Getting Fired by My Own Physician

Tuesday      August 5, 2003      Grand Junction Free Press      Page 10
(c) Copyright 2003, Marilyn MacGruder Barnewall, All Rights Reserved
Grammy's Axioms, Special to the Grand Junction Free Press

By Marilyn MacGruder Barnewall

Axiom: People value truth, but don't like those who tell it.

     The letter from my primary care physician went beyond cold to cold and impersonal.
     "Dear (Add any name -- mine was on this letter): As of the date you sign for receipt of this Certified letter, the ABCDEFG Medical Group will no longer provide medical care for you."
     The first paragraph went on to tell me that none of partnership corporation's subsidiary groups would provide service, either.
     A second paragraph informed me that the medical group of four family practitioner physicians would provide emergency medical services for a period not to exceed thirty (30) days.
     I have never been fired by a doctor before. In fact, I have always gotten along with my doctors very well. I respect and admire them. If I do not, I find another doctor.
     When I became disabled, my medical alternatives became limited. Why? Because the powers Health Maintenance Organizations (HMOs) bestow upon primary care physicians (PCPs) are huge. Without PCP referrals, you cannot even get to God.
     In the old days, I probably would have laughed at such arrogance. This, however, had to do with a potentially malignant growth on my leg. I was not laughing.
     I qualified for Social Security Disability and Medicare in 1992, but did not take advantage of it until 1996. I had private hospitalization insurance until that time. I had paid huge premiums for it all my life and seldom used it.
     With private insurance, I could select my own doctors and if I needed to see a specialist, I could call and make an appointment. Then, I was introduced to managed care.
      Everything progressed nicely. The primary care physician who wrote me the nasty letter was a good doctor. He referred me to the best rheumatologist in the state. He was the one who identified my fibromyalgia (FMS) -- a difficult disease to diagnose.
     Two weeks before I got the letter -- an abuse and exercise of power in its worst form -- another physician who was a friend looked at a growth on my leg and said "You really ought to talk with your PCP about that. It could be malignant."
     I had intended to ask my primary doc about it for months, but I always had so many important health issues going on. I forgot. The growth on my leg was about a year old.
     I decided I'd stop at my primary care doctor's office on my way home and make an appointment. My doctor was off that day, but one of his partners could see me in ten minutes if I wanted to wait, the girls at the desk told me. I hadn't met this particular physician before, but had been treated by three of the four partners. Those three provided quality care.
     "You were right to have this looked at," said physician partner number four. "This kind of growth is high risk for squamous cell carcinoma." He smiled.
     I asked to be referred to a surgeon.
     "Fortunately, HMO has given family practitioners permission to remove skin growths ... we can do it right here and much less expensively."
     What a stupid thing for a doctor to say to a patient. My top priority should be saving money for my HMO rather than getting the most qualified medical care for a growth he had just told me was at high risk for cancer?
     Understand me. Saving money within the health care system is important. Very important. But my personal health ranks number one on my list of priorities. This was not a head cold about which I quibbled.
     A month earlier, my mother's family practitioner had frozen a growth on her neck. Two weeks later, it grew back. Her PCP surgically removed and biopsied it. It was malignant.
     Her PCP did not get the entire tumor. It grew back, even more quickly this time. She was finally referred to a surgeon who removed all of the growth. Three office calls and medical procedures before getting a patient to the right doctor -- a surgeon -- do not sound like less expensive ways to run a business to me.
     During the same time frame, my next door neighbor's son had a benign sebaceous cyst removed from his forehead by his family practitioner (same HMO as mine). He was out of work for a month and will require at least two plastic surgery procedures to correct the damage done.
     By the time it was over, this sebaceous cyst the family practitioner was given permission to remove by HMO because it is less expensive will cost well into five figures, rather than three (if the kid doesn't sue him). Wow! That sure saved money!
     These two experiences were rooted firmly in my mind as I once again requested to be referred to either a dermatologist or a surgeon. The smile disappeared from partner Number Four's face.
     "HMO says we can do this procedure here. I will not give you a referral. Call and make an appointment with your own doctor after tomorrow. I will write up my notes and have them in your file by then."
     With that, he turned on his heel and he and his unfriendly bedside manner left the room.
     And it was at this moment the difference between the medical care I had received pre-HMO and managed care became apparent: Doctors were now in control of my choices, not me. The bottom line, not my health, had become the primary consideration. Decisions like this result in non-personalized "care." Group decisions are always non-personal and seldom result in care.
     For example, skin growths like mine are not categorized as high or low-risk for malignancy. All family practitioners are encouraged to remove all skin growths because it is less expensive. Not all family practitioners are good surgeons -- which is why they became family physicians.
     In the two cases I'm aware of, that lower-cost theory was totally wrong. Since those are the only two cases I know of where a PCP removed skin growths, the percentage of error was pretty high. I do not know who made the original assumption, but it is a wrong one. It is a faulty assumption that leaps to an erroneous conclusion.
     According to a survey on the Internet by dermatologists, research proves that primary care or family physicians misdiagnose melanoma, the most virulent and deadly form of skin cancer, 61 percent of the time.
     This is someone I want surgically removing a skin tumor? Not
      My HMO is a good one. Until a procedure occurred that had life-threatening implications about which the HMO had issued a dictate, everything moved smoothly. My care was good. Not as flexible as it used to be, but good.
     I did return to my PCP's office to see my own doctor. His people skills are much smoother than Number Four's. And, I trust him. His answer, however, was the same. No referral to a surgeon. He did offer to refer me to a dermatologist, however.
     I scheduled an appointment with him for the next week to have the growth removed. His office called the next day. He had an opening with time to perform the surgery that afternoon. Would I like to come in early and get it over with? I agreed.
     With all of my fears and misgivings over this situation, this physician had earned my trust. Did I like the result? No. I would have preferred a surgeon perform the procedure. I thought of my mother's problem, of my neighbor's son's problem.
     They brought in the consent form I had to sign before he would perform the surgery. It was supposed to explain all of the risks.
     It bothered me that the greatest risk of all -- from my perspective -- was not listed. So, I listed it.
     Under the sentence stating that all of the risks had been explained to me and that I fully understood them as explained, I added these words: "...and, I have been informed that this is the only surgical alternative available to me." I then signed the form.
      It was the truth. A stark truth, perhaps, but the truth, nonetheless. To leave the sentence out of the stated risks was to bend the truth. If it was an ugly truth, the ugliness was not mine. I did not create it. They did. The sentence I added, of course, placed the PCP in a dangerous position relative to malpractice if he erred in removing and diagnosing the growth on my leg.
     Like a spoiled little child whose mommy won't provide a favorite toy, he became angry. He referred me to a surgeon to remove the growth. It was benign (thank you, Lord).
     How sad that because so much power over who managed care patients can see for medical procedures has been vested in primary care physicians, patients cannot share personal fears with the people to whom they trust their lives.
     If they do express their fears -- as I did -- a letter firing them as patients might come by Certified Mail a week later.
     The health care I have received from HMO doctors has been just fine ... until we got to an life-threatening issue.
     That is precisely when I want to be in control of the quality of my medical care.
     It is precisely at that point that managed care appears to remove control from patient hands and put it into the hands of accountants.