hellothere Posted October 24, 2012 Report Share Posted October 24, 2012 Hi, I'm a third year student planning to apply to med school next year. And I have a real-life ethics question, and I wanted to hear your opinions. My family moved to Ontario about 10 years ago. We live in a small city outside of Toronto (about an hour by car), and we couldn't find a family doctor accepting patients in our city. So we got a doctor in Toronto, and we've been with him ever since. He's not the greatest person ever, but he seems more or less competent, and we have no major complaints. Except he does this one weird thing, where we get tested every year, then he calls us to his office to tell us the results. For example, my mom got a call a few weeks ago from the nurse in his office, telling her that there was a problem with her tests, and that she should come in at some point. The nurse refused to say what it was (which is understandable, because of the liability issues, I guess). My mom is actually out of the country right now, and she can't come in any time soon, obviously. So we've all been panicking about what it could be, but my doctor seems adamant that she needs to come in. This is not the first time it has happened. Once, she had some vitamin deficiency, so the doctor made her come all the way to Toronto so that he can tell her to buy some vitamin supplements from a drugstore (non-prescription). He doesn't seem to realize that his patients go through a lot of agony when he does this, especially when you can't even book appointments immediately. The explanation that I heard is that he gets paid per patient visit, so he really wants his patients to come in. Do you think this is ethical? Is this allowed? I obviously haven't voiced this to my family (especially not now), but I always feel that he has a shady side to him, and I'm a bit suspicious; maybe he's cheating the system to make more money, or something. I mean, if it's something serious that needs to be treated, he should call her, tell her to cut her trip short, and come home, or something, right? What if it develops into something more serious, because he hasn't told anything on the phone? What are your opinions? Link to comment Share on other sites More sharing options...
Para D Posted October 24, 2012 Report Share Posted October 24, 2012 Family doctors, like most others, are paid per visit (fee for service). Depending on the province they can bill for different types of visits or lengths of visits. Most make there money by having many short visits, say 5 minutes. That way if the billing is per 15 minutes, they can see 3 patients in that time period and bill for the minimum 15. Its not the best system and it does lead to a lot of patient and consult selection. Why take on a complex case that will take 45 minutes if you could take on 9 other patients and bill 9 times as much? On the flip side sometimes patients have follow up questions or there are other factors that can't be assessed on the phone, like drug interactions, so you can't simply do everything on the phone. Plus the time he would spend on the phone can't be billed so he is essentially working for free every time he calls. This is just a quick overview of the situation, the problems run much deeper and as you pointed out there is an ethical element to the problem. Some doctors prevent their patients from coming in by making contingencies during the initial appointment. For instance if they test your vitamin B12 and find that it is low they have already discussed what the treatment will be and give you a prescription in advanced so they can have the nurse/secretary call you and tell you to go get it filled. This doesn't work in every situation but next time you are there let him know the difficulties and stress he has induced and tell him you are going to go doctor shopping if he can't be more accommodating. Link to comment Share on other sites More sharing options...
carolynH Posted October 24, 2012 Report Share Posted October 24, 2012 Family doctors, like most others, are paid per visit (fee for service). Depending on the province they can bill for different types of visits or lengths of visits. Most make there money by having many short visits, say 5 minutes. That way if the billing is per 15 minutes, they can see 3 patients in that time period and bill for the minimum 15. Its not the best system and it does lead to a lot of patient and consult selection. Why take on a complex case that will take 45 minutes if you could take on 9 other patients and bill 9 times as much? On the flip side sometimes patients have follow up questions or there are other factors that can't be assessed on the phone, like drug interactions, so you can't simply do everything on the phone. Plus the time he would spend on the phone can't be billed so he is essentially working for free every time he calls. This is just a quick overview of the situation, the problems run much deeper and as you pointed out there is an ethical element to the problem. Some doctors prevent their patients from coming in by making contingencies during the initial appointment. For instance if they test your vitamin B12 and find that it is low they have already discussed what the treatment will be and give you a prescription in advanced so they can have the nurse/secretary call you and tell you to go get it filled. This doesn't work in every situation but next time you are there let him know the difficulties and stress he has induced and tell him you are going to go doctor shopping if he can't be more accommodating. I agree with Para D. Most doctors love easy appointments like these. Some doctors even prescribe medications to patients who take them for years with only a 3 months supply with no refill instead of x3 refills (for a 1 year supply). This way, the patient will have to see the doctor every 3 months to get a new prescription or say to be assessed by the doctor to see if the medication needs to be altered. Some doctors will have you come in to see the results of your check-up even if everything's fine. I have more than one doctor told me that doctors welcome healthy patients. They dread taking in patients with a lot of health issues, although they couldn't refuse. So to answer your questions, NO, it is not against the rule for your family doctor to do this. Is it ethical? Well, it is kind of borderline in my opinion. As for doctor shopping, I don't think that's a threat because of the family doctor shortage. I wouldn't recommend using this tactic. Link to comment Share on other sites More sharing options...
