. She is one of those old-fashioned types that worry about her bills, even though the government is picking up the tab. After she told me that her out-of-pocket expense was zero, I reassured her that she (unlike the government) was doing well and closed the topic.

She came back 6 months later and reported occasional problems with her arthritis, but overall, she was still doing well. Her anxiety over the cost of her biologic prescription, however, was not improving. At this point she wanted me to review a stack of her explanations of Medicare benefits (EOMB). The cost of the drug was $6,092 in June 2012, $15,846 in July 2012, and $16,583 in August 2012. She asked if I had changed her biologic dose, but I had not. Six months earlier, her treatments had been about $15,000 each, so the $6,092 bill for June was unusually low. The July and August bills were in line with the previous costs, although the prices were creeping up.

My frustrated patient called the hospital to find out why the charges for her biologic therapy were so high and so variable, but she didn’t get any satisfaction from her inquiries. She was told that the billing for her treatments had been outsourced. When she asked for a phone number where she could find an answer to her questions, the number wasn’t available. She asked the hospital employees if they would be able to locate the phone number if they needed it to recover a lost paycheck. That seemed like a wonderful question, but the hospital employees didn’t appreciate her insightful line of inquiry.

The hospital couldn’t or wouldn’t answer my patient’s valid questions, and I couldn’t either. Her arthritis continued to do well, but her drug combination had an expensive price tag to match its effectiveness. I ordered some labs, reassured her that she was still doing well, and asked her to return to see me in another 6 months.

Our health care system is in a muddle. Everyone is spending other people’s money in a system that doesn’t seem to have any checks or balances. My patient deserved answers regarding the cost of her treatment, but she had run into a brick wall. In an effort to distract an anxious patient to whom I’m giving an injection, I sometimes quip, "This won’t hurt me a bit." Regarding health care costs, my old gag could be reworded to, "This won’t cost me a bit." I probably won’t be able to explain her EOMB when she returns in 6 months, but hey, it’s somebody else’s money.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

Jane (not her real name) is an 83-year-old woman with rheumatoid arthritis. She was doing well on a combination of methotrexate and a biologic, but at her last visit she was aghast over the price of her biologic treatments. She is one of those old-fashioned types that worry about her bills, even though the government is picking up the tab. After she told me that her out-of-pocket expense was zero, I reassured her that she (unlike the government) was doing well and closed the topic.

She came back 6 months later and reported occasional problems with her arthritis, but overall, she was still doing well. Her anxiety over the cost of her biologic prescription, however, was not improving. At this point she wanted me to review a stack of her explanations of Medicare benefits (EOMB). The cost of the drug was $6,092 in June 2012, $15,846 in July 2012, and $16,583 in August 2012. She asked if I had changed her biologic dose, but I had not. Six months earlier, her treatments had been about $15,000 each, so the $6,092 bill for June was unusually low. The July and August bills were in line with the previous costs, although the prices were creeping up.

My frustrated patient called the hospital to find out why the charges for her biologic therapy were so high and so variable, but she didn’t get any satisfaction from her inquiries. She was told that the billing for her treatments had been outsourced. When she asked for a phone number where she could find an answer to her questions, the number wasn’t available. She asked the hospital employees if they would be able to locate the phone number if they needed it to recover a lost paycheck. That seemed like a wonderful question, but the hospital employees didn’t appreciate her insightful line of inquiry.

The hospital couldn’t or wouldn’t answer my patient’s valid questions, and I couldn’t either. Her arthritis continued to do well, but her drug combination had an expensive price tag to match its effectiveness. I ordered some labs, reassured her that she was still doing well, and asked her to return to see me in another 6 months.

Our health care system is in a muddle. Everyone is spending other people’s money in a system that doesn’t seem to have any checks or balances. My patient deserved answers regarding the cost of her treatment, but she had run into a brick wall. In an effort to distract an anxious patient to whom I’m giving an injection, I sometimes quip, "This won’t hurt me a bit." Regarding health care costs, my old gag could be reworded to, "This won’t cost me a bit." I probably won’t be able to explain her EOMB when she returns in 6 months, but hey, it’s somebody else’s money.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

*We are now well into the New Year. Many people have abandoned their New Year’s resolutions, and some probably can’t even remember theirs, but for many of my patients, the true significance of a new calendar year is their health insurance. Some patients have new insurance. Those that have the same insurance have to start all over again to meet their deductible, and some have to begin a new struggle to get financial assistance to pay for expensive biologic medications. Prices go up and up, and benefits shrink and sometimes vanish entirely, leaving doctors and patients to try and cope with a tremendous headache. Patients are caught between a cruel disease and miracle medications that are almost always out of their reach financially. This plight is summarized eloquently in an excerpt from a letter one of my patients recently sent me:

Dr. Greenbaum,

I thought I should tell you what is going on with my [biologic]. First, thank you for your help with the [biologic] foundation application. Unlike last year, they have not approved my application. ... The [biologic] has been a great help with my rheumatoid arthritis (RA) and I hope at some point in the near future to be able to continue using it. It is, however, very expensive even with Medicare Part D. It is so expensive that it would have a negative long-term impact on our long term financial situation. For this reason, I am continuing to seek financial assistance until all options are exhausted before I change the financial structure of our retirement. All this means that at present, I am not taking [my prescribed biologic]. ... I intend to maintain our relationship. I am working, hoping, and praying that during this difficult time I will not experience any setbacks or flares and that my efforts will prove successful. ...

The foundation is a nonprofit patient-assistance program that provides the biologic at no cost to qualifying patients with no or limited drug coverage." Unfortunately, patients need to renew their support every year, leaving patients to worry what they will do if they are not approved for additional coverage. When the foundation runs out of money, it is discouraging for patients who had done well on the biologic previously. Desperate patients look to their rheumatologist to pull off some therapeutic sleight of hand or to locate alternative drug company largesse.

That isn’t fair. With the money drug companies make off our patients and our prescriptions, I think they have a moral obligation to continue to assist every patient they have started to help, rather than create panic and havoc year after year.

Some patients try to be resourceful during these crises. A common coping strategy that many of my patients adopt is to stretch the dose interval of their medication. One of my patients with psoriatic arthritis stretched the normal 2-week interval of his biologic dosing to 3.5 weeks, or until his hands and feet started to hurt. I often remind patients that I am not endowed with x-ray vision, but you don’t have to be a genius to predict that stretching out doses is not going to do an optimal job of impeding the radiographic progression of their disease!

One of my other RA patients with commercial insurance has done very well on his biologic, but because of the inadequacy of his insurance benefits, he runs out of medication at the end of every calendar year, and then he has to either do the big stretch for a few months or subsist on samples that my office gives him when we have them. We both got sick of this, and I had the bright idea that I’d like to have him switch drugs to one of the new kids on the biologic block. The nurse went through the motions of checking his insurance coverage, and we got back a message that was both blunt and discouraging. Regardless of which biologic I prescribed, my patient would be responsible for 45% of the bill. With a price tag of about $25,000 a year, that was a complete conversation stopper.

Insurance companies are sometimes more willing to foot the bill for drugs given in the doctor’s office or an infusion clinic even though it is more expensive because of additional sizable clinic and administration fees. That mentality never made much sense to me. Why would insurance agree to pay extra for a patient to get the medication in my office but refuse to pay to have them use the medication at home?

I tried to start another patient on one of these drugs, hoping that its patient assistance program would be more helpful, but his experience indicates that some patients are so dreadfully underinsured that it is almost impossible to start them on biologic drugs. I got the following charming note regarding my luckless patient:

[This drug] is not covered unless the patient tries and fails two other biologics. Also, he has to pay 20% through medical benefit or 33% through pharmacy benefit, so he probably cannot afford it.

The New Year is well underway, and I can tell I’m going to need all my creative powers to help my patients get the care they need. Perhaps my resolution should be to steer my patients toward the medication that works best and has the most generous and fairly administered support program, provided I can figure out which medication that is and that I don’t forget my resolution.

* This article was modified on 3/4/2013.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

Readers can e-mail Dr. Greenbaum at rhnews@elsevier.com.

*We are now well into the New Year. Many people have abandoned their New Year’s resolutions, and some probably can’t even remember theirs, but for many of my patients, the true significance of a new calendar year is their health insurance. Some patients have new insurance. Those that have the same insurance have to start all over again to meet their deductible, and some have to begin a new struggle to get financial assistance to pay for expensive biologic medications. Prices go up and up, and benefits shrink and sometimes vanish entirely, leaving doctors and patients to try and cope with a tremendous headache. Patients are caught between a cruel disease and miracle medications that are almost always out of their reach financially. This plight is summarized eloquently in an excerpt from a letter one of my patients recently sent me:

Dr. Greenbaum,

I thought I should tell you what is going on with my [biologic]. First, thank you for your help with the [biologic] foundation application. Unlike last year, they have not approved my application. ... The [biologic] has been a great help with my rheumatoid arthritis (RA) and I hope at some point in the near future to be able to continue using it. It is, however, very expensive even with Medicare Part D. It is so expensive that it would have a negative long-term impact on our long term financial situation. For this reason, I am continuing to seek financial assistance until all options are exhausted before I change the financial structure of our retirement. All this means that at present, I am not taking [my prescribed biologic]. ... I intend to maintain our relationship. I am working, hoping, and praying that during this difficult time I will not experience any setbacks or flares and that my efforts will prove successful. ...

The foundation is a nonprofit patient-assistance program that provides the biologic at no cost to qualifying patients with no or limited drug coverage." Unfortunately, patients need to renew their support every year, leaving patients to worry what they will do if they are not approved for additional coverage. When the foundation runs out of money, it is discouraging for patients who had done well on the biologic previously. Desperate patients look to their rheumatologist to pull off some therapeutic sleight of hand or to locate alternative drug company largesse.

That isn’t fair. With the money drug companies make off our patients and our prescriptions, I think they have a moral obligation to continue to assist every patient they have started to help, rather than create panic and havoc year after year.

Some patients try to be resourceful during these crises. A common coping strategy that many of my patients adopt is to stretch the dose interval of their medication. One of my patients with psoriatic arthritis stretched the normal 2-week interval of his biologic dosing to 3.5 weeks, or until his hands and feet started to hurt. I often remind patients that I am not endowed with x-ray vision, but you don’t have to be a genius to predict that stretching out doses is not going to do an optimal job of impeding the radiographic progression of their disease!

One of my other RA patients with commercial insurance has done very well on his biologic, but because of the inadequacy of his insurance benefits, he runs out of medication at the end of every calendar year, and then he has to either do the big stretch for a few months or subsist on samples that my office gives him when we have them. We both got sick of this, and I had the bright idea that I’d like to have him switch drugs to one of the new kids on the biologic block. The nurse went through the motions of checking his insurance coverage, and we got back a message that was both blunt and discouraging. Regardless of which biologic I prescribed, my patient would be responsible for 45% of the bill. With a price tag of about $25,000 a year, that was a complete conversation stopper.

Insurance companies are sometimes more willing to foot the bill for drugs given in the doctor’s office or an infusion clinic even though it is more expensive because of additional sizable clinic and administration fees. That mentality never made much sense to me. Why would insurance agree to pay extra for a patient to get the medication in my office but refuse to pay to have them use the medication at home?

I tried to start another patient on one of these drugs, hoping that its patient assistance program would be more helpful, but his experience indicates that some patients are so dreadfully underinsured that it is almost impossible to start them on biologic drugs. I got the following charming note regarding my luckless patient:

[This drug] is not covered unless the patient tries and fails two other biologics. Also, he has to pay 20% through medical benefit or 33% through pharmacy benefit, so he probably cannot afford it.

The New Year is well underway, and I can tell I’m going to need all my creative powers to help my patients get the care they need. Perhaps my resolution should be to steer my patients toward the medication that works best and has the most generous and fairly administered support program, provided I can figure out which medication that is and that I don’t forget my resolution.

