Specialist as Gateway Doctor

In a previous posting, I wrote about the importance of an excellent gateway physician; that is, the primary care physician. You need this person to refer you to excellent specialists and to make decisions on whatever is in your best interest, not health-management corporations.

If you find yourself in the position of needing a specialist, and you get an outstanding one based on the same litmus tests you used to find your general physician, you can also use your specialist as your gateway to other specialists. (Notice that I said an "outstanding" doctor because nothing less will do.)

For your convenience, I've repeated the litmus tests below:

Litmus test one: During your meeting, give an emotional prompt, like: “I’m afraid of blood tests.” Observe the doctor’s reactions. Is he/she emotionally vested in you? Reassuring? If not, find another doctor.

Litmus test two: Sometime in the week following your exam, call the doctor to ask a question. Does the doctor call you back promptly? Does he or she communicate with you clearly and patiently? Does he or she take your concerns seriously? If the answer to any of these is “no,” find another doctor.

Litmus test three: Based on litmus tests one and two, do you LOVE your doctor? If you are feeling badly about him/her or just so-so, find another doctor. Don’t settle for mediocrity because if there were a medical crisis, a doctor you love and who cares deeply about your welfare will be the one who fights for you.

Litmus test four: Does the doctor play “ring around the patient,” where he/she continuously throws statistics to impress you with his or her know-how? Does he/she come with print-outs of pages from the Internet to illustrate these statistics? Do you feel confused during and/or after the session?

Run – do not walk – away from this doctor.

Litmus test five: Does the doctor use scare tactics, telling you all the terrible things that can happen to you? Is he/she dismissive of your emotional and physical needs? Does he or she sound like a doctor who has watched too many ER or Grey's Anatomy episodes? If so, this is not the doctor for you.

My oncologist meets -- actually exceeds -- all the above criteria. When I need a referral to a specialist, therefore, I call my oncologist. He's an extraordinary, brilliant doctor, yet down to Earth.  He also returns ALL my calls in a matter of a few hours, even when he's on vacation.

 

For those of you who think this type of doctor is a rarity, you are right. 

However, with persistence, checking a variety of specialists out, and by asking questions, you can find such a doctor.

Take the incompetent pediatrician I fired, for example. I needed a real pediatrician to examine my daughter, so I called my oncologist, who gave me the name of one he said was excellent. I told my specialist about my bad experience, and he said, and I quote: "I can guarantee you that you won't be disappointed with her."

Yes, a doctor used the word "guarantee."

And we all know that doctors rarely put such a gold seal of approval on other doctors, nor is "guarantee" in doctors' general vocabulary. That filled me with confidence, and my appointment with the new-hire pediatrician is, thankfully, next week.

While my oncologist's word has proven to be good as gold, I know that, at the end of the day, it's still me who has to make the decision about whether a specialist is good. But it sure helps to have an excellent specialist gateway doctor on your side.

In a near-future posting, I will be covering how I get the records from the pediatrician I fired to the one I'm probably going to hire. 

Yes, the answer is fax machine, or showing up in person to get copies. 

Seems simple, doesn't it? Stay tuned because bad doctors often have bad administrative personnel (and trust me, these people were in a daze on the day of our appointment). This may be another Traincar Named Quagmire episode, minus the train.

Beth L. Gainer is a professional writer and has published numerous academic and magazine articles, as well as an essay on her breast cancer experience in the anthology Voices of Breast Cancer by LaChance Publishing. She writes about a potpourri of topics, including motherhood and her Chinese adoption experience at http://currents-living-discovery.blogspot.com/, and her cat Hemi blogs at http://www.catterchatter.blogspot.com/. Beth teaches writing and literature at Robert Morris University in the Chicago area. She has a guest posting on The World's Strongest Librarian at http://worldsstrongestlibrarian.com/3597/sharing-a-loved-ones-pain-guest-post-by-beth-gainer/.

She can be contacted at bethlgainer@gmail.com and gainercallingtheshots@gmail.com.