jerkstore Posted October 24, 2012 Report Share Posted October 24, 2012 ^^ Christ I hope they are heavily audited. Link to comment Share on other sites More sharing options...
quackster Posted October 24, 2012 Report Share Posted October 24, 2012 you're easily forgetting it's unethical for him to share your mother's personal health information with you. Your panic is justified by the fact that you care for your mother, but not justifiable by the doctor's actions. If it was a matter of life or death, I'm sure he would have communicated that somehow without divulging your mother's medical problem. By the way he has communicated with your family, it doesn't sound like something too horrible is going on. Also, don't forget that communication is a two-way street. It may not be common knowledge to the doctor that you live an hour away and getting to his office is a pain. This is something you should tell him. If you are getting tests done, bring this to his attention, and ask if he could possibly do a phone consultation to follow up on an abnormal test result, presuming it's appropriate (i.e., doesn't need to examine you, do a further test). As for that one time he brought her in just to tell her to take some OTC meds - as others have said, some conversations need to be had face-to-face, as inconsequential as they may seem, doctors have a lot at stake liability wise. You also may not have the full picture of your mother's health to make a judgement about whether a visit is necessary or not. Yes, doctors make money per visit, but it is not the sole reason they call you in Link to comment Share on other sites More sharing options...
hellothere Posted October 24, 2012 Author Report Share Posted October 24, 2012 you're easily forgetting it's unethical for him to share your mother's personal health information with you. Your panic is justified by the fact that you care for your mother, but not justifiable by the doctor's actions. Well, some of the anecdotes (such as the vitamin deficiency) was communicated to my mother, who then relayed it to me in tears (in fact, she was crying for a week before she could go in for her appointment, convinced that she was very very sick). My mom also spoke to my doctor briefly on the phone for this one also, and he refused to say anything. As future doctors, how do you feel about this issue? I wonder if some of us will be doing the same thing in 10-20 years... Link to comment Share on other sites More sharing options...
futureGP Posted October 24, 2012 Report Share Posted October 24, 2012 it's changing, and most docs are part of a mixed model --> some FFS and some paid per patient enrolled, so these unethical practices become unnecessary but still, it's how the system has become :S to make docs make these unethical acts Link to comment Share on other sites More sharing options...
Tacrolimus Posted October 24, 2012 Report Share Posted October 24, 2012 We're facing the same problem. Our family doc has become extremely greedy...forcing us to make appointments for little or no reason. He will not prescribe any refills and you have to go back to him after 3 months just so he can write another prescription for Calcitrate. Thinking of switching doctors, but I'm hearing these kind of stories from other people too.. Link to comment Share on other sites More sharing options...
schmitty Posted October 24, 2012 Report Share Posted October 24, 2012 We're facing the same problem. Our family doc has become extremely greedy...forcing us to make appointments for little or no reason. He will not prescribe any refills and you have to go back to him after 3 months just so he can write another prescription for Calcitrate. Thinking of switching doctors, but I'm hearing these kind of stories from other people too.. Yeah, that's not cool. My Wife's doctor is the perfect combo I think. Still need to come in to get results (that's standard), but for usual stuff like prescription he will give tons. I.e. for standard stuff that he knows the patient will be on for a long time he will give 12 months and ask that patients come back after that for a checkup. Link to comment Share on other sites More sharing options...
