Home Forums Discussions General Discussion The Interview

I was rushing back to the office today to make the first appointment (He was a new patient). I completed the payroll, finished my emails , filled all the Rx requests, and reviewed my schedule.

The patient showed up at 9:15 AM for a 9:20 AM appointment. He was asked to come in at least 20 minutes early to allow for paperwork and medication review (He didn't bring his meds, we ask all patients to bring them in for review or to provide all this information before the day of the appointment).

In the background I hear the new patient yelling at my staff that we don't need his social security number and that he was here to interview me.

My staff explains that I don't do interviews (I'll never be on Oprah, thank God) and that we collect the Social for identification purposes.

The attempts to talk to him were in vain.

I stepped to the front, thanked the gentleman for his time and told him that we were probably not the practice for him and asked him nicely to leave.

"I'm reporting you to the state."

Thank you, have a great day.

" I knew you weren't the kind of doctor for me when I saw you."

Thank you, please leave and have a great day.

End of story .

We set aside 40 minutes with me for new patients (usual slots are 20 minutes). We could have had another new patient in those slots or 2 f/u patients. We don't double or triple book as a few articles I have read recently have suggested to increase revenues (if that works for you great, but I try not to do that). If I am running late , the patient is notified at 15 minutes and offered another appointment slot at 30 minutes. We value the time of our patients and expect them to respect our time also.

I am a good doctor and well trained. Sometimes , patient expectations are can be too great and we have to control our time.

When did we start having to interview for our patients? I don't have the time for this.
Reimbursements are down. They'll be going down another 2% April 1st (great day for that to happen).

What is happening to our profession. We need to take control back. It can't all be about physicians giving in. Patient's have to accept responsibility also.

Just as an aside, when we moved to this community, our pediatrician brought us in to interview us. I was told that he does this to evaluate the parents and the children. I didn't like it, but it worked for him. He has a very busy practice.


I have Dr. Oz's phone number on my monitor. When a patient makes a comment about "Dr.Oz says", I refer them to the number to get the clarification.

"Never, never, never give up" Winston Churchill.

Frustrated in Florida.
(I know you should never write anything longer than the amount of time you could spend reading it in the bathroom but, it has been a trying day. Mea culpa, mea culpa, mea maxima culpa).

We will do interviews. We charge the patient $50 if they would like to interview the doctor for 15 minutes. Really.

Also, the moment that guy raised his voice I (not Alice) would have gone out, told him that he is not required to provide his SSN, but we also have the right not to take him on as a patient if chooses not to. And we always exercise that right. Continued rudeness leads to my asking them to leave. I have had to call security once or twice.

Back in 2006 there was this big thing about SSNs and we had alot of people making a fuss about it. They either gave the SSN, or they did not become patients. Hasn't happened in quite a while now (oh no, famous last words).

What up? So your story made me sad, mad, curse, and in the end smile because you stood up for yourself and your staff. I have done this many times in the past. Last week we had a patient who i had seen a long time ago many times...he was an MVA case (car accident)...apparently we didn't get paid for one of the visits and also for his medicare co-insurance...my billing person was catching up to all the billing stuff and he went after her on the phone. he said "oh so what you and your billing partner need to paint the walls or need to go buy some food or something that you are ocming after me for money now"...i simply called the guy and asked him what his deal is. he responded by saying that my billing person was getting angry at him..so i asked him what he expected when he decided to belittle my billing people and if he expected them to kiss his feet and say oh sir you are correct...he said he was joking..i let him know that it doesn't work that way...if he wants to be seen here, he will act like a decent human being and he will respect me and my staff. he had an appointment for the next day and i simply told him we were canceling his new problem appointment till he figured out how he was going to treat my staff and vendors.

I am proud of you for kicking the guy out of your office. Iwould have done the same thing and documented it. I would def document your situation for when he does report you to the state.

I no longer have tolerance for rude patients who expect me or my staff to be their punching bag. I am a hell of a freaking doctor (most of my patients will tell you so)... i care for my patients way more then i should and text and email people from across the world...but i won't take [censored] anymore...i haven't for a few years...i don't do it in my personaal life and i am not going to in my practice either...

I had another incident yesterday that makes me sick but i don't want to continue to hijack your post...i would be more then happy to share if anyone wants to know

Thank you Dr. Mody.