The ABCs of HMOs

Awhile ago, I mentioned that I would address the topic of HMOs and why they are not necessarily the enemy of quality medical treatment. This is the topic of this posting.

Disclaimer: I can only speak from my experience and about my particular HMO, and I am not a paid promoter of HMOs.

OK, now that we got that out of the way, let's delve into the world of managed care, as well as how you can best make the HMO work for you.

Advantages of HMOs over PPOs

As one of the people lucky enough to have medical insurance, I am very happy with my HMO. Some primary care physician groups do not have quality doctors, I'm sure, but I selected my primary care physician based on a group affliated with a first-rate hospital.

Unlike the horror stories you hear in the media, my HMO doctors are outstanding.

Through my HMO, I was able to get all my cancer treatment -- chemo, surgery, radiation, etc. -- free of charge. Trust me, I saw the statements of all the charges I would have owed -- enough to give anyone heart trouble and a new set of specialists -- and I know that with a PPO I would've had to pay a certain portion of it, and a small portion would've still been a ga-zillion dollars.

Also, what PPOs don't emphasize is that they have a ceiling, where they won't pay anymore after a certain amount of funds are exhausted. The cap is a high amount, so it's not a problem for routine problems and conditions, but cancer treatments and reconstructive surgery would have driven a sledgehammer through a PPO's ceiling, and expenses would've gone through the roof.

HMO: That's A-Okay

Another little-known fact is this: many HMOs will cover a medically necessary procedure done by out-of-network doctors -- if the primary care physician, also known as the gateway doctor, advocates on your behalf. That is why it's so important to have an excellent relationship with your gateway doctor and to hire the best one for your needs.

When you have an excellent gateway doctor, the HMO experience can be wonderful. That's the key: finding and hiring that gateway doctor to help you help the HMO meet your needs.

In my situation, I needed a double mastectomy with reconstruction. Because I was young, fit, and active, a double tram flap procedure was not an option because too much abdominal muscle would be removed, and I might not ever be able to sit up on my own. According to my doctors, the procedure I needed to reconstruct both breasts was a Diep flap, a more cutting-edge surgery (pun intended), designed to preserve as much of my abdominal wall as possible.

One doctor of reconstructive surgery who was recommended to me by many medical professionals was out of my HMO network, although affiliated with my hospital. I wanted him as my surgeon, but as he was out of network, my gateway doctor said that in order to make a case to the HMO that I needed the skilled Diep flap surgeon, I had to first see the in-network plastic surgeon to ask his recommendations. While I dreaded this pain-in-the-butt step, it had to be done, explained my doctor, as she and my oncologist were drafting their letters on why I needed the Diep flap procedure.

Here was the key on which my fate would turn: If the in-network plastic surgeon could do the Diep flap, then he would be my surgeon. However, when I saw him, he said I needed the Diep flap, but he is not skilled in this arena, and I'd need to go out of network. He drafted a letter on my behalf to the HMO, stating that I needed this procedure that he did not perform.

A few weeks later, the HMO came to its conclusion: It would cover the ENTIRE cost of the Diep flap, hospital stay, and all followups as needed. And, because my surgeon needed a doctor skilled in this type of surgery to help him (also out-of-network), the HMO paid for that additional surgeon as well.

Cost to me: 0 cents. Cost to my quality of life: priceless.

Whether you have an HMO or PPO, though, the key is to have the right doctors in place, so if a time of medical need arises, they will advocate for you.

Beth L. Gainer is a professional writer and has published an essay on her breast cancer experience in the anthology Voices of Breast Cancer by LaChance Publishing. She teaches writing and literature at Robert Morris College in the Chicago area. She can be contacted at bethlgainer@gmail.com and gainercallingtheshots@gmail.com. She also blogs on the adventures of her cats, Hemi and Cosette, at http://www.catterchatter.blogspot.com/.

"You're Fired!"