* This article was modified on 3/4/2013.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

Readers can e-mail Dr. Greenbaum at rhnews@elsevier.com.

*We are now well into the New Year. Many people have abandoned their New Year’s resolutions, and some probably can’t even remember theirs, but for many of my patients, the true significance of a new calendar year is their health insurance. Some patients have new insurance. Those that have the same insurance have to start all over again to meet their deductible, and some have to begin a new struggle to get financial assistance to pay for expensive biologic medications. Prices go up and up, and benefits shrink and sometimes vanish entirely, leaving doctors and patients to try and cope with a tremendous headache. Patients are caught between a cruel disease and miracle medications that are almost always out of their reach financially. This plight is summarized eloquently in an excerpt from a letter one of my patients recently sent me:

Dr. Greenbaum,

I thought I should tell you what is going on with my [biologic]. First, thank you for your help with the [biologic] foundation application. Unlike last year, they have not approved my application. ... The [biologic] has been a great help with my rheumatoid arthritis (RA) and I hope at some point in the near future to be able to continue using it. It is, however, very expensive even with Medicare Part D. It is so expensive that it would have a negative long-term impact on our long term financial situation. For this reason, I am continuing to seek financial assistance until all options are exhausted before I change the financial structure of our retirement. All this means that at present, I am not taking [my prescribed biologic]. ... I intend to maintain our relationship. I am working, hoping, and praying that during this difficult time I will not experience any setbacks or flares and that my efforts will prove successful. ...

The foundation is a nonprofit patient-assistance program that provides the biologic at no cost to qualifying patients with no or limited drug coverage." Unfortunately, patients need to renew their support every year, leaving patients to worry what they will do if they are not approved for additional coverage. When the foundation runs out of money, it is discouraging for patients who had done well on the biologic previously. Desperate patients look to their rheumatologist to pull off some therapeutic sleight of hand or to locate alternative drug company largesse.

That isn’t fair. With the money drug companies make off our patients and our prescriptions, I think they have a moral obligation to continue to assist every patient they have started to help, rather than create panic and havoc year after year.

Some patients try to be resourceful during these crises. A common coping strategy that many of my patients adopt is to stretch the dose interval of their medication. One of my patients with psoriatic arthritis stretched the normal 2-week interval of his biologic dosing to 3.5 weeks, or until his hands and feet started to hurt. I often remind patients that I am not endowed with x-ray vision, but you don’t have to be a genius to predict that stretching out doses is not going to do an optimal job of impeding the radiographic progression of their disease!

One of my other RA patients with commercial insurance has done very well on his biologic, but because of the inadequacy of his insurance benefits, he runs out of medication at the end of every calendar year, and then he has to either do the big stretch for a few months or subsist on samples that my office gives him when we have them. We both got sick of this, and I had the bright idea that I’d like to have him switch drugs to one of the new kids on the biologic block. The nurse went through the motions of checking his insurance coverage, and we got back a message that was both blunt and discouraging. Regardless of which biologic I prescribed, my patient would be responsible for 45% of the bill. With a price tag of about $25,000 a year, that was a complete conversation stopper.

Insurance companies are sometimes more willing to foot the bill for drugs given in the doctor’s office or an infusion clinic even though it is more expensive because of additional sizable clinic and administration fees. That mentality never made much sense to me. Why would insurance agree to pay extra for a patient to get the medication in my office but refuse to pay to have them use the medication at home?

I tried to start another patient on one of these drugs, hoping that its patient assistance program would be more helpful, but his experience indicates that some patients are so dreadfully underinsured that it is almost impossible to start them on biologic drugs. I got the following charming note regarding my luckless patient:

[This drug] is not covered unless the patient tries and fails two other biologics. Also, he has to pay 20% through medical benefit or 33% through pharmacy benefit, so he probably cannot afford it.

The New Year is well underway, and I can tell I’m going to need all my creative powers to help my patients get the care they need. Perhaps my resolution should be to steer my patients toward the medication that works best and has the most generous and fairly administered support program, provided I can figure out which medication that is and that I don’t forget my resolution.

* This article was modified on 3/4/2013.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

Readers can e-mail Dr. Greenbaum at rhnews@elsevier.com.

Sometime in the last millennium I vaguely recall learning how to write a prescription, but learning how many refills to put on a prescription has some subtle nuances that I didn’t discover until much later in life. I try to give patients enough refills on their medications to last until the next appointment, but because of medical-legal implications, I shy away from giving them refills for the entire year.

I’ve noticed over the years that some patients do not get their lab tests done despite my telling them that they must have them done before they get a refill. If these patients are taking methotrexate and not getting their lab tests done, I try to make sure they come for an office visit every few months and get their lab work at the time of their visit. But for a variety of reasons, this isn’t always feasible. If the tests don’t get done, patients sometimes misinterpret their lack of refills as a tacit permission, or unspoken instruction, from the doctor to stop the medication. In reality, all it really means is that they should have called the office for a refill. If such patients come in for 6-month follow-up visits and I notice that they haven’t been doing their labs, I gently remind them that they need to do their labs more frequently. I might schedule their next visit in 6 months, but I will only refill their methotrexate for 3 months. Three months later, when they need a refill on their prescription, I won’t give it to them if they haven’t done their lab work.

Patients also may find that they don’t feel any worse when they run out of medication, and so they decide not to refill it. It’s just human nature that they look for an exit strategy. The sad fact is that sometimes our treatments aren’t as effective as we would like to imagine. If the medication was working like a miracle, the patient would be more zealous about refilling it.

I’m often tempted to ask patients, "if you ate your last slice of bread, would you stop eating bread, or would you buy some more?" Strange as it may seem, some people like their bread a lot more than they like our medications!

Sometime in the last millennium I vaguely recall learning how to write a prescription, but learning how many refills to put on a prescription has some subtle nuances that I didn’t discover until much later in life. I try to give patients enough refills on their medications to last until the next appointment, but because of medical-legal implications, I shy away from giving them refills for the entire year.

I’ve noticed over the years that some patients do not get their lab tests done despite my telling them that they must have them done before they get a refill. If these patients are taking methotrexate and not getting their lab tests done, I try to make sure they come for an office visit every few months and get their lab work at the time of their visit. But for a variety of reasons, this isn’t always feasible. If the tests don’t get done, patients sometimes misinterpret their lack of refills as a tacit permission, or unspoken instruction, from the doctor to stop the medication. In reality, all it really means is that they should have called the office for a refill. If such patients come in for 6-month follow-up visits and I notice that they haven’t been doing their labs, I gently remind them that they need to do their labs more frequently. I might schedule their next visit in 6 months, but I will only refill their methotrexate for 3 months. Three months later, when they need a refill on their prescription, I won’t give it to them if they haven’t done their lab work.

Patients also may find that they don’t feel any worse when they run out of medication, and so they decide not to refill it. It’s just human nature that they look for an exit strategy. The sad fact is that sometimes our treatments aren’t as effective as we would like to imagine. If the medication was working like a miracle, the patient would be more zealous about refilling it.

I’m often tempted to ask patients, "if you ate your last slice of bread, would you stop eating bread, or would you buy some more?" Strange as it may seem, some people like their bread a lot more than they like our medications!

Sometime in the last millennium I vaguely recall learning how to write a prescription, but learning how many refills to put on a prescription has some subtle nuances that I didn’t discover until much later in life. I try to give patients enough refills on their medications to last until the next appointment, but because of medical-legal implications, I shy away from giving them refills for the entire year.

I’ve noticed over the years that some patients do not get their lab tests done despite my telling them that they must have them done before they get a refill. If these patients are taking methotrexate and not getting their lab tests done, I try to make sure they come for an office visit every few months and get their lab work at the time of their visit. But for a variety of reasons, this isn’t always feasible. If the tests don’t get done, patients sometimes misinterpret their lack of refills as a tacit permission, or unspoken instruction, from the doctor to stop the medication. In reality, all it really means is that they should have called the office for a refill. If such patients come in for 6-month follow-up visits and I notice that they haven’t been doing their labs, I gently remind them that they need to do their labs more frequently. I might schedule their next visit in 6 months, but I will only refill their methotrexate for 3 months. Three months later, when they need a refill on their prescription, I won’t give it to them if they haven’t done their lab work.

Patients also may find that they don’t feel any worse when they run out of medication, and so they decide not to refill it. It’s just human nature that they look for an exit strategy. The sad fact is that sometimes our treatments aren’t as effective as we would like to imagine. If the medication was working like a miracle, the patient would be more zealous about refilling it.

I’m often tempted to ask patients, "if you ate your last slice of bread, would you stop eating bread, or would you buy some more?" Strange as it may seem, some people like their bread a lot more than they like our medications!

I first saw Mr. Smith (not his real name) in April of 1997 regarding severe problems with arthritis and prolonged morning stiffness. He told me that his feet hurt so badly that he felt as if he had spikes going through them. His rheumatoid factor was weakly positive. Because Mr. Smith was extremely uncomfortable at his first visit, I put him on prednisone, and I had him come back a week later for a follow-up visit. I started him on methotrexate. His rheumatoid arthritis (RA) improved nicely, and over the next few months, he was able to taper off his prednisone.

Mr. Smith continued to do well over the next 15 years. He was pleased with his progress, and I had the satisfaction of watching his improvement. This satisfactory arrangement might have continued until retirement, or death do us part, except for one small hitch.

Office copayments are on the rise. I know this because my office jots this amount on the patient’s superbill. Five or ten dollar copayments are a thing of the past, and copayments ranging from $30 to $45, and sometimes as high as $60, are common these days. Patients vote with their feet when the costs of their visits become exorbitant. My nurse sent me the following note regarding Mr. Smith via our electronic medical records system:

Spoke with patient. He has seen Dr. Greenbaum for RA. He sees Dr. Blank (not his real name) for primary care. Patient has to pay $45 copay with Dr. Greenbaum and zero copay for Dr. Blank. Can Dr. Blank take over filling his prescriptions for RA? This will save him money.

Dr. Blank is a bright young internist in my group, and I knew he was quite capable of refilling Mr. Smith’s methotrexate and monitoring his labs, so I sadly typed back my acquiescence for the transfer of Mr. Smith’s care. I certainly couldn’t blame Mr. Smith. Why would he want to waste $45, several times a year, if his arthritis was doing well? In addition, patients hate having multiple doctors. Even in the best-case scenario, it’s confusing, expensive, and time consuming. In addition, patients have good reason to worry more about medication interactions when there are multiple prescribers involved. Long ago, in my training years, a patient at the VA told me that I was one of his favorite doctors. I was flattered to hear this, but after he mentioned that he had six different doctors, I began to wonder if this was really an optimal way to care for patients.

My patients frequently try to cajole me to assume some or all of their primary care. This line of wheedling sounds something like, "Gee doc, couldn’t you just refill my blood pressure medication? It will save me the time and expense of having to make an appointment to see my primary care provider (PCP) just to get refills on my medication." Sometimes I cave into these blandishments and sometimes I don’t. Undoubtedly, the same scenario occurs in the PCP’s office. Many of my patients are probably asking their PCP to refill their arthritis medications so they don’t have to go to the trouble and expense of seeing me, effectively transferring some or all of their arthritis care to their PCP. This type of behind-the-scenes attrition is more subtle than Mr. Smith’s explicit request to save $45, but probably is very common. The higher the office copayment, the more economic incentive patients have to streamline their care. Patients love having one doctor in charge of everything, and who can blame them?