rmorelan Posted October 24, 2012 Report Share Posted October 24, 2012 ^^ Christ I hope they are heavily audited. auditing won't help they are not charging for anything they are not allowed to charge for. They are following the rules - the problem is therefore the rules and those need to be changed. Link to comment Share on other sites More sharing options...
jerkstore Posted October 24, 2012 Report Share Posted October 24, 2012 auditing won't help they are not charging for anything they are not allowed to charge for. They are following the rules - the problem is therefore the rules and those need to be changed. We need Romney! Link to comment Share on other sites More sharing options...
hellothere Posted October 24, 2012 Author Report Share Posted October 24, 2012 I guess the problem is that we don't have the usual leveraging tools that we normally have as consumers. Especially in Canada, the whole "take it, or leave it" really doesn't work, since, well, we can't actually leave it. It all seems very strange to me, because the medical students that I've met have been really nice folks. Maybe something happens along the way...? (Haha can you tell that I'm having doubts about the future?) I actually dream of the government installing a system like this: Patients get to evaluate their doctors every 5 years, say. The doctors also take a qualifying exam to renew their licenses at around those times, which will make sure that they stay on top of everything that's going on. They don't have to be particularly difficult, but it hopefully will weed out the super terrible doctors. Instead, the medical schools will take something like 10% more students, and the government will disqualify 10% of the doctors every 5 years, or something. Of course, this probably will cost tons, and it will never happen, but isn't this an okay solution to keeping Canada's medical system in check? Well, okay, the 10% is arbitrary and quite high, but you get the idea. Link to comment Share on other sites More sharing options...
mm88 Posted October 24, 2012 Report Share Posted October 24, 2012 The government sure as hell won't willing spend money to de-license ANY doctor they've spent hundreds of thousands of dollars on just so people can avoid "****ty" experiences at the doctor.... It's probably better to just put up with them rather than have even fewer doctors by de-licensing a bunch twice a decade. They're providing an essential service, so they get to call the shots; and sometimes there's just nothing you can do about those people. Link to comment Share on other sites More sharing options...
future_doc Posted October 24, 2012 Report Share Posted October 24, 2012 auditing won't help they are not charging for anything they are not allowed to charge for. They are following the rules - the problem is therefore the rules and those need to be changed. Yes. And running a successful practice is both medicine and a business. To tie up a physician on the phone, where does it end, with how many patients - this is not efficient use of time and there is no payment. A lawyer charges for phone calls, not a physician. I understand. Moreover, the law of supply and demand comes into play, it is not a buyer's market. Let the physician charge for his time, for phone calls and things will change. Change the rules. Link to comment Share on other sites More sharing options...
rmorelan Posted October 24, 2012 Report Share Posted October 24, 2012 I guess the problem is that we don't have the usual leveraging tools that we normally have as consumers. Especially in Canada, the whole "take it, or leave it" really doesn't work, since, well, we can't actually leave it. It all seems very strange to me, because the medical students that I've met have been really nice folks. Maybe something happens along the way...? (Haha can you tell that I'm having doubts about the future?) I actually dream of the government installing a system like this: Patients get to evaluate their doctors every 5 years, say. The doctors also take a qualifying exam to renew their licenses at around those times, which will make sure that they stay on top of everything that's going on. They don't have to be particularly difficult, but it hopefully will weed out the super terrible doctors. Instead, the medical schools will take something like 10% more students, and the government will disqualify 10% of the doctors every 5 years, or something. Of course, this probably will cost tons, and it will never happen, but isn't this an okay solution to keeping Canada's medical system in check? Well, okay, the 10% is arbitrary and quite high, but you get the idea. cannot put a picked percentage on that. People are either qualified or they are not. You can set the standard though. Also the government doesn't license people the college does and it sure isn't in a big hurry to expel members in such a relatively blunt fashion. The government cannot currently disqualify anyone. Link to comment Share on other sites More sharing options...
leviathan Posted October 24, 2012 Report Share Posted October 24, 2012 Patients aren't really in a position to evaluate doctors for medical competency. I also wouldn't want to see drug seekers, neurotic patients, needy patients, over-privileged/entitled patients voting poorly on doctors who don't give them what they want. Link to comment Share on other sites More sharing options...