In a previous blog, I mentioned that I would share my know-how of hiring and firing doctors. Long before "the Donald" made "You're Fired!" the catch-phrase of the millenium, hiring and firing people was and is a part of doing business.

But despite all the sweet business deals to be had, there's no business more important than the hiring and firing of doctors. Your health -- and possibly your life -- depends on it.

Let's discuss the easiest part first: hiring doctors. You love a doctor and decide to use him or her. It's as simple as that. During your litmus tests of finding a gateway doctor or a specialist, you know this doctor is for you.

In more specialized circumstances -- like after you have met with a bunch of loser-doctors -- you can reveal during your interview that you are looking for that special doctor. For example, during the final planning of my mastectomy, I had the reconstruction surgeons lined up, but I needed a mastectomy surgeon.

The first thing I said to her was this: "I've got all my doctors in place -- except one. I need someone to do the mastectomy. I'm hoping you are the missing link." She laughed and said she hoped she was, too, and it turned out that she was a breast cancer survivor who had a single mastectomy and was sweet and kind and very empathetic.

I hired her on the spot.

(I didn't go into all the details about how the other two surgeons wanted to remove my ovaries and uterus and breasts. I also didn't tell her that, in my frustration with one of the organ grinders, I had the nerve to tell him that he might as well give me a sex-change operation, and alarmingly, the doctor just glared at me instead of laughing like his assistant.)

Now for the difficult part: how does one fire a doctor?

I wish I could tell you that I yelled at a doctor and pointed at him, saying "You're Fired!" as I stormed out of the office, but that would be false.

Truth is, it's always been really difficult and painful for me before, during, and after cancer to keep from crumbling under the authority of a doctor. In my previous blog, Say "No" to Thugs, I discuss how some doctors abuse their authority to bully their patients into compliance.

Here are the different ways I fired doctors (highlighted in red), and every case involved heartache and an embarrassing discovery that my mascara wasn't waterproof. You will notice that, except for a couple of times, "firing" meant simply walking away from these doctors.

**The surgeon who was so great to me during diagnosis and prognosis, but years later claimed it was unethical to do a preventive mastectomy: I flat-out told him he was wrong and that my gut instinct was right. He sneered at me, and I told him I was using another doctor.

**The gynecologist who lied to me when I was in my first trimester by telling me there was a 99.5% chance I'd carry this baby to term because he wanted to see me happy. I complained about him to his colleagues and never came back after my post-miscarriage D&C.

**The gynecologist who scolded me for my medical decision not to follow his advice. I left the office crying, but I never came back.

**The second-opinion oncologist who told me that if I didn't submit to his treatment, I'd be dead in a year -- causing me to leave yet another doctor's office crying. I called the first oncologist I saw, and he calmed me down and told me that I had no reason to believe that death was around the corner. I called the second-opinion guy and told him I would not take his advice and I was seeing another doctor.

These are just some of the doctors I fired, but they provide a very simple truth: we all have the capacity to advocate for ourselves and that firing doctors need not be dramatic -- and that sometimes the most courageous acts involve quietly walking away.

Beth L. Gainer is a professional writer and has published an essay on her breast cancer experience in the anthology Voices of Breast Cancer by LaChance Publishing. She teaches writing and literature at Robert Morris University in the Chicago area. She can be contacted at bethlgainer@gmail.com and gainercallingtheshots@gmail.com.

Say 'No' to Thugs

We are able to say “no” to our children, teenagers, relatives, friends, and significant others. So why is it so difficult to say "no" to doctors?

Society is groomed to say “yes” to authority figures – particularly doctors. Maybe it's because we are inundated with TV shows and all kinds of medi-dramas that place doctors smack in the middle of a medical pedestal. From TV's Marcus Welby to Emergency to Trapper John MD to ER to Grey's Anatomy, it's all the same rhetoric: a doctor's word is good as gold.

I've built a team of excellent doctors, all of whom I trust with my life. But I couldn't get to this point without making hard decisions about which doctors to hire and fire. (In a future blog, I will discuss how to hire and fire doctors.)