Insurers have enshrined the notion that PCPs are good for their bottom line, but specialists are driving up the high cost of health care. Of course, there are some caveats regarding this health care strategy. The desired cost savings of having the PCP assume the role of the specialist is not always feasible. Over the years, I’ve seen some PCPs put their patients on a masterful combination of RA medications. The treatment plan of those patients read just like a medical textbook chapter, but they weren’t doing well because they didn’t have RA. Don’t get me wrong, rheumatologists make mistakes, too, but some of these patients were on corticosteroids unnecessarily for years, and some are never able to taper off entirely. Sometimes a transfer of care is appropriate, and sometimes it isn’t. Perhaps in the near future, the rheumatologist’s role will be quite circumscribed. We’ll make a diagnosis, initiate treatment, and send the patient back to the PCP with just occasional input from us. This consultative approach will work for patients that are doing well, but not for sicker or more complicated patients. Some patients will have to pay higher office copayments, but others might get off cheap.

I understand intellectually that if I had retained every patient that I ever saw, this wouldn’t be the best thing for me. My practice would be hypertrophied beyond recognition and would probably have been closed to new patients years ago. On the other hand, it bothers me to think that insurance companies are creating a thieves’ market that will cause my most satisfied patients to race for the life rafts and abandon the small ship of my practice. Perhaps it is selfish of me, but what will my practice look like if all the stable, happy patients are siphoned off by economic incentives and redirected back to primary care? The only patients that will be left in my waiting room will be those who are too sick or too unhappy to be cared for by their PCP. These patients will probably include patients with chronic pain, the deeply depressed, patients with rare or complicated illness, and other difficult subsets of patients that PCPs tend to avoid caring for. That will be a much tougher practice environment, but perhaps that is the bleak future for specialists, and I should get ready for it. I’ll tighten my belt a notch and ask the dry cleaner to put some extra starch in my white coat.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

I first saw Mr. Smith (not his real name) in April of 1997 regarding severe problems with arthritis and prolonged morning stiffness. He told me that his feet hurt so badly that he felt as if he had spikes going through them. His rheumatoid factor was weakly positive. Because Mr. Smith was extremely uncomfortable at his first visit, I put him on prednisone, and I had him come back a week later for a follow-up visit. I started him on methotrexate. His rheumatoid arthritis (RA) improved nicely, and over the next few months, he was able to taper off his prednisone.

Mr. Smith continued to do well over the next 15 years. He was pleased with his progress, and I had the satisfaction of watching his improvement. This satisfactory arrangement might have continued until retirement, or death do us part, except for one small hitch.

Office copayments are on the rise. I know this because my office jots this amount on the patient’s superbill. Five or ten dollar copayments are a thing of the past, and copayments ranging from $30 to $45, and sometimes as high as $60, are common these days. Patients vote with their feet when the costs of their visits become exorbitant. My nurse sent me the following note regarding Mr. Smith via our electronic medical records system:

Spoke with patient. He has seen Dr. Greenbaum for RA. He sees Dr. Blank (not his real name) for primary care. Patient has to pay $45 copay with Dr. Greenbaum and zero copay for Dr. Blank. Can Dr. Blank take over filling his prescriptions for RA? This will save him money.

Dr. Blank is a bright young internist in my group, and I knew he was quite capable of refilling Mr. Smith’s methotrexate and monitoring his labs, so I sadly typed back my acquiescence for the transfer of Mr. Smith’s care. I certainly couldn’t blame Mr. Smith. Why would he want to waste $45, several times a year, if his arthritis was doing well? In addition, patients hate having multiple doctors. Even in the best-case scenario, it’s confusing, expensive, and time consuming. In addition, patients have good reason to worry more about medication interactions when there are multiple prescribers involved. Long ago, in my training years, a patient at the VA told me that I was one of his favorite doctors. I was flattered to hear this, but after he mentioned that he had six different doctors, I began to wonder if this was really an optimal way to care for patients.

My patients frequently try to cajole me to assume some or all of their primary care. This line of wheedling sounds something like, "Gee doc, couldn’t you just refill my blood pressure medication? It will save me the time and expense of having to make an appointment to see my primary care provider (PCP) just to get refills on my medication." Sometimes I cave into these blandishments and sometimes I don’t. Undoubtedly, the same scenario occurs in the PCP’s office. Many of my patients are probably asking their PCP to refill their arthritis medications so they don’t have to go to the trouble and expense of seeing me, effectively transferring some or all of their arthritis care to their PCP. This type of behind-the-scenes attrition is more subtle than Mr. Smith’s explicit request to save $45, but probably is very common. The higher the office copayment, the more economic incentive patients have to streamline their care. Patients love having one doctor in charge of everything, and who can blame them?

Insurers have enshrined the notion that PCPs are good for their bottom line, but specialists are driving up the high cost of health care. Of course, there are some caveats regarding this health care strategy. The desired cost savings of having the PCP assume the role of the specialist is not always feasible. Over the years, I’ve seen some PCPs put their patients on a masterful combination of RA medications. The treatment plan of those patients read just like a medical textbook chapter, but they weren’t doing well because they didn’t have RA. Don’t get me wrong, rheumatologists make mistakes, too, but some of these patients were on corticosteroids unnecessarily for years, and some are never able to taper off entirely. Sometimes a transfer of care is appropriate, and sometimes it isn’t. Perhaps in the near future, the rheumatologist’s role will be quite circumscribed. We’ll make a diagnosis, initiate treatment, and send the patient back to the PCP with just occasional input from us. This consultative approach will work for patients that are doing well, but not for sicker or more complicated patients. Some patients will have to pay higher office copayments, but others might get off cheap.

I understand intellectually that if I had retained every patient that I ever saw, this wouldn’t be the best thing for me. My practice would be hypertrophied beyond recognition and would probably have been closed to new patients years ago. On the other hand, it bothers me to think that insurance companies are creating a thieves’ market that will cause my most satisfied patients to race for the life rafts and abandon the small ship of my practice. Perhaps it is selfish of me, but what will my practice look like if all the stable, happy patients are siphoned off by economic incentives and redirected back to primary care? The only patients that will be left in my waiting room will be those who are too sick or too unhappy to be cared for by their PCP. These patients will probably include patients with chronic pain, the deeply depressed, patients with rare or complicated illness, and other difficult subsets of patients that PCPs tend to avoid caring for. That will be a much tougher practice environment, but perhaps that is the bleak future for specialists, and I should get ready for it. I’ll tighten my belt a notch and ask the dry cleaner to put some extra starch in my white coat.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

I first saw Mr. Smith (not his real name) in April of 1997 regarding severe problems with arthritis and prolonged morning stiffness. He told me that his feet hurt so badly that he felt as if he had spikes going through them. His rheumatoid factor was weakly positive. Because Mr. Smith was extremely uncomfortable at his first visit, I put him on prednisone, and I had him come back a week later for a follow-up visit. I started him on methotrexate. His rheumatoid arthritis (RA) improved nicely, and over the next few months, he was able to taper off his prednisone.

Mr. Smith continued to do well over the next 15 years. He was pleased with his progress, and I had the satisfaction of watching his improvement. This satisfactory arrangement might have continued until retirement, or death do us part, except for one small hitch.

Office copayments are on the rise. I know this because my office jots this amount on the patient’s superbill. Five or ten dollar copayments are a thing of the past, and copayments ranging from $30 to $45, and sometimes as high as $60, are common these days. Patients vote with their feet when the costs of their visits become exorbitant. My nurse sent me the following note regarding Mr. Smith via our electronic medical records system:

Spoke with patient. He has seen Dr. Greenbaum for RA. He sees Dr. Blank (not his real name) for primary care. Patient has to pay $45 copay with Dr. Greenbaum and zero copay for Dr. Blank. Can Dr. Blank take over filling his prescriptions for RA? This will save him money.

Dr. Blank is a bright young internist in my group, and I knew he was quite capable of refilling Mr. Smith’s methotrexate and monitoring his labs, so I sadly typed back my acquiescence for the transfer of Mr. Smith’s care. I certainly couldn’t blame Mr. Smith. Why would he want to waste $45, several times a year, if his arthritis was doing well? In addition, patients hate having multiple doctors. Even in the best-case scenario, it’s confusing, expensive, and time consuming. In addition, patients have good reason to worry more about medication interactions when there are multiple prescribers involved. Long ago, in my training years, a patient at the VA told me that I was one of his favorite doctors. I was flattered to hear this, but after he mentioned that he had six different doctors, I began to wonder if this was really an optimal way to care for patients.

My patients frequently try to cajole me to assume some or all of their primary care. This line of wheedling sounds something like, "Gee doc, couldn’t you just refill my blood pressure medication? It will save me the time and expense of having to make an appointment to see my primary care provider (PCP) just to get refills on my medication." Sometimes I cave into these blandishments and sometimes I don’t. Undoubtedly, the same scenario occurs in the PCP’s office. Many of my patients are probably asking their PCP to refill their arthritis medications so they don’t have to go to the trouble and expense of seeing me, effectively transferring some or all of their arthritis care to their PCP. This type of behind-the-scenes attrition is more subtle than Mr. Smith’s explicit request to save $45, but probably is very common. The higher the office copayment, the more economic incentive patients have to streamline their care. Patients love having one doctor in charge of everything, and who can blame them?

Insurers have enshrined the notion that PCPs are good for their bottom line, but specialists are driving up the high cost of health care. Of course, there are some caveats regarding this health care strategy. The desired cost savings of having the PCP assume the role of the specialist is not always feasible. Over the years, I’ve seen some PCPs put their patients on a masterful combination of RA medications. The treatment plan of those patients read just like a medical textbook chapter, but they weren’t doing well because they didn’t have RA. Don’t get me wrong, rheumatologists make mistakes, too, but some of these patients were on corticosteroids unnecessarily for years, and some are never able to taper off entirely. Sometimes a transfer of care is appropriate, and sometimes it isn’t. Perhaps in the near future, the rheumatologist’s role will be quite circumscribed. We’ll make a diagnosis, initiate treatment, and send the patient back to the PCP with just occasional input from us. This consultative approach will work for patients that are doing well, but not for sicker or more complicated patients. Some patients will have to pay higher office copayments, but others might get off cheap.

I understand intellectually that if I had retained every patient that I ever saw, this wouldn’t be the best thing for me. My practice would be hypertrophied beyond recognition and would probably have been closed to new patients years ago. On the other hand, it bothers me to think that insurance companies are creating a thieves’ market that will cause my most satisfied patients to race for the life rafts and abandon the small ship of my practice. Perhaps it is selfish of me, but what will my practice look like if all the stable, happy patients are siphoned off by economic incentives and redirected back to primary care? The only patients that will be left in my waiting room will be those who are too sick or too unhappy to be cared for by their PCP. These patients will probably include patients with chronic pain, the deeply depressed, patients with rare or complicated illness, and other difficult subsets of patients that PCPs tend to avoid caring for. That will be a much tougher practice environment, but perhaps that is the bleak future for specialists, and I should get ready for it. I’ll tighten my belt a notch and ask the dry cleaner to put some extra starch in my white coat.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

Just before I opened the exam room door, my ever-diligent nurse alerted me that my next patient was accompanied by Santa Claus, or at least a spouse in a rundown Santa outfit. I would have been alright even without the heads up, but it’s nice to avoid being taken by surprise in one’s own clinic.

As it turned out, he didn’t have the full-blown Santa outfit. He was sporting a Santa hat, a long white beard, blue-tinted sunglasses, and jeans. The remainder of the typical Santa costume was silk screened on a red T-shirt. The long white beard seemed to be his own, rather than a costume. While I’m not a connoisseur, taken in total, his Santa outfit was shabby in comparison to others I’ve seen. On my office light box (one of those big old-fashioned things that doctors used to use to review radiographs before everything went digital), I have a photo of one of my other patients dressed as Santa. Wearing the traditional red jacket and pants with a big black belt, seated next to his Christmas tree with children and grandchildren, his holiday aura was regal in comparison to the specimen in my exam room visitor chair.

At the end of the visit, the patient, Santa, and I were chatting, and out of the blue, Santa popped a question. "Where do you think I retired from?"