1234 Posted October 25, 2012 Report Share Posted October 25, 2012 it's changing, and most docs are part of a mixed model --> some FFS and some paid per patient enrolled, so these unethical practices become unnecessary but still, it's how the system has become :S to make docs make these unethical acts All family physicians are part of mixed models. Every physician gets remuneration for roster size and characterization, as well as visits. Link to comment Share on other sites More sharing options...
sprinkles Posted October 25, 2012 Report Share Posted October 25, 2012 Well, some of the anecdotes (such as the vitamin deficiency) was communicated to my mother, who then relayed it to me in tears (in fact, she was crying for a week before she could go in for her appointment, convinced that she was very very sick). My mom also spoke to my doctor briefly on the phone for this one also, and he refused to say anything. As future doctors, how do you feel about this issue? I wonder if some of us will be doing the same thing in 10-20 years... I think what he did was very inappropriate. I'm going under the assumption that you HAVE communicated to him that you live far away. But even if you didn't...I understand why he can't tell you whats wrong with her but why can't he tell your mother? Your mom should call (from abroad) and ask whats wrong. If he keeps being difficult she should say "is this something urgent that I need to cancel my trip for? Or is this something minor that would be ok until I get back? In my mind (and most other people's) you don't give bad news over the phone. So when you DO get have your doctor telling you to come in ASAP! its very worrying! HE SHOULD KNOW THAT. He should know that "something is wrong with your tests" worries people. When I had a blood test the secretary called to talk to me. I wasn't there so they refused to tell my mom based on confidentiality. I called and the secretary (not even doctor) told me it shows I have vitamin D deficiency and I should go buy supplements. Thats not even something a doctor NEEDS to tell you. its not rocket science Link to comment Share on other sites More sharing options...
rmorelan Posted October 25, 2012 Report Share Posted October 25, 2012 All family physicians are part of mixed models. Every physician gets remuneration for roster size and characterization, as well as visits. All? I thought some still opted to be on the fee service only plan still. Walk in clinics spring to mind as well I guess. Link to comment Share on other sites More sharing options...
rmorelan Posted October 25, 2012 Report Share Posted October 25, 2012 I think what he did was very inappropriate. I'm going under the assumption that you HAVE communicated to him that you live far away. But even if you didn't...I understand why he can't tell you whats wrong with her but why can't he tell your mother? Your mom should call (from abroad) and ask whats wrong. If he keeps being difficult she should say "is this something urgent that I need to cancel my trip for? Or is this something minor that would be ok until I get back? In my mind (and most other people's) you don't give bad news over the phone. So when you DO get have your doctor telling you to come in ASAP! its very worrying! HE SHOULD KNOW THAT. He should know that "something is wrong with your tests" worries people. When I had a blood test the secretary called to talk to me. I wasn't there so they refused to tell my mom based on confidentiality. I called and the secretary (not even doctor) told me it shows I have vitamin D deficiency and I should go buy supplements. Thats not even something a doctor NEEDS to tell you. its not rocket science broader question I guess is why they have to have a family doctor that is so far away? If it is a supply things then there is a major problem there. You cannot put all the blame on the doctor for time needed if the patient lives so far outside his/her usual area. Link to comment Share on other sites More sharing options...