Not questioning doctors can result in all sorts of problems for the patient. At its very worst, though, not questioning doctors can land you a spot at the county coroner's -- and not an adventuresome one like that depicted in Quincy.

And if you find yourself facing a combative doctor who is trying to bully you into compliance, use a very effective technique: civil disobedience.

In short, say "no" to thugs.

Here are just some of the doctor thugs I said "no" to:

• At the time of my diagnosis, I sought a second oncologist's opinion. He chose a treatment protocol that I later learned would likely have caused long-term damage to my heart. I also asked him about harvesting my eggs because, despite my dire terror, I was hoping to have a baby after cancer. He said, "You might want to think about how fair it is to bring a child into this world, only leave it an orphan." I left that appointment sobbing. I said "no" to him and "yes" to the first oncologist I had seen. And each day I am grateful for that decision.
• When I was planning my preventive double mastectomy, a surgeon also recommended other organs get removed as a prevention. Based on the judgment of my excellent gateway doctor and excellent oncologist, I said "no." He proceeded to bully me by interrogating me on the phone as to why I was not removing these organs, and I infuriated him (not purposefully) when I said that I was following the advice of my other doctors instead of his advice.
• Dr. Remove-All-Your-Organs finally got over his anger with me and, in an act of good will, offered my mastectomy surgeon his assistance in the removal of my breast tissue. She called me to ask what I'd prefer: her alone or the two of them working together. I told her that I didn't want that man to ever touch me and didn't want him anywhere near me on that day. In fact, he'd better not even be in the operating room! (I would've liked to say, he'd better not even be in the same hospital as me on that day, but that would be pushing my luck.)
• Another doctor I consulted who wanted to remove some organs during the mastectomy (yes, there was another organ-fixated doctor) started interrogating me after the surgery as to why I didn't follow his advice. I was stifled at that point, but once I got my bearings, I fired him.

This is not to say that we should barrel into a doctor's office, treat them with disrespect, or be deliberately contrary. Doctors are often right about our medical needs.

However, we should never forfeit our rights to be key players in our own health care. And if you encounter arrogant bully-doctors, just employ civil disobedience: Say "no" to thugs.

Beth L. Gainer is a professional writer and has published an essay on her breast cancer experience in the anthology Voices of Breast Cancer by LaChance Publishing. She teaches writing and literature at Robert Morris College in the Chicago area. She can be contacted at bethlgainer@gmail.com and gainercallingtheshots@gmail.com. She also blogs on the adventures of her cats, Hemi and Cosette, at http://www.catterchatter.blogspot.com/.

Top Five Quick Tips on Choosing Doctors

In a previous blog, I covered Litmus tests for how to assess whether a doctor is right for you. Here, in a nutshell, are the top five things to keep in mind when considering a doctor -- from gateway doctor (primary care physician/internist/family doctor) to specialist:

1. Bring a notebook to your first appointment with questions written in advance. Leave ample space under each question for you to write notes.

2. See if the doctor answers your questions to your satisfaction and thoroughly -- in a way you can understand it.

3. Observe the doctor's body language. See if the doctor maintains excellent eye contact, and when you bring up your concern, whether he/she seems in a rush or simply sits down and talks with you. In addition, see if the doctor is distant from you emotionally and physically. If the doctor is comfortable being physically close to you while answering questions, that's a good sign.

4. Give the doctor an emotional prompt on a topic that really concerns you, such as: "I'm really worried about my cholesterol levels." If the doctor is empathetic and great at putting you at ease, that's a great sign.

5. Call the doctor back the day after your appointment to bring up another real concern. If he or she calls you back promptly and reassures you/answers your questions, that's a sign that the doctor is vested in your emotional and physical well-being and respects you.

These methods aren't foolproof, but they really are crucial in your quest to find the doctor who's right for you.