The event was well documented.

frank, please call me ketan...sorry again to hijack the post ...

Frank,

I have noticed for the first time in 20 years of practice a palpable change in a growing number of patients over the past year or so. Maybe I am becoming wiser and a bit more perceptive, but I do not think so. But, it is a hint of anger and frustration, and maybe a bit of belligerence.
However, once a month we have nurse meetings for educational purposes, but one of the educational forums I would like to offer is an office crisis management plan. I have been thinking about this for sometime, but really started to think more about this when the urologist was shot recently in his office.
I think it best if one has a semblance of a plan to deal with a crisis should it ever develop.
But before I put too much time into this, just wondering if anyone has any good resources or input of how best to handle a crisis in the office.
Frank your experience today is far from this but got me thinking again about this very issue.

I am extremely pleased you quoted Churchill, but I have a differing quote that is far less enlightening.

?We should seek by all means in our power to avoid war, by analyzing possible causes, by trying to remove them, by discussion in a spirit of collaboration and good will. I cannot believe that such a program would be rejected by the people of this country, even if it does mean the establishment of personal contact with the dictators.?

Neville Chamberlain quote

Frank you did the right thing!!!

P.S. I think I will use your tactic the next time an Oz question pops up.

Frank, perfect response.

We do the same. I really love it when people don't want to give their SSN. I have heard them say "I don't want the government to get it." Really.

Some years ago as was mentioned above there was this huge flap about SSN's. On the FAA pilot's medical form there is a spot for it. When pilots refused to give it, the FAA said "Fine. You don't have to. We will give you a 9 digit pseudo-SSN that you will have to use on all future correspondence and applications. Don't misplace it, or we won't issue any further certificates." That solved the problem.

Like Wayne, when we meet a patient it is with my expectation that it is sort of a bilateral interview. I want to know what the patient's expectations for care may be, and want him/her to know how I practice medicine. Usually it fits fine or we can accommodate each other's styles. Sometimes not, and we agree it is a bad fit. I charge for the visit.

Unless you are really hungry, life is too short to let these idiots into your practice.

The idea of a crisis plan is a good one, especially if you are in a building that does not have security. We simply call downstairs and ask the personnel to come ask the person to leave and escort them out of the building. True they can only ask,but Ive already told them we have NO Problem if they wish to call the police if the person is non-cooperative. Go ahead. Please call the police.

I had a patient who became angry because we asked him to pay his 90 day+ bill (under $20) before he was seen. He had been sent 3 notices which he first denied then acknowledged. There was no financial hardship in his case. I stepped in and told him we would be happy to reschedule him. After an angry tirade he decided to report me to the state. Because I had made sure my staff and I documented everything right away, the case was dismissed by the state after reviewing the record. Score 1 for the physician.

My response is always, please feel free to report me to the state, I would be happy to talk to them. We document all calls and notices sent. I am telling you, the day that we get the respect we deserve and the govt looks at us seriously is going to be the day we band together and all strike for a week...oh wait...we won't do harm...there goes that plan

Be glad you don't live in NY. In NY, the DOH investigates ALL complaints against doctors, even when it is obviously patently false. So for instance, if a patient calls to complain about something with say their copay or that you didn't see them long enough so they want a refund(just anything that is not in their charter to deal with) they actually encourage the person to come up with another complaint. This invites the person to lie and claim "their office was dirty." Now, this is an 'infection control' issue so now they have an excuse. Then, even after their disruptive surpize visit where they take photographs of the clean office,they want to review your entire operations to look for something to charge you with. They just will not dismiss the case when they see the complaint was obviously false, and even in fact encourage the false complaint by not just saying "we'll look into it" when the person complains about you collecting your fee without seeing them "long enough."

Just as a side note, we never take SSN. Most people are very protective of them around here and I tend to agree with them. Identity fraud is no joke and we have no need of their SSN to identify them.

We also don't collect SSnumbers at this point. I just don't need them for what i do. Though I think in Frank's case, if you are dealing with a lot of medicare, isn't the ssnumber the medicare number? so i don't see why the patient would be upset about it.

My wrinkle on this from today is a Vietnam vet with PTSD who became agitated when we asked to take his picture for the demographics sheet. I find this much less annoying than the SSN conspiracy buffs. At least he has some reason for his behavior.