hellothere Posted October 25, 2012 Author Report Share Posted October 25, 2012 broader question I guess is why they have to have a family doctor that is so far away? If it is a supply things then there is a major problem there. You cannot put all the blame on the doctor for time needed if the patient lives so far outside his/her usual area. We looked everywhere when we moved into our current city, but we couldn't find anyone who accepted patients, except this one doctor about 45 minutes away (but the word of mouth was that she was so bad that people kept leaving her), so we decided to find one in Toronto instead. The supply of family doctors, as far as I know, has always been a problem. And yes, every time the nurse calls, and every time we go in for appointments, we tell them that we live very far, and that we would appreciate not making that extra trip. So far it has had a very minimal effect. Maybe I should have provided less personal details; I mostly just wanted to know what my doctor was doing was common practice. Because, you know, my mother started taking my doctor less seriously. And like now, she has no plans to cut her trip short, and she figures it's just some other stupid issue. But at some point, it's possible that she actually will have something serious, and she'll neglect to see the doctor for months. It /must/ be the case that the doctor has some obligation to let his patients know in a timely manner if there is something seriously wrong with them (especially if it requires immediate treatment), whether they come into the office or not. And if that happens, I really hope the doctor is liable. After reading your responses, I believe that my doctor is being at least borderline unethical. Like the boy who cried wolf, I hope he gets caught in his own unethical-ness one day (hopefully at no cost of his patients, though!) Link to comment Share on other sites More sharing options...
future_doc Posted October 25, 2012 Report Share Posted October 25, 2012 Your mother is free to go to another doctor, e.g., walk-in clinic, etc. You are placing on the shoulders of the physician, your own responsibility. I would not accept a patient with your negative attitude. Link to comment Share on other sites More sharing options...
rmorelan Posted October 25, 2012 Report Share Posted October 25, 2012 We looked everywhere when we moved into our current city, but we couldn't find anyone who accepted patients, except this one doctor about 45 minutes away (but the word of mouth was that she was so bad that people kept leaving her), so we decided to find one in Toronto instead. The supply of family doctors, as far as I know, has always been a problem.http://premed101.com/forums/index.php And yes, every time the nurse calls, and every time we go in for appointments, we tell them that we live very far, and that we would appreciate not making that extra trip. So far it has had a very minimal effect. Maybe I should have provided less personal details; I mostly just wanted to know what my doctor was doing was common practice. Because, you know, my mother started taking my doctor less seriously. And like now, she has no plans to cut her trip short, and she figures it's just some other stupid issue. But at some point, it's possible that she actually will have something serious, and she'll neglect to see the doctor for months. It /must/ be the case that the doctor has some obligation to let his patients know in a timely manner if there is something seriously wrong with them (especially if it requires immediate treatment), whether they come into the office or not. And if that happens, I really hope the doctor is liable. After reading your responses, I believe that my doctor is being at least borderline unethical. Like the boy who cried wolf, I hope he gets caught in his own unethical-ness one day (hopefully at no cost of his patients, though!) Perhaps but I would really say this is standard practise so I honestly don't think he will get into trouble, particularly because the distances involved are not his really his concern and he/she applies this policy to all of the patients in the clinic. Often there are very good reasons as well to give news only in person. This is not to confuse being ethical with being nice or convenient. Link to comment Share on other sites More sharing options...
hellothere Posted October 25, 2012 Author Report Share Posted October 25, 2012 I would not accept a patient with your negative attitude. Whoa. This feels... unethical! Extreme much? Honestly, as I have stated, I have no major complaints. I just think an equal treatment of a vitamin deficiency with something life-threatening is confusing and sometimes traumatic to the patients, and that this should not happen too often. I think we've beaten this horse to death; we should let it rest. To me, it is clear that this issue will not be resolved further. Link to comment Share on other sites More sharing options...
future_doc Posted October 25, 2012 Report Share Posted October 25, 2012 You have taught me that if I were to do FM, I would have a sign saying: The Dr. Will not accept phone calls from patients under any circumstances. If you have an emergency, go directly to the hospital. I also would not accept any patients from out of the vicinity of my office. however, I hope not to be practicing FM. Link to comment Share on other sites More sharing options...
Recommended Posts
Archived
This topic is now archived and is closed to further replies.