Taken by surprise, I replied without thinking, "the Salvation Army?"

"I love you, too, doc," replied Santa patiently, but with a tinge of irony. Santa pulled out his wallet and showed me his police officer’s badge. I’m not sure what sort of guess Santa expected I might make regarding his previous employment history, but he probably felt that "Salvation Army" was a bit insulting. In retrospect, I could see that a reply of "undercover detective," would have made him feel much better, but now I didn’t know what I could say that would make the situation less awkward, so I didn’t say much.

After he and his wife were safely out of earshot, I mentioned to the nurse that Santa had asked me to guess what his previous career had been, and I had guessed "Salvation Army" rather than police officer. She laughed sympathetically and told me that she too had taken him for "a bell ringer." That made me feel better about my faux pas. If you run into Santa in your office, and he asks you to guess his previous line of work, my advice is to aim high. A little flattery can never hurt Santa’s feelings.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. 

Just before I opened the exam room door, my ever-diligent nurse alerted me that my next patient was accompanied by Santa Claus, or at least a spouse in a rundown Santa outfit. I would have been alright even without the heads up, but it’s nice to avoid being taken by surprise in one’s own clinic.

As it turned out, he didn’t have the full-blown Santa outfit. He was sporting a Santa hat, a long white beard, blue-tinted sunglasses, and jeans. The remainder of the typical Santa costume was silk screened on a red T-shirt. The long white beard seemed to be his own, rather than a costume. While I’m not a connoisseur, taken in total, his Santa outfit was shabby in comparison to others I’ve seen. On my office light box (one of those big old-fashioned things that doctors used to use to review radiographs before everything went digital), I have a photo of one of my other patients dressed as Santa. Wearing the traditional red jacket and pants with a big black belt, seated next to his Christmas tree with children and grandchildren, his holiday aura was regal in comparison to the specimen in my exam room visitor chair.

At the end of the visit, the patient, Santa, and I were chatting, and out of the blue, Santa popped a question. "Where do you think I retired from?"

Taken by surprise, I replied without thinking, "the Salvation Army?"

"I love you, too, doc," replied Santa patiently, but with a tinge of irony. Santa pulled out his wallet and showed me his police officer’s badge. I’m not sure what sort of guess Santa expected I might make regarding his previous employment history, but he probably felt that "Salvation Army" was a bit insulting. In retrospect, I could see that a reply of "undercover detective," would have made him feel much better, but now I didn’t know what I could say that would make the situation less awkward, so I didn’t say much.

After he and his wife were safely out of earshot, I mentioned to the nurse that Santa had asked me to guess what his previous career had been, and I had guessed "Salvation Army" rather than police officer. She laughed sympathetically and told me that she too had taken him for "a bell ringer." That made me feel better about my faux pas. If you run into Santa in your office, and he asks you to guess his previous line of work, my advice is to aim high. A little flattery can never hurt Santa’s feelings.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. 

Just before I opened the exam room door, my ever-diligent nurse alerted me that my next patient was accompanied by Santa Claus, or at least a spouse in a rundown Santa outfit. I would have been alright even without the heads up, but it’s nice to avoid being taken by surprise in one’s own clinic.

As it turned out, he didn’t have the full-blown Santa outfit. He was sporting a Santa hat, a long white beard, blue-tinted sunglasses, and jeans. The remainder of the typical Santa costume was silk screened on a red T-shirt. The long white beard seemed to be his own, rather than a costume. While I’m not a connoisseur, taken in total, his Santa outfit was shabby in comparison to others I’ve seen. On my office light box (one of those big old-fashioned things that doctors used to use to review radiographs before everything went digital), I have a photo of one of my other patients dressed as Santa. Wearing the traditional red jacket and pants with a big black belt, seated next to his Christmas tree with children and grandchildren, his holiday aura was regal in comparison to the specimen in my exam room visitor chair.

At the end of the visit, the patient, Santa, and I were chatting, and out of the blue, Santa popped a question. "Where do you think I retired from?"

Taken by surprise, I replied without thinking, "the Salvation Army?"

"I love you, too, doc," replied Santa patiently, but with a tinge of irony. Santa pulled out his wallet and showed me his police officer’s badge. I’m not sure what sort of guess Santa expected I might make regarding his previous employment history, but he probably felt that "Salvation Army" was a bit insulting. In retrospect, I could see that a reply of "undercover detective," would have made him feel much better, but now I didn’t know what I could say that would make the situation less awkward, so I didn’t say much.

After he and his wife were safely out of earshot, I mentioned to the nurse that Santa had asked me to guess what his previous career had been, and I had guessed "Salvation Army" rather than police officer. She laughed sympathetically and told me that she too had taken him for "a bell ringer." That made me feel better about my faux pas. If you run into Santa in your office, and he asks you to guess his previous line of work, my advice is to aim high. A little flattery can never hurt Santa’s feelings.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. 

I hope the surgeons reading this article don’t take offense, but some of you guys need to polish your bedside manner. A 56-year-old woman told me about her recent visit with a neurosurgeon, and she was quite upset. She had gone to see him at the suggestion of her family doctor, hoping to get some relief for her back pain.

The surgeon wasn’t very personable, to put it mildly. He reluctantly emerged from behind his desk, did a token 30-second neurologic examination but didn’t examine her back. He told my patient that her problems were not amenable to surgery. She was put off by his cursory exam, but to add insult to injury, he made a dismissive wave of his hand.

She quickly came to the conclusion that she wouldn’t receive relief or empathy at this office, but she couldn’t understand why the doctor hadn’t examined her back. She wanted some explanation of the neurosurgeon’s decision making. The explanation consisted of just four words: "I am a surgeon." She rephrased her question a few times, and each time received another "I am a surgeon." I would have liked to have been a fly on the wall, but she insists that she heard this refrain multiple times during the course of a very brief visit. After the sixth repetition, the surgeon was showing some signs of irritability.

I could have warned this surgeon that there are days when clinic just doesn’t go smoothly. I also could have counseled my patient. Many times, when I debrief my patients after their encounters with my surgical colleagues, they are upset that the surgeon didn’t seem to spend any time with them or pay attention to their complaints.

It isn’t fair, because invariably this ends up consuming my time. The surgeon saves 5 minutes by rushing off to see the next patient, but I lose 10 minutes trying to explain the surgeon’s brusque manner. I usually explain the surgical mindset as follows: In any new-patient evaluation, the surgeon asks a question, "Is this a surgical problem?" If the answer is no, the surgeon’s attention span falls off precipitously.

Ironically, this patient’s specialty is corporate communication, and she couldn’t believe that a neurosurgeon could be so devoid of interpersonal skills. She repeatedly demanded some further explanation of his decision. The exasperated neurosurgeon emerged from behind his desk a second time, and walked over to a light box that had MRI images of her spine. His intention to explain her MRI was good. For the sake of simplifying the discussion, he wanted to exclude extraneous soft tissues and focus on the spinal cord and nerves.

That was fine, but since he was talking to an overweight, middle-aged woman, he might have striven for a bit of diplomacy. My patient said that he made another dismissive wave of his hand and said, "All this is fat." This didn’t go over well. The surgeon was ready to end the discussion and send my unhappy patient back to her family doctor but, because of her superior communication and reasoning skills, she suggested a referral to a pain management doctor. The neurosurgeon gladly accepted this counter proposal, and I suspect he was glad to move on to the next patient.

Neurosurgeons aren’t the only surgical specialists lacking in bedside manner. One of my rheumatoid arthritis patients suffered a painful string of hip dislocations shortly after a total hip replacement. As painful and debilitating as this was for my patient, it also upset the fine sensibility of the orthopedic surgeon who saw himself as perfect and infallible. After multiple dislocations, the orthopedist’s mental anguish reached a crescendo, and he yelled at the patient in his waiting room, "I don’t know what you’re doing wrong! I’ve done everything right!" It must be hell to be so perfect.

My patient was admitted to the hospital. While the nurse was helping her get off the commode, her total hip replacement dislocated again. The nurse was a witness that my patient was following postop protocol to the letter. This painful and embarrassing episode provided a small amount of vindication for my patient. I thought she might cry, but she didn’t.

I’m always ready for tearful contingencies. I always make a point of having a box of tissues within arm’s reach in all my exam rooms because of an encounter that made an impression on me as a medical student.

A neurosurgeon in clinic was examining an older woman who had complaints of pain and weakness in one leg. The neurosurgeon checked her leg strength by having her raise her leg off the exam table against his resistance. His arms looked muscular in his surgical scrubs, and he easily pushed down on her leg until it gave way and returned to the exam table. Armed with this finding of weakness on physical exam, he turned his back on her to write a note in her chart. While he was writing with his back turned, he started to explain that he was going to send her for a myelogram to find out what was wrong with her leg. This was in the early 1980s, and an MRI was not an option.

From my strategic vantage point in the back of the exam room, I could see the patient, and I doubt very much that she knew what a myelogram was or how it might help her. She probably would have appreciated a few words of explanation, but none was forthcoming. The surgeon continued to jot his notes, and the patient started to cry. The startled neurosurgeon spun around and said, "You wanted help, and you’re going to get it!" His tone was a bit nasty, and he seemed to imply that she would have to bear the responsibility of taking up his valuable time with her complaints.

The surgeon returned to his chart and I was left face to face with the tearful patient. I reached into my pants pocket and gave the patient a tissue to wipe her eyes. Passing out tissues didn’t seem to be one of his professional skills. I don’t think he even noticed that his patient was crying, but if I had asked him about it, he probably would have told me, "I am a surgeon."

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

I hope the surgeons reading this article don’t take offense, but some of you guys need to polish your bedside manner. A 56-year-old woman told me about her recent visit with a neurosurgeon, and she was quite upset. She had gone to see him at the suggestion of her family doctor, hoping to get some relief for her back pain.

The surgeon wasn’t very personable, to put it mildly. He reluctantly emerged from behind his desk, did a token 30-second neurologic examination but didn’t examine her back. He told my patient that her problems were not amenable to surgery. She was put off by his cursory exam, but to add insult to injury, he made a dismissive wave of his hand.

She quickly came to the conclusion that she wouldn’t receive relief or empathy at this office, but she couldn’t understand why the doctor hadn’t examined her back. She wanted some explanation of the neurosurgeon’s decision making. The explanation consisted of just four words: "I am a surgeon." She rephrased her question a few times, and each time received another "I am a surgeon." I would have liked to have been a fly on the wall, but she insists that she heard this refrain multiple times during the course of a very brief visit. After the sixth repetition, the surgeon was showing some signs of irritability.

I could have warned this surgeon that there are days when clinic just doesn’t go smoothly. I also could have counseled my patient. Many times, when I debrief my patients after their encounters with my surgical colleagues, they are upset that the surgeon didn’t seem to spend any time with them or pay attention to their complaints.

It isn’t fair, because invariably this ends up consuming my time. The surgeon saves 5 minutes by rushing off to see the next patient, but I lose 10 minutes trying to explain the surgeon’s brusque manner. I usually explain the surgical mindset as follows: In any new-patient evaluation, the surgeon asks a question, "Is this a surgical problem?" If the answer is no, the surgeon’s attention span falls off precipitously.

Ironically, this patient’s specialty is corporate communication, and she couldn’t believe that a neurosurgeon could be so devoid of interpersonal skills. She repeatedly demanded some further explanation of his decision. The exasperated neurosurgeon emerged from behind his desk a second time, and walked over to a light box that had MRI images of her spine. His intention to explain her MRI was good. For the sake of simplifying the discussion, he wanted to exclude extraneous soft tissues and focus on the spinal cord and nerves.