As of the past 18 mo, we discharge patients whose parents refuse vaccinations. Best decision I ever made-- I only lost about 15 patients and my Hypertension has been cured from not having to refute unending idiotic arguments against vaccinations all day.

How many said that taking the vaccine may have the side effect of making them only able to walk backwards?

We had a similar event happen on Monday to that of Frank's.

Grandfather comes in with a new patient (We usually require the parent at the initial appointment but...) He had apparently been corralled into bringing the patient to the office. He came a little early, I was the only one in the office at the time.

I checked and saw that all the insurance information was not in the computer. I asked him for the insurance card, He did not have it. He called the Mom, who stated she had come in and given it last week. I spoke to her (on the GF cell phone) and told her that without the information he could not be seen, and that she could fax it to us.

I then went on and asked for the shot records, the GF stated he didn't have those either, called the Mom back who stated he did not have any immunizations. I told him he would require a lot of shots today. Mom told GF she did not believe in vaccines.

That is an automatic disqualification in my office. A basic tenet of my practice is that vaccines are life saving and those who disagree can find someone who will coddle to their position, it just won't be me. I told GF that and the process was ended. Truly, the GF was apologetic, I believe he was placed in an untenable position.

Unfortunately this was a waste of 10-15 minutes while I was reviewing faxes, and getting things started for the day, but well worth it to keep a likely troublesome family out of the practice.

When the Receptionist arrived, she did state that the Mom came in late on Thursday (we are open late that day), made an appointment, that she had copied the insurance card but was busy and planned on entering the information on Monday. Mom was told to bring the immunization records and did not argue or state she did not believe in shots. Apparently she was very pleasant on this meeting.

At the practice where I was previously employed, all phone calls in to the front desk/billing/etc were recorded (this is legally fine so long as the message that says "if this is a medical emergency, please hang up and dial 911" also says "this call may be recorded for quality assurance purposes"). Then if a patient complained about a staff member being rude or a staff member got chewed out by a patient, the office manager could listen to the actual conversation. Thanks to this system, I fired several patients who were shockingly rude to the front office but always polite to me. It was nice to be able to tell them that I will NOT have my staff treated that way etc and be absolutely certain of what I was talking about...it wasn't just one person's word against another's.

As far as vaccines, I've found that most parents are just scared and wanting to do the right thing for their children. I am usually able to gradually get vaccines in to their kids over time as we develop a relationship. I figure taking the time with them is eventually lifesaving when I can convince them to vaccinate...but I know most doctors don't have the luxury of time. About half the families I've seen who started by saying, "We don't vaccinate" now have mostly or fully vaccinated kids. Just my two cents.

I'm willing to have the "vaccine talk" to parents of newborns. I have seen a lot of underimmunized patients and will work with parents who have issues but are willing to be vaccinated.

Having had the "vaccine talk" in the past to people who "agreed to disagree," and wished to remain unimmunized, I no longer feel that I am willing to compromise on a basic tenant of my practice. There are others out there, and I have enough business that I don't need the headache.

Additionally after reading about a doctor being sued for not immunizing a child who subsequently died, (I don't know how that turned out, nor do I want to) I decided it wasn't worth the effort.

I guess the parents claimed that they didn't really understand that the vaccines could prevent a life-threatening illness and if he had only taken the time to explain it properly then they would have had their child vaccinated so it is HIS fault that they chose not to have their child vaccinated. No one ever wants to take responsibility for their own decisions.

Isn't it always our fault? Today I recieved a letter from a patient who hasn't paid his wife's portion of co-insurance for a walking boot. He sent a letter two years ago with a check for the co-insurance of the visit but not the boot. In the letter back then they claimed that the boot i gave was way too big for her and she needed to go to walgreens to get something similar...uh first you can't get the walking boot i use in walgreens...but any how, we called three times to say we can adjust it if you return the boot since you haven't used it and say it is too big. Guess what? they never called back. Now we just were cleaning up all the old crap and outstanding bills and he resent a new letter...along with the old letter askign us to reconsider because the boot was too big...just annoying...i wanted to call them and ask what happpened when we called you asking you to just drop off the unused boot and we would actually not only adjust the bill but report to insurance that it was returned and would return the money they paid us for it...it is a freaking joke...needless to say i will never see this patient or their family again...;)

I am wondering whether the these conditions will change Jan 1, 2014, when Obamacare begins to add 38 million previously uninsured folks trying to find doctors. We may need to give prospective new patients pre-applications; add some good new people and clean house of chronic "boat anchors". Is there a way to check the crime database, or to screen out litigious people or bad credit risks? I feel sorry for all those physician-extenders who fill in for the doctor shortage, and end up with our riffraff.