That was fine, but since he was talking to an overweight, middle-aged woman, he might have striven for a bit of diplomacy. My patient said that he made another dismissive wave of his hand and said, "All this is fat." This didn’t go over well. The surgeon was ready to end the discussion and send my unhappy patient back to her family doctor but, because of her superior communication and reasoning skills, she suggested a referral to a pain management doctor. The neurosurgeon gladly accepted this counter proposal, and I suspect he was glad to move on to the next patient.

Neurosurgeons aren’t the only surgical specialists lacking in bedside manner. One of my rheumatoid arthritis patients suffered a painful string of hip dislocations shortly after a total hip replacement. As painful and debilitating as this was for my patient, it also upset the fine sensibility of the orthopedic surgeon who saw himself as perfect and infallible. After multiple dislocations, the orthopedist’s mental anguish reached a crescendo, and he yelled at the patient in his waiting room, "I don’t know what you’re doing wrong! I’ve done everything right!" It must be hell to be so perfect.

My patient was admitted to the hospital. While the nurse was helping her get off the commode, her total hip replacement dislocated again. The nurse was a witness that my patient was following postop protocol to the letter. This painful and embarrassing episode provided a small amount of vindication for my patient. I thought she might cry, but she didn’t.

I’m always ready for tearful contingencies. I always make a point of having a box of tissues within arm’s reach in all my exam rooms because of an encounter that made an impression on me as a medical student.

A neurosurgeon in clinic was examining an older woman who had complaints of pain and weakness in one leg. The neurosurgeon checked her leg strength by having her raise her leg off the exam table against his resistance. His arms looked muscular in his surgical scrubs, and he easily pushed down on her leg until it gave way and returned to the exam table. Armed with this finding of weakness on physical exam, he turned his back on her to write a note in her chart. While he was writing with his back turned, he started to explain that he was going to send her for a myelogram to find out what was wrong with her leg. This was in the early 1980s, and an MRI was not an option.

From my strategic vantage point in the back of the exam room, I could see the patient, and I doubt very much that she knew what a myelogram was or how it might help her. She probably would have appreciated a few words of explanation, but none was forthcoming. The surgeon continued to jot his notes, and the patient started to cry. The startled neurosurgeon spun around and said, "You wanted help, and you’re going to get it!" His tone was a bit nasty, and he seemed to imply that she would have to bear the responsibility of taking up his valuable time with her complaints.

The surgeon returned to his chart and I was left face to face with the tearful patient. I reached into my pants pocket and gave the patient a tissue to wipe her eyes. Passing out tissues didn’t seem to be one of his professional skills. I don’t think he even noticed that his patient was crying, but if I had asked him about it, he probably would have told me, "I am a surgeon."

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

I hope the surgeons reading this article don’t take offense, but some of you guys need to polish your bedside manner. A 56-year-old woman told me about her recent visit with a neurosurgeon, and she was quite upset. She had gone to see him at the suggestion of her family doctor, hoping to get some relief for her back pain.

The surgeon wasn’t very personable, to put it mildly. He reluctantly emerged from behind his desk, did a token 30-second neurologic examination but didn’t examine her back. He told my patient that her problems were not amenable to surgery. She was put off by his cursory exam, but to add insult to injury, he made a dismissive wave of his hand.

She quickly came to the conclusion that she wouldn’t receive relief or empathy at this office, but she couldn’t understand why the doctor hadn’t examined her back. She wanted some explanation of the neurosurgeon’s decision making. The explanation consisted of just four words: "I am a surgeon." She rephrased her question a few times, and each time received another "I am a surgeon." I would have liked to have been a fly on the wall, but she insists that she heard this refrain multiple times during the course of a very brief visit. After the sixth repetition, the surgeon was showing some signs of irritability.

I could have warned this surgeon that there are days when clinic just doesn’t go smoothly. I also could have counseled my patient. Many times, when I debrief my patients after their encounters with my surgical colleagues, they are upset that the surgeon didn’t seem to spend any time with them or pay attention to their complaints.

It isn’t fair, because invariably this ends up consuming my time. The surgeon saves 5 minutes by rushing off to see the next patient, but I lose 10 minutes trying to explain the surgeon’s brusque manner. I usually explain the surgical mindset as follows: In any new-patient evaluation, the surgeon asks a question, "Is this a surgical problem?" If the answer is no, the surgeon’s attention span falls off precipitously.

Ironically, this patient’s specialty is corporate communication, and she couldn’t believe that a neurosurgeon could be so devoid of interpersonal skills. She repeatedly demanded some further explanation of his decision. The exasperated neurosurgeon emerged from behind his desk a second time, and walked over to a light box that had MRI images of her spine. His intention to explain her MRI was good. For the sake of simplifying the discussion, he wanted to exclude extraneous soft tissues and focus on the spinal cord and nerves.

That was fine, but since he was talking to an overweight, middle-aged woman, he might have striven for a bit of diplomacy. My patient said that he made another dismissive wave of his hand and said, "All this is fat." This didn’t go over well. The surgeon was ready to end the discussion and send my unhappy patient back to her family doctor but, because of her superior communication and reasoning skills, she suggested a referral to a pain management doctor. The neurosurgeon gladly accepted this counter proposal, and I suspect he was glad to move on to the next patient.

Neurosurgeons aren’t the only surgical specialists lacking in bedside manner. One of my rheumatoid arthritis patients suffered a painful string of hip dislocations shortly after a total hip replacement. As painful and debilitating as this was for my patient, it also upset the fine sensibility of the orthopedic surgeon who saw himself as perfect and infallible. After multiple dislocations, the orthopedist’s mental anguish reached a crescendo, and he yelled at the patient in his waiting room, "I don’t know what you’re doing wrong! I’ve done everything right!" It must be hell to be so perfect.

My patient was admitted to the hospital. While the nurse was helping her get off the commode, her total hip replacement dislocated again. The nurse was a witness that my patient was following postop protocol to the letter. This painful and embarrassing episode provided a small amount of vindication for my patient. I thought she might cry, but she didn’t.

I’m always ready for tearful contingencies. I always make a point of having a box of tissues within arm’s reach in all my exam rooms because of an encounter that made an impression on me as a medical student.

A neurosurgeon in clinic was examining an older woman who had complaints of pain and weakness in one leg. The neurosurgeon checked her leg strength by having her raise her leg off the exam table against his resistance. His arms looked muscular in his surgical scrubs, and he easily pushed down on her leg until it gave way and returned to the exam table. Armed with this finding of weakness on physical exam, he turned his back on her to write a note in her chart. While he was writing with his back turned, he started to explain that he was going to send her for a myelogram to find out what was wrong with her leg. This was in the early 1980s, and an MRI was not an option.

From my strategic vantage point in the back of the exam room, I could see the patient, and I doubt very much that she knew what a myelogram was or how it might help her. She probably would have appreciated a few words of explanation, but none was forthcoming. The surgeon continued to jot his notes, and the patient started to cry. The startled neurosurgeon spun around and said, "You wanted help, and you’re going to get it!" His tone was a bit nasty, and he seemed to imply that she would have to bear the responsibility of taking up his valuable time with her complaints.

The surgeon returned to his chart and I was left face to face with the tearful patient. I reached into my pants pocket and gave the patient a tissue to wipe her eyes. Passing out tissues didn’t seem to be one of his professional skills. I don’t think he even noticed that his patient was crying, but if I had asked him about it, he probably would have told me, "I am a surgeon."

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

It’s 11 p.m. Do you know where your oxycodone prescription is? Every day I refill prescriptions for various pain medications. These requests raise my concern only if the number of pills is very large, or the patient is requesting an early refill. Because refills are such a frequent task, I don’t analyze them too much, but truthfully there are issues to be apprehensive about.

I saw an 81-year-old man with chronic back pain. Fortunately, he seemed to get some relief using a TENS (transcutaneous electrical nerve stimulator) unit, in combination with tramadol that his family doctor prescribed. I was pleased with this outcome, but his daughter piped up and asked me if I would prescribe hydrocodone for him. I was looking for a polite way to say no, or to at least ask if hydrocodone was really called for, since he was doing well with his current treatment. While I was searching for the right diplomatic formula, his daughter told me that her father’s family doctor used to prescribe hydrocodone, but he had voluntarily given up his DEA license. It wasn’t that big a deal, according to the daughter, but some of his patients had been selling their pills, while other patients had committed suicide.

I was getting ready to deny the daughter’s request with an emphatic "no," but luckily for me, the patient piped up and said he didn’t feel like he needed hydrocodone, so I was spared a potentially unpleasant discussion with his daughter. As far as I know, my patients haven’t sold their medication or committed suicide, but neither category of patient is likely to come to the office and confess their sins.

Doctors are always in a quandary about pain medication. Pain is the "fifth vital sign" and while we have to do a good job of controlling pain, we also have to deal with concerns about patients who are abusing or diverting our prescriptions. In order to balance these demands, urine drug testing has been touted as a necessity.

Many representatives of companies that perform toxicology testing have found their way to my office doorstep, but I’ve dragged my feet for years on this issue. I glibly told one company representative that I have hundreds of patients on chronic pain medication. He got so excited I think he envisioned setting up a bus or a big-top tent in my office parking lot so we could line up all the suspects, I mean patients, for their tests. But I had very mixed emotions about testing. How would I explain this to patients? "Excuse me, Grandma, but I need to make sure that you aren’t taking cocaine or selling your hydrocodone, so you’ll need to give us a urine specimen. The lab tech will watch as you pull up your petticoat and pee in this cup." How often would the testing be repeated? Would all patients be tested, or would there be exceptions? If there were exceptions, what were the criteria?

Even before I resolved these sticky questions, I had an experience in the office that gave me some added insight into the value of testing. A middle-aged man came to see me about his gout. His gout seemed quite well controlled on his current medications, but he was still taking oxycodone a few times a day for pain. After chatting with him, I didn’t have a clear idea of why he was taking so much oxycodone. In a casual way, I told him that the standard of care was to do a urine drug screen. He said that was fine, and he left with his lab order. He never did his drug screen, and he never returned to the office. He probably went to an office that didn’t ask so many questions.

I gradually reached a comfort level discussing testing with patients, but many delicate areas of medicine require some practice. "Roll over, it’s time for your annual rectal exam," is tough to say when you’re a shy medical student, but after a while it becomes second nature. Asking patients for a urine drug screen should be relatively easy by comparison, but there are many issues involved. Psychologically it is much easier for me to tell a new patient, "Okay, if I am going to prescribe opioids for you, this is one of the prerequisites." I’m much more squeamish explaining this change of protocol to patients that I have been seeing for years.

My practice finally seemed to iron out many of the small details that had previously hampered me from testing. The lab shipped us a box that was so large, and so heavy, I thought that perhaps FedEx had delivered a toilet, but in fact the box was crammed with specimen cups, plastic bags, and lab requisitions as a sign of the lab’s optimism about the amount of business they expected me to generate for them.

One of my long-term patients with chronic back pain came in. I’m on chummy terms with him, and over the course of many years I learned many details about his divorces, his kids, and their college plans. He’s been on a hefty dose of oxycodone for many years, and over the last 10-15 years I let him talk me into increasing the dose a few times, against my better judgment.

I gave him a nice little speech, and I explained that I had been prescribing his pain medication for many years, but I felt that my practice needed to incorporate urine drug testing to be consistent with the current standard of care. He agreed readily, and I dispatched him to the restroom with his specimen cup. I heaved a sigh of relief, and congratulated myself on my suave little speech.

Unfortunately, I wasn’t so suave or well prepared when I got his test results back a few days later. After a few more days of intense deliberation, I mailed him a note which read as follows: "I regret to inform you that you failed your urine drug screen. There was no evidence of oxycodone in your urine, even though I have been prescribing a large dose of this medication for you. Therefore, I will be unable to prescribe further pain medication for you."

I felt like a fool for prescribing so much pain medication without ever confirming that he was actually using it. I’m suspicious that he was selling his pills, and my prescriptions probably put his kids through college, but I’ll never know for sure. It was a tough pill for me to swallow, but it’s better late than never.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him at rhnews@elsevier.com.

It’s 11 p.m. Do you know where your oxycodone prescription is? Every day I refill prescriptions for various pain medications. These requests raise my concern only if the number of pills is very large, or the patient is requesting an early refill. Because refills are such a frequent task, I don’t analyze them too much, but truthfully there are issues to be apprehensive about.

I saw an 81-year-old man with chronic back pain. Fortunately, he seemed to get some relief using a TENS (transcutaneous electrical nerve stimulator) unit, in combination with tramadol that his family doctor prescribed. I was pleased with this outcome, but his daughter piped up and asked me if I would prescribe hydrocodone for him. I was looking for a polite way to say no, or to at least ask if hydrocodone was really called for, since he was doing well with his current treatment. While I was searching for the right diplomatic formula, his daughter told me that her father’s family doctor used to prescribe hydrocodone, but he had voluntarily given up his DEA license. It wasn’t that big a deal, according to the daughter, but some of his patients had been selling their pills, while other patients had committed suicide.

I was getting ready to deny the daughter’s request with an emphatic "no," but luckily for me, the patient piped up and said he didn’t feel like he needed hydrocodone, so I was spared a potentially unpleasant discussion with his daughter. As far as I know, my patients haven’t sold their medication or committed suicide, but neither category of patient is likely to come to the office and confess their sins.

Doctors are always in a quandary about pain medication. Pain is the "fifth vital sign" and while we have to do a good job of controlling pain, we also have to deal with concerns about patients who are abusing or diverting our prescriptions. In order to balance these demands, urine drug testing has been touted as a necessity.

Many representatives of companies that perform toxicology testing have found their way to my office doorstep, but I’ve dragged my feet for years on this issue. I glibly told one company representative that I have hundreds of patients on chronic pain medication. He got so excited I think he envisioned setting up a bus or a big-top tent in my office parking lot so we could line up all the suspects, I mean patients, for their tests. But I had very mixed emotions about testing. How would I explain this to patients? "Excuse me, Grandma, but I need to make sure that you aren’t taking cocaine or selling your hydrocodone, so you’ll need to give us a urine specimen. The lab tech will watch as you pull up your petticoat and pee in this cup." How often would the testing be repeated? Would all patients be tested, or would there be exceptions? If there were exceptions, what were the criteria?

Even before I resolved these sticky questions, I had an experience in the office that gave me some added insight into the value of testing. A middle-aged man came to see me about his gout. His gout seemed quite well controlled on his current medications, but he was still taking oxycodone a few times a day for pain. After chatting with him, I didn’t have a clear idea of why he was taking so much oxycodone. In a casual way, I told him that the standard of care was to do a urine drug screen. He said that was fine, and he left with his lab order. He never did his drug screen, and he never returned to the office. He probably went to an office that didn’t ask so many questions.

I gradually reached a comfort level discussing testing with patients, but many delicate areas of medicine require some practice. "Roll over, it’s time for your annual rectal exam," is tough to say when you’re a shy medical student, but after a while it becomes second nature. Asking patients for a urine drug screen should be relatively easy by comparison, but there are many issues involved. Psychologically it is much easier for me to tell a new patient, "Okay, if I am going to prescribe opioids for you, this is one of the prerequisites." I’m much more squeamish explaining this change of protocol to patients that I have been seeing for years.

My practice finally seemed to iron out many of the small details that had previously hampered me from testing. The lab shipped us a box that was so large, and so heavy, I thought that perhaps FedEx had delivered a toilet, but in fact the box was crammed with specimen cups, plastic bags, and lab requisitions as a sign of the lab’s optimism about the amount of business they expected me to generate for them.

One of my long-term patients with chronic back pain came in. I’m on chummy terms with him, and over the course of many years I learned many details about his divorces, his kids, and their college plans. He’s been on a hefty dose of oxycodone for many years, and over the last 10-15 years I let him talk me into increasing the dose a few times, against my better judgment.

I gave him a nice little speech, and I explained that I had been prescribing his pain medication for many years, but I felt that my practice needed to incorporate urine drug testing to be consistent with the current standard of care. He agreed readily, and I dispatched him to the restroom with his specimen cup. I heaved a sigh of relief, and congratulated myself on my suave little speech.

Unfortunately, I wasn’t so suave or well prepared when I got his test results back a few days later. After a few more days of intense deliberation, I mailed him a note which read as follows: "I regret to inform you that you failed your urine drug screen. There was no evidence of oxycodone in your urine, even though I have been prescribing a large dose of this medication for you. Therefore, I will be unable to prescribe further pain medication for you."

I felt like a fool for prescribing so much pain medication without ever confirming that he was actually using it. I’m suspicious that he was selling his pills, and my prescriptions probably put his kids through college, but I’ll never know for sure. It was a tough pill for me to swallow, but it’s better late than never.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him at rhnews@elsevier.com.

It’s 11 p.m. Do you know where your oxycodone prescription is? Every day I refill prescriptions for various pain medications. These requests raise my concern only if the number of pills is very large, or the patient is requesting an early refill. Because refills are such a frequent task, I don’t analyze them too much, but truthfully there are issues to be apprehensive about.

I saw an 81-year-old man with chronic back pain. Fortunately, he seemed to get some relief using a TENS (transcutaneous electrical nerve stimulator) unit, in combination with tramadol that his family doctor prescribed. I was pleased with this outcome, but his daughter piped up and asked me if I would prescribe hydrocodone for him. I was looking for a polite way to say no, or to at least ask if hydrocodone was really called for, since he was doing well with his current treatment. While I was searching for the right diplomatic formula, his daughter told me that her father’s family doctor used to prescribe hydrocodone, but he had voluntarily given up his DEA license. It wasn’t that big a deal, according to the daughter, but some of his patients had been selling their pills, while other patients had committed suicide.

I was getting ready to deny the daughter’s request with an emphatic "no," but luckily for me, the patient piped up and said he didn’t feel like he needed hydrocodone, so I was spared a potentially unpleasant discussion with his daughter. As far as I know, my patients haven’t sold their medication or committed suicide, but neither category of patient is likely to come to the office and confess their sins.

Doctors are always in a quandary about pain medication. Pain is the "fifth vital sign" and while we have to do a good job of controlling pain, we also have to deal with concerns about patients who are abusing or diverting our prescriptions. In order to balance these demands, urine drug testing has been touted as a necessity.

Many representatives of companies that perform toxicology testing have found their way to my office doorstep, but I’ve dragged my feet for years on this issue. I glibly told one company representative that I have hundreds of patients on chronic pain medication. He got so excited I think he envisioned setting up a bus or a big-top tent in my office parking lot so we could line up all the suspects, I mean patients, for their tests. But I had very mixed emotions about testing. How would I explain this to patients? "Excuse me, Grandma, but I need to make sure that you aren’t taking cocaine or selling your hydrocodone, so you’ll need to give us a urine specimen. The lab tech will watch as you pull up your petticoat and pee in this cup." How often would the testing be repeated? Would all patients be tested, or would there be exceptions? If there were exceptions, what were the criteria?

Even before I resolved these sticky questions, I had an experience in the office that gave me some added insight into the value of testing. A middle-aged man came to see me about his gout. His gout seemed quite well controlled on his current medications, but he was still taking oxycodone a few times a day for pain. After chatting with him, I didn’t have a clear idea of why he was taking so much oxycodone. In a casual way, I told him that the standard of care was to do a urine drug screen. He said that was fine, and he left with his lab order. He never did his drug screen, and he never returned to the office. He probably went to an office that didn’t ask so many questions.

I gradually reached a comfort level discussing testing with patients, but many delicate areas of medicine require some practice. "Roll over, it’s time for your annual rectal exam," is tough to say when you’re a shy medical student, but after a while it becomes second nature. Asking patients for a urine drug screen should be relatively easy by comparison, but there are many issues involved. Psychologically it is much easier for me to tell a new patient, "Okay, if I am going to prescribe opioids for you, this is one of the prerequisites." I’m much more squeamish explaining this change of protocol to patients that I have been seeing for years.

My practice finally seemed to iron out many of the small details that had previously hampered me from testing. The lab shipped us a box that was so large, and so heavy, I thought that perhaps FedEx had delivered a toilet, but in fact the box was crammed with specimen cups, plastic bags, and lab requisitions as a sign of the lab’s optimism about the amount of business they expected me to generate for them.

One of my long-term patients with chronic back pain came in. I’m on chummy terms with him, and over the course of many years I learned many details about his divorces, his kids, and their college plans. He’s been on a hefty dose of oxycodone for many years, and over the last 10-15 years I let him talk me into increasing the dose a few times, against my better judgment.

I gave him a nice little speech, and I explained that I had been prescribing his pain medication for many years, but I felt that my practice needed to incorporate urine drug testing to be consistent with the current standard of care. He agreed readily, and I dispatched him to the restroom with his specimen cup. I heaved a sigh of relief, and congratulated myself on my suave little speech.

Unfortunately, I wasn’t so suave or well prepared when I got his test results back a few days later. After a few more days of intense deliberation, I mailed him a note which read as follows: "I regret to inform you that you failed your urine drug screen. There was no evidence of oxycodone in your urine, even though I have been prescribing a large dose of this medication for you. Therefore, I will be unable to prescribe further pain medication for you."

I felt like a fool for prescribing so much pain medication without ever confirming that he was actually using it. I’m suspicious that he was selling his pills, and my prescriptions probably put his kids through college, but I’ll never know for sure. It was a tough pill for me to swallow, but it’s better late than never.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him at rhnews@elsevier.com.

Patient visits can be full of unexpected stories and ghastly surprises. My most recent visit with Mrs. PMR (not her real name), age 84, felt just like hundreds of other visits with polymyalgia rheumatica patients. We discussed her prednisone dose in detail. She was doing well on 5 mg a day, and she felt enthusiastic and optimistic about trying to taper her prednisone a little bit further. We agreed that each month she would try decreasing her daily dose by 1 mg.

Photo Zoonar/thinkstockphoto.com

Out of left field, so to speak, she announced that she wanted to tell me a story. Her parents died in 1978, and after she and her sister had attended to their parents’ funeral arrangements, the sisters decided they would prearrange their own funeral needs, so their families would be spared some of the trouble and expense involved when their time came. She and her sister made their own funeral arrangements with a local home, and then they went to the cemetery, picked out their own graves, and paid for them in full.

Fast forward 30 plus years, and my patient’s sister was in failing health. A family member called to inform her of this sad news, and the topic of funerals and final expenses came up. My patient’s mind was at ease since she and her sister had planned and paid in full for everything many years earlier. Unfortunately, the funeral home had changed hands several times over the years, and when Mrs. PMR investigated, she was thunderstruck and indignant to find out that the new proprietors had buried another woman in her grave. This strange woman was now the eternal next-door neighbor of Mr. PMR, her late husband!

Her message to the funeral director was charming in its simplicity: "Get her out of my grave!"

The funeral director asked her to consider the emotional pain exhuming the other woman would inflict on the woman’s family. My patient was not easily mollified, and she threatened to get a lawyer and notify the local television station. The funeral director must have realized that he was over a barrel – or a casket – and offered my patient her choice of other graves, plus $3,000.

Mrs. PMR graciously accepted this offer, and used the cash to buy a nicer marker for her sister. She felt it would be sacrilegious to spend the money on anything else. Fortunately for me, her arthritis was doing well, and all I had to do was nod sympathetically.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

Patient visits can be full of unexpected stories and ghastly surprises. My most recent visit with Mrs. PMR (not her real name), age 84, felt just like hundreds of other visits with polymyalgia rheumatica patients. We discussed her prednisone dose in detail. She was doing well on 5 mg a day, and she felt enthusiastic and optimistic about trying to taper her prednisone a little bit further. We agreed that each month she would try decreasing her daily dose by 1 mg.