Riffraff? Let's try to turn this thread on its head.
Perhaps it is the difficult patient that presents the greatest challenge to our clinical skills (and patience). Perhaps it's the "boat anchor" that most deserve our compassion (not coddling). There's been a lot of helpful articles on this issue. Here's one: http://www.aafp.org/afp/2005/1115/p2063.html

John, I respectfully disagree.

The article you provided, including the example patient, seems to relate to patients with difficult clinical problems, personality disorders, noncompliance. We likely all struggle with these patients but continue to see them.

The posts above describe:
-- "new patient yelling at my staff that we don't need his social security number and that he was here to interview me",
-- a patient asked to pay who stated "so what you and your billing partner need to paint the walls or need to go buy some food or something that you are coming after me for money now"
-- patients who refuse to provide their SSN
-- "a patient who became angry because we asked him to pay his 90 day+ bill (under $20) before he was seen"
-- "patients whose parents refuse vaccinations"
-- "several patients who were shockingly rude to the front office but always polite to me"
-- "a patient who hasn't paid his wife's portion of co-insurance for a walking boot"
-- and I made reference to litigious patients
Have these now become personality disorders?

In the interest of accuracy, I should have used the term "deadbeats". And in the case of parents that refuse to immunize "potential defendants in a personal injury tort". IMHO many, if not most persons described in the posts above just don't have respect for their fellow man, even someone trying to help them.

Dear John,

Thanks for your thoughtful and respectful comments. You raise some great issues.

You asked, "Have these now become personality disorders?" In fact yes, many of these patients do have personality disorders. I have often had a difficult patient that was driving me crazy until I realized, "Oh, right, she's borderline. Of course! Now her behavior makes more sense."

To look at it another way difficult patients are all spiritually sick. These are people who are not at peace, not happy. The patient who yells at my staff about whether to provide his SSN is usually deeply fearful of the world. These are people who have serious character defects. I have a few myself and have been really obnoxious a time or two (or three).

I find it helpful to frame the problem this way: problem patients are sick (physically, mentally or spiritually). They deserve my compassion, just as nice/compliant patients who are sick. The two year-old with the ear infection, screaming at me, kicking, spitting, trying to bite me as I look in his ears is a great metaphor for all problem patients.

We all get angry at difficult patients. The question is how do we respond to that anger. Frank, at the beginning of this thread, sounds like was able to handle a difficult situation without reacting in anger. Bravo! That's the first step, to avoid reacting out of anger.

But when I'm in these situations, even if I don't react with overt hostility, I will often feel my blood boiling inside. If I take some time to think about the problem patient and the incident, to try to see how they might be suffering, to have compassion for them, to remember that God's in charge, I'm not in control of everyone and everything. It helps sometimes just to vent--perhaps here in a thread like this.

The danger, of course, is to let the anger aroused by the difficult patient eat me up inside, to take it out on myself, eat a dozen donuts or drink a couple of six-packs, or to take it out on others, the next patient, my staff, or my wife.

And no, I don't have this all figured out. Wish I did! It's a lot easier to write about it from the comfort of an armchair while sipping a cup of coffee that to actually do it. I would welcome any thoughts you or others have about how to deal with the difficult patient. No doubt my comeuppance for this post will be a bushelful of difficult patients at my office today. :-)

With best wishes,

John

Thanks for your thoughts. You have made some great points.

John and John,

I agree with you both. I do not think either position has to be mutually exclusive.
However, John H. you have had me ripping through box after box of old college books looking for the book in the link below. I definitely want to re-read it again if I can ever find it.
But your post reminded me of this book I read many years ago in an old college course, taught by a Harvard trained theologian. Which was one of the best in my undergraduate experience.
If you are interested in a light and easy read, I highly recommend it.
http://en.wikipedia.org/wiki/The_Sickness_Unto_Death

Thanks Jimmie. I never thought the ACUB would venture into Kierkegaard! :-)
The book is available free online.

Kierkegaard provides a better overall perspective than Neville Chamberlain (also quoted above).