Photo Zoonar/thinkstockphoto.com

Out of left field, so to speak, she announced that she wanted to tell me a story. Her parents died in 1978, and after she and her sister had attended to their parents’ funeral arrangements, the sisters decided they would prearrange their own funeral needs, so their families would be spared some of the trouble and expense involved when their time came. She and her sister made their own funeral arrangements with a local home, and then they went to the cemetery, picked out their own graves, and paid for them in full.

Fast forward 30 plus years, and my patient’s sister was in failing health. A family member called to inform her of this sad news, and the topic of funerals and final expenses came up. My patient’s mind was at ease since she and her sister had planned and paid in full for everything many years earlier. Unfortunately, the funeral home had changed hands several times over the years, and when Mrs. PMR investigated, she was thunderstruck and indignant to find out that the new proprietors had buried another woman in her grave. This strange woman was now the eternal next-door neighbor of Mr. PMR, her late husband!

Her message to the funeral director was charming in its simplicity: "Get her out of my grave!"

The funeral director asked her to consider the emotional pain exhuming the other woman would inflict on the woman’s family. My patient was not easily mollified, and she threatened to get a lawyer and notify the local television station. The funeral director must have realized that he was over a barrel – or a casket – and offered my patient her choice of other graves, plus $3,000.

Mrs. PMR graciously accepted this offer, and used the cash to buy a nicer marker for her sister. She felt it would be sacrilegious to spend the money on anything else. Fortunately for me, her arthritis was doing well, and all I had to do was nod sympathetically.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

Patient visits can be full of unexpected stories and ghastly surprises. My most recent visit with Mrs. PMR (not her real name), age 84, felt just like hundreds of other visits with polymyalgia rheumatica patients. We discussed her prednisone dose in detail. She was doing well on 5 mg a day, and she felt enthusiastic and optimistic about trying to taper her prednisone a little bit further. We agreed that each month she would try decreasing her daily dose by 1 mg.

Photo Zoonar/thinkstockphoto.com

Out of left field, so to speak, she announced that she wanted to tell me a story. Her parents died in 1978, and after she and her sister had attended to their parents’ funeral arrangements, the sisters decided they would prearrange their own funeral needs, so their families would be spared some of the trouble and expense involved when their time came. She and her sister made their own funeral arrangements with a local home, and then they went to the cemetery, picked out their own graves, and paid for them in full.

Fast forward 30 plus years, and my patient’s sister was in failing health. A family member called to inform her of this sad news, and the topic of funerals and final expenses came up. My patient’s mind was at ease since she and her sister had planned and paid in full for everything many years earlier. Unfortunately, the funeral home had changed hands several times over the years, and when Mrs. PMR investigated, she was thunderstruck and indignant to find out that the new proprietors had buried another woman in her grave. This strange woman was now the eternal next-door neighbor of Mr. PMR, her late husband!

Her message to the funeral director was charming in its simplicity: "Get her out of my grave!"

The funeral director asked her to consider the emotional pain exhuming the other woman would inflict on the woman’s family. My patient was not easily mollified, and she threatened to get a lawyer and notify the local television station. The funeral director must have realized that he was over a barrel – or a casket – and offered my patient her choice of other graves, plus $3,000.

Mrs. PMR graciously accepted this offer, and used the cash to buy a nicer marker for her sister. She felt it would be sacrilegious to spend the money on anything else. Fortunately for me, her arthritis was doing well, and all I had to do was nod sympathetically.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

Patient complaints about the high cost of prescription drugs are a leitmotif of many office visits, and sometimes they are the main theme. Patients are crying out for our help on this issue, even if the medication is not related to our specialty. One of my elderly rheumatoid arthritis patients recently told me that the cost of his pioglitazone had gone up an additional $50 to reach a staggering monthly cost of $148. Not all that glitters is gold, but it might as well be judging from the price tag. He and his wife gave up their cable television so they could pay for the drug. He didn’t come across as one of those well-heeled retirees who are not eligible for drug company assistance. I went online and printed out the manufacturer’s patient assistance form. I wasn’t sure he’d be able to fill out the form, but I hold on to the hope that getting his cable service restored will be enough of an incentive for him to get this done.

It feels like the only bargains in medicine are the old generic drugs. I know I’m really dating myself with this confession, but I remember when Tagamet (cimetidine) was brand name only. It was the blockbuster drug of the day. When I was new in practice, the Tagamet sales rep pleaded: "I really want you to prescribe a lot of Tagamet, because my holiday bonus is on the line!" This story stands out in my mind as a moment of refreshing candor by a drug representative.

Expensive stomach medications to mend or prevent the onslaught of gastric mucosal damage caused by our nonsteroidal anti-inflammatory drugs (NSAIDs) have always been a part of the background of my rheumatology practice. Although the names of the medications have changed, the high price tags associated with these drugs have remained a consistent feature. But back in omeprazole’s heyday, the first proton pump inhibitor was dubbed "the purple pill." Now that it is available inexpensively over the counter, it has been stripped of its regal purple color. It is now a mousey brown, and its expensive cousin Nexium is adorned with the royal color. Considering the drug’s price tag, they probably should have made it green, like the color of newly printed cash, but I suspect the marketing people didn’t think that "the green pill" had the same sales appeal as the purple pill.

For many patients on chronic NSAID therapy, a second drug to help prevent ulcers and GI bleeding is appropriate, but this raises the patient’s drug costs, and it is very hard to convince asymptomatic patients that they need to take the purple pill, or anything else for that matter, when they don’t perceive it as necessary.

Although GI symptoms and endoscopic findings of ulceration correlate poorly, I invariably continue to ask patients about upset stomach symptoms, and I always ask whether they have a history of ulcer disease. Once a patient gives a history of ulcers, I try to get an idea of the severity of the problem, and I ask follow-up questions regarding hospitalization, blood transfusion, or surgery. Nowadays, only the sickest patients with active GI bleeding require hospitalization, but things were different in the distant days before our high-priced drugs. One man told me that he had an ulcer in 1965. Treatment options were very limited. Ulcer patients from that era frequently tell me their treatment included dietary remedies such as eating baby food for 6 weeks.

My patient was hospitalized in the era before proton pump inhibitors. He told me he had been having a lot of upper abdominal pain, and the doctor ordered an injection of pain medication. The evening nurse administered this but forgot to chart it. The old saying goes, "if you didn’t chart it, you didn’t do it." That was exactly the conclusion of the night nurse. Seeing that the injection had not been charted, she also gave my patient a shot.

Perhaps my patient was exaggerating, or perhaps the passage of about 46 years altered his memory of the event, but he told me that after receiving two injections fairly close together, he slept for 3 days. He probably benefited from the sleep, and when he finally woke up from his iatrogenic hibernation, his hospital roommate told him that he had become a semi-celebrity. Lots of important people from the hospital administration had been holding candlelight vigils at his bedside and were hoping that he would recover and not sue the hospital.

Hospital administrators were only too happy to make amends, and they reassured my patient that the nurse who had failed to document his first dose of pain medication had been summarily fired. Although some people might have been appeased by this bit of obsequious viciousness, for my patient it had the opposite than intended effect. He told them they had to rehire the nurse immediately, or he would sue the hospital. He had the hospital over a barrel, the hospital knew it, and they promptly rehired the nurse.

Anyone could make a mistake, he told me, and besides that, the nurse was a widow with two children to raise. I was overwhelmed by this man’s magnanimous spirit, but I was bothered by a nagging question. He had been sick and heavily sedated for 3 days, so how did he know that the nurse was a widow with two children? I asked him this question, since digressions like this are the best part of my job. When I spoke with him, he was a tremulous old man with many chronic problems, but at the time of his hospitalization he had been a police officer. He had investigated the accidental death of the nurse’s husband! I was awed by this amazing coincidence, and I couldn’t help but think that perhaps the greatest form of quality improvement is forgiving an occasional mistake, something that has become increasingly rare in health care. It seems as if everyone is touting the greatness of evidence-based medicine, but there’s a lot of homespun wisdom in this anecdote. Perhaps a little more wisdom, plus some low-cost generics, might be just the thing health care reform is lacking.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him at rhnews@elsevier.com.

Patient complaints about the high cost of prescription drugs are a leitmotif of many office visits, and sometimes they are the main theme. Patients are crying out for our help on this issue, even if the medication is not related to our specialty. One of my elderly rheumatoid arthritis patients recently told me that the cost of his pioglitazone had gone up an additional $50 to reach a staggering monthly cost of $148. Not all that glitters is gold, but it might as well be judging from the price tag. He and his wife gave up their cable television so they could pay for the drug. He didn’t come across as one of those well-heeled retirees who are not eligible for drug company assistance. I went online and printed out the manufacturer’s patient assistance form. I wasn’t sure he’d be able to fill out the form, but I hold on to the hope that getting his cable service restored will be enough of an incentive for him to get this done.

It feels like the only bargains in medicine are the old generic drugs. I know I’m really dating myself with this confession, but I remember when Tagamet (cimetidine) was brand name only. It was the blockbuster drug of the day. When I was new in practice, the Tagamet sales rep pleaded: "I really want you to prescribe a lot of Tagamet, because my holiday bonus is on the line!" This story stands out in my mind as a moment of refreshing candor by a drug representative.

Expensive stomach medications to mend or prevent the onslaught of gastric mucosal damage caused by our nonsteroidal anti-inflammatory drugs (NSAIDs) have always been a part of the background of my rheumatology practice. Although the names of the medications have changed, the high price tags associated with these drugs have remained a consistent feature. But back in omeprazole’s heyday, the first proton pump inhibitor was dubbed "the purple pill." Now that it is available inexpensively over the counter, it has been stripped of its regal purple color. It is now a mousey brown, and its expensive cousin Nexium is adorned with the royal color. Considering the drug’s price tag, they probably should have made it green, like the color of newly printed cash, but I suspect the marketing people didn’t think that "the green pill" had the same sales appeal as the purple pill.

For many patients on chronic NSAID therapy, a second drug to help prevent ulcers and GI bleeding is appropriate, but this raises the patient’s drug costs, and it is very hard to convince asymptomatic patients that they need to take the purple pill, or anything else for that matter, when they don’t perceive it as necessary.

Although GI symptoms and endoscopic findings of ulceration correlate poorly, I invariably continue to ask patients about upset stomach symptoms, and I always ask whether they have a history of ulcer disease. Once a patient gives a history of ulcers, I try to get an idea of the severity of the problem, and I ask follow-up questions regarding hospitalization, blood transfusion, or surgery. Nowadays, only the sickest patients with active GI bleeding require hospitalization, but things were different in the distant days before our high-priced drugs. One man told me that he had an ulcer in 1965. Treatment options were very limited. Ulcer patients from that era frequently tell me their treatment included dietary remedies such as eating baby food for 6 weeks.

My patient was hospitalized in the era before proton pump inhibitors. He told me he had been having a lot of upper abdominal pain, and the doctor ordered an injection of pain medication. The evening nurse administered this but forgot to chart it. The old saying goes, "if you didn’t chart it, you didn’t do it." That was exactly the conclusion of the night nurse. Seeing that the injection had not been charted, she also gave my patient a shot.

Perhaps my patient was exaggerating, or perhaps the passage of about 46 years altered his memory of the event, but he told me that after receiving two injections fairly close together, he slept for 3 days. He probably benefited from the sleep, and when he finally woke up from his iatrogenic hibernation, his hospital roommate told him that he had become a semi-celebrity. Lots of important people from the hospital administration had been holding candlelight vigils at his bedside and were hoping that he would recover and not sue the hospital.

Hospital administrators were only too happy to make amends, and they reassured my patient that the nurse who had failed to document his first dose of pain medication had been summarily fired. Although some people might have been appeased by this bit of obsequious viciousness, for my patient it had the opposite than intended effect. He told them they had to rehire the nurse immediately, or he would sue the hospital. He had the hospital over a barrel, the hospital knew it, and they promptly rehired the nurse.

Anyone could make a mistake, he told me, and besides that, the nurse was a widow with two children to raise. I was overwhelmed by this man’s magnanimous spirit, but I was bothered by a nagging question. He had been sick and heavily sedated for 3 days, so how did he know that the nurse was a widow with two children? I asked him this question, since digressions like this are the best part of my job. When I spoke with him, he was a tremulous old man with many chronic problems, but at the time of his hospitalization he had been a police officer. He had investigated the accidental death of the nurse’s husband! I was awed by this amazing coincidence, and I couldn’t help but think that perhaps the greatest form of quality improvement is forgiving an occasional mistake, something that has become increasingly rare in health care. It seems as if everyone is touting the greatness of evidence-based medicine, but there’s a lot of homespun wisdom in this anecdote. Perhaps a little more wisdom, plus some low-cost generics, might be just the thing health care reform is lacking.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him at rhnews@elsevier.com.

Patient complaints about the high cost of prescription drugs are a leitmotif of many office visits, and sometimes they are the main theme. Patients are crying out for our help on this issue, even if the medication is not related to our specialty. One of my elderly rheumatoid arthritis patients recently told me that the cost of his pioglitazone had gone up an additional $50 to reach a staggering monthly cost of $148. Not all that glitters is gold, but it might as well be judging from the price tag. He and his wife gave up their cable television so they could pay for the drug. He didn’t come across as one of those well-heeled retirees who are not eligible for drug company assistance. I went online and printed out the manufacturer’s patient assistance form. I wasn’t sure he’d be able to fill out the form, but I hold on to the hope that getting his cable service restored will be enough of an incentive for him to get this done.

It feels like the only bargains in medicine are the old generic drugs. I know I’m really dating myself with this confession, but I remember when Tagamet (cimetidine) was brand name only. It was the blockbuster drug of the day. When I was new in practice, the Tagamet sales rep pleaded: "I really want you to prescribe a lot of Tagamet, because my holiday bonus is on the line!" This story stands out in my mind as a moment of refreshing candor by a drug representative.

Expensive stomach medications to mend or prevent the onslaught of gastric mucosal damage caused by our nonsteroidal anti-inflammatory drugs (NSAIDs) have always been a part of the background of my rheumatology practice. Although the names of the medications have changed, the high price tags associated with these drugs have remained a consistent feature. But back in omeprazole’s heyday, the first proton pump inhibitor was dubbed "the purple pill." Now that it is available inexpensively over the counter, it has been stripped of its regal purple color. It is now a mousey brown, and its expensive cousin Nexium is adorned with the royal color. Considering the drug’s price tag, they probably should have made it green, like the color of newly printed cash, but I suspect the marketing people didn’t think that "the green pill" had the same sales appeal as the purple pill.

For many patients on chronic NSAID therapy, a second drug to help prevent ulcers and GI bleeding is appropriate, but this raises the patient’s drug costs, and it is very hard to convince asymptomatic patients that they need to take the purple pill, or anything else for that matter, when they don’t perceive it as necessary.

Although GI symptoms and endoscopic findings of ulceration correlate poorly, I invariably continue to ask patients about upset stomach symptoms, and I always ask whether they have a history of ulcer disease. Once a patient gives a history of ulcers, I try to get an idea of the severity of the problem, and I ask follow-up questions regarding hospitalization, blood transfusion, or surgery. Nowadays, only the sickest patients with active GI bleeding require hospitalization, but things were different in the distant days before our high-priced drugs. One man told me that he had an ulcer in 1965. Treatment options were very limited. Ulcer patients from that era frequently tell me their treatment included dietary remedies such as eating baby food for 6 weeks.

My patient was hospitalized in the era before proton pump inhibitors. He told me he had been having a lot of upper abdominal pain, and the doctor ordered an injection of pain medication. The evening nurse administered this but forgot to chart it. The old saying goes, "if you didn’t chart it, you didn’t do it." That was exactly the conclusion of the night nurse. Seeing that the injection had not been charted, she also gave my patient a shot.

Perhaps my patient was exaggerating, or perhaps the passage of about 46 years altered his memory of the event, but he told me that after receiving two injections fairly close together, he slept for 3 days. He probably benefited from the sleep, and when he finally woke up from his iatrogenic hibernation, his hospital roommate told him that he had become a semi-celebrity. Lots of important people from the hospital administration had been holding candlelight vigils at his bedside and were hoping that he would recover and not sue the hospital.

Hospital administrators were only too happy to make amends, and they reassured my patient that the nurse who had failed to document his first dose of pain medication had been summarily fired. Although some people might have been appeased by this bit of obsequious viciousness, for my patient it had the opposite than intended effect. He told them they had to rehire the nurse immediately, or he would sue the hospital. He had the hospital over a barrel, the hospital knew it, and they promptly rehired the nurse.

Anyone could make a mistake, he told me, and besides that, the nurse was a widow with two children to raise. I was overwhelmed by this man’s magnanimous spirit, but I was bothered by a nagging question. He had been sick and heavily sedated for 3 days, so how did he know that the nurse was a widow with two children? I asked him this question, since digressions like this are the best part of my job. When I spoke with him, he was a tremulous old man with many chronic problems, but at the time of his hospitalization he had been a police officer. He had investigated the accidental death of the nurse’s husband! I was awed by this amazing coincidence, and I couldn’t help but think that perhaps the greatest form of quality improvement is forgiving an occasional mistake, something that has become increasingly rare in health care. It seems as if everyone is touting the greatness of evidence-based medicine, but there’s a lot of homespun wisdom in this anecdote. Perhaps a little more wisdom, plus some low-cost generics, might be just the thing health care reform is lacking.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him at rhnews@elsevier.com.

My waiting room has a sign asking patients to turn off their cell phones when they are taken to an exam room. Practically everyone ignores the sign or conveniently forgets about their phone, until it starts chirping in the middle of an office visit. I once bought a photo of Bobby Knight screaming and having a temper tantrum on the basketball court. Everyone around here knows the famous coach, and my intention was to make an exam room poster with a caption reading, "I want you to turn off your cell phone!" Inertia got the better of me, and I never made the poster.

I used to feel that the noisy ring tones coming from patients’ phones were a rude and disrespectful intrusion into the sanctified atmosphere of the exam room. Everyone has a cell phone these days, and my attitude has gradually changed. Keeping patients cooped up in a boring little exam room, with only some stale old magazines for entertainment, isn’t fair, especially since I’m frequently late for appointments. Smart phones are much more amusing than my old magazines, and patients with phones tend to be happier and more forgiving about my tardiness, so banning phone use doesn’t help my popularity.

Patient cell phones can also be very helpful. Many times a patient can’t recall some key detail about their medication. They might only recall that they started a new little white pill, but they can’t recall its name or its dosage. Patients frequently whip out their phones and call home. They speak with a family member who can read them the prescription bottle, which is much faster than any other option I have for retrieving that critical information. In addition, patients frequently use their phones to show me photos of their swollen joints or other clinical findings.

This is the information age and the era of instant communication, and holding people incommunicado is usually deemed unacceptable, rude, or insensitive. I recently entered an exam room and a woman was talking on her cell phone. She was a little bit slow to say good-bye to her caller, so I shuffled papers for a few moments while she finished her call. I asked her whom she had been speaking to (I’m a doctor – I’m licensed to snoop), and she told me it was her son who had enlisted in the navy a few months earlier. Like any parent, she was concerned about her son, and happy that she could stay in touch. It would have been insufferably pompous for me to demand that she not use her phone.

I still have my photo of Bobby Knight that I bought on eBay. Perhaps I can still make a poster and get my money’s worth. Perhaps I’ll change the caption to "I want you to have your flu shot!"

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

My waiting room has a sign asking patients to turn off their cell phones when they are taken to an exam room. Practically everyone ignores the sign or conveniently forgets about their phone, until it starts chirping in the middle of an office visit. I once bought a photo of Bobby Knight screaming and having a temper tantrum on the basketball court. Everyone around here knows the famous coach, and my intention was to make an exam room poster with a caption reading, "I want you to turn off your cell phone!" Inertia got the better of me, and I never made the poster.

I used to feel that the noisy ring tones coming from patients’ phones were a rude and disrespectful intrusion into the sanctified atmosphere of the exam room. Everyone has a cell phone these days, and my attitude has gradually changed. Keeping patients cooped up in a boring little exam room, with only some stale old magazines for entertainment, isn’t fair, especially since I’m frequently late for appointments. Smart phones are much more amusing than my old magazines, and patients with phones tend to be happier and more forgiving about my tardiness, so banning phone use doesn’t help my popularity.

Patient cell phones can also be very helpful. Many times a patient can’t recall some key detail about their medication. They might only recall that they started a new little white pill, but they can’t recall its name or its dosage. Patients frequently whip out their phones and call home. They speak with a family member who can read them the prescription bottle, which is much faster than any other option I have for retrieving that critical information. In addition, patients frequently use their phones to show me photos of their swollen joints or other clinical findings.

This is the information age and the era of instant communication, and holding people incommunicado is usually deemed unacceptable, rude, or insensitive. I recently entered an exam room and a woman was talking on her cell phone. She was a little bit slow to say good-bye to her caller, so I shuffled papers for a few moments while she finished her call. I asked her whom she had been speaking to (I’m a doctor – I’m licensed to snoop), and she told me it was her son who had enlisted in the navy a few months earlier. Like any parent, she was concerned about her son, and happy that she could stay in touch. It would have been insufferably pompous for me to demand that she not use her phone.

I still have my photo of Bobby Knight that I bought on eBay. Perhaps I can still make a poster and get my money’s worth. Perhaps I’ll change the caption to "I want you to have your flu shot!"

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.

My waiting room has a sign asking patients to turn off their cell phones when they are taken to an exam room. Practically everyone ignores the sign or conveniently forgets about their phone, until it starts chirping in the middle of an office visit. I once bought a photo of Bobby Knight screaming and having a temper tantrum on the basketball court. Everyone around here knows the famous coach, and my intention was to make an exam room poster with a caption reading, "I want you to turn off your cell phone!" Inertia got the better of me, and I never made the poster.

I used to feel that the noisy ring tones coming from patients’ phones were a rude and disrespectful intrusion into the sanctified atmosphere of the exam room. Everyone has a cell phone these days, and my attitude has gradually changed. Keeping patients cooped up in a boring little exam room, with only some stale old magazines for entertainment, isn’t fair, especially since I’m frequently late for appointments. Smart phones are much more amusing than my old magazines, and patients with phones tend to be happier and more forgiving about my tardiness, so banning phone use doesn’t help my popularity.

Patient cell phones can also be very helpful. Many times a patient can’t recall some key detail about their medication. They might only recall that they started a new little white pill, but they can’t recall its name or its dosage. Patients frequently whip out their phones and call home. They speak with a family member who can read them the prescription bottle, which is much faster than any other option I have for retrieving that critical information. In addition, patients frequently use their phones to show me photos of their swollen joints or other clinical findings.

This is the information age and the era of instant communication, and holding people incommunicado is usually deemed unacceptable, rude, or insensitive. I recently entered an exam room and a woman was talking on her cell phone. She was a little bit slow to say good-bye to her caller, so I shuffled papers for a few moments while she finished her call. I asked her whom she had been speaking to (I’m a doctor – I’m licensed to snoop), and she told me it was her son who had enlisted in the navy a few months earlier. Like any parent, she was concerned about her son, and happy that she could stay in touch. It would have been insufferably pompous for me to demand that she not use her phone.

I still have my photo of Bobby Knight that I bought on eBay. Perhaps I can still make a poster and get my money’s worth. Perhaps I’ll change the caption to "I want you to have your flu shot!"

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.