(That was shamelessly lifted from Wikipedia -- it's been a long time since I read Kierkegaard, but it certainly merits a re-acquaintance.)

I think that the secret to these situations is not to allow the disruptive person to become the "dictator" with whom we have to associate -- and eventually either forcefully eject or appease. That is a no-win.

We are certainly in control of our personal space in our own offices -- and should be able to control the agenda, since they are asking for the service, and we are not legally obligated to provide it.

I have a serious problem with the situation when a new patient (child or adult parent, for example) is brought in by one of those folks with a borderline personality who also has guardianship over the new patient.

That is really challenging.
I throw the bums out, but I try to work with them if they have dependents in need. Sometimes that turns into appeasing dictators -- and then I risk dispair.

It may also be the case that what for one of us is challenging is for another disruptive. I have had a few patients who literally no one else in town would see whom I kind of got to like after some fairly difficult encounters. One had been forcibly removed from the VA clinic by security, and they have a pretty broad acceptance policy. There are others I just could not stand that another colleague found fairly pleasant. I have one very bright patient with his professor spouse who both take copious notes on legal pads, research every issue exhaustively using real studies (not just internet hooey), and took several minutes once to correct me when I referred to one study as a "metaanalysis" when it was more properly a review of the literature as it did not possess the correct statistical format. It took some getting used to, but now is really quite an educational experience, as long as my staff knows that there is no such thing as a brief visit when scheduling. Obviously, there is no amount of money that will ever reimburse us for this stuff. Some things are done because they just have to be done, and some can be perversely enjoyed.

"Perversely enjoyed"! That's great, David. Some days when people ask my how I am I will respond, "Suffering joyfully." I love to see the furrowed brows.

You bring up a good point that some difficult patients fit better with Dr. Y and some better with Dr. Z.

Physicians may be a little sensitive and demanding to the control and respect issues. We all know that mortals should not exasperate us demigods.

But at least we are training the patients we discharge to treat the next doc better. Call it negative feedback.

@ John H.,
No Sickness unto Death, but found Fear and Trembling and Martin Buber's "I and Thou", so getting closer--but nice to know it is on line, just in case. But I am old school, I like reading from a book.

Frank,

Just following up on my initial thought, but our local police force has a Sargent that will come in to the office and work with the staff on developing a contingency crisis plan and he will be offering his insight at our next nurse educational meeting later this month. I will keep you updated on how the experience goes for our staff.

Thanks Jimmie.

I may reach out to our local PD to see if they have a program

Having worked in both physical and technology security, practices are a particularly challenging environment to secure.

As I advised a long-time board member after a break-in, a steel door with a hardened frame is the single best investment that you can make. Because confrontations typically occur in the front end of a practice, there will be a natural choke point where you can install that door. Also select a unique, but non-remarkable phrase that can be used, even under duress, that everyone understands means quietly call 911 and lock the barrier door.

In addition to a regular locking handle, an integrated frame lock will deter anything short of an entire-frame breaching charge.

The barrier door keeps everyone on the other side of the door safe, and that is best that you can hope for in that circumstance.

The other key is to talk with your front end staff about methods to de-escalate an interchange that is becoming emotional and/or confrontational. You really don't want either of those in your practice, even if the staff member is completely correct.

Frank,

Just as a followup to this issue, if you are able to have your local PD come by the office it is well worth it.
Yesterday we had two officers spend about an hour with the staff and several of the docs to give a nice presentation and several take home messages.
1. Have a plan in place, keep a count of staff to account for everyone, and have a designated area to meet up in a crisis.
2. As Indy said above--have a barrier and a method to de-escalate.
3. Have either a sounding device or flashing light system, so all staff and docs can be aware when a crisis is developing.
4. Call 911 ASAP and alternatively there is a non-emergent # to the police that can be used in less critical situations.
5. Educational Classes available provided by local police--ours offer a free 12 week course, and learn anything from tazing to doing a ride around, to shooting a handgun.

I think your topic has been most helpful, and thank you for bringing this up.

One of our next nurse meetings will involve teaching de-escalation techniques by bringing an expert to discuss the judo-talkdown technique.

Does anyone know if there is way to assign appropriate CPT to the appropriate ICD( when finishing up chart entry before final acceptance so that all ICD-9 codes are not assigned to all the CPT's