The Gateway Doctor

My grandmother always told me, "If you have your health, you have everything." As a child, I didn't understand the truth in these words. I didn't heed these words as a healthy young adult: I came from very genetically healthy stock -- people in my family die of old age for goodness sakes, even the ones exposed to asbestos, lead, and various other toxins!

I didn't heed my grandma's words until I was diagnosed with breast cancer. Because let's face it: I, as so many people, took my health for granted -- until I didn't have it.

Now I'm going to spin my grandma's words to suit my medical-advocacy purpose: "If you have a great gateway doctor, you have everything."

Besides you, the most important person managing your health care is the "gateway doctor," also known as the primary care physician, internist, general family doctor, etc. Whether or not you are healthy, whether or not your family has had the same physician they have felt comfortable with for decades, whether or not your doctor is well-versed in all of the new medical technologies, whether or not your doctor has had an established practice with a good reputation, it all boils down to this:

Do you trust your family doctor with your life?

If the answer is anything but a resounding, enthusiastic "YES!," find another doctor immediately. Your life is too precious to take a chance with incompetence and mediocrity.

I measure competent doctors by their medical and emotional know-how. They must be medically competent (sounds like I'm stating the obvious, but it needs to be stated) and they must have your best interest at heart. The latter point means more than just bedside manner: I have had doctors be pleasant to me during an examination, but mere pleasantries are not enough.

You must LOVE your doctor.

As is the case with specialists, the ideal gateway doctor cares about you as a patient and will work as hard as possible to advocate for you. Another perk is that a great family-practice physician tends to keep company with other excellent doctors -- and that opens the gateway to outstanding medical care.

I was lucky to have an outstanding gateway doctor in place before I got diagnosed with breast cancer. She was my physician for years because we had great patient-doctor chemistry.

Let me tell you what she did for me during my breast cancer journey:

She called me often, coaching me through the diagnosis and prognosis. She listened to me, and validated my concerns. She encouraged questions and provided prompt answers. She returned my phone calls, often on the same day that I left her a message. And she was working behind the scenes and putting an excellent team in place for me. She landed a great surgeon, steered me toward a fantastic medical oncologist and radiation oncologist. These top-level professionals all worked tirelessly to save my life, but they didn't treat me as if I were a mere patient.

They treated me like family.

And they were all HMO doctors.

(In a future blog, I will dispel the myth that all HMO doctors are bad.)

And even though I had a medical team of specialists who were unbelievably outstanding and kind -- like off-the-charts brilliant and sweet people -- I probably wouldn't have crossed paths with them, had it not been for my gateway doctor, whom I have called my guardian angel.

So now that I've waxed poetic about my gateway doctor, here are some litmus tests that can help you find the doctor that's right for you. These tests also apply to specialists, but you need a great PCP in place before you can even consider a specialist.

You'll need to set up a routine exam, perhaps with several doctors, to find the right one so please be patient.

Litmus test one: During your meeting, give an emotional prompt, like: “I’m afraid of blood tests.” Observe the doctor’s reactions. Is he/she emotionally vested in you? Reassuring? If not, find another doctor.

Litmus test two: Sometime in the week following your exam, call the doctor to ask a question. Does the doctor call you back promptly? Does he or she communicate with you clearly and patiently? Does he or she take your concerns seriously? If the answer to any of these is “no,” find another doctor.

Litmus test three: Based on litmus tests one and two, do you LOVE your doctor? If you are feeling badly about him/her or just so-so, find another doctor. Don’t settle for mediocrity because if there were a medical crisis, a doctor you love and who cares deeply about your welfare will be the one who fights for you.

Litmus test four: Does the doctor play “ring around the patient,” where he/she continuously throws statistics to impress you with his or her know-how? Does he/she come with print-outs of pages from the Internet to illustrate these statistics? Do you feel confused during and/or after the session?

Run – do not walk – away from this doctor.

Litmus test five: Does the doctor use scare tactics, telling you all the terrible things that can happen to you? Is he/she dismissive of your emotional and physical needs? Does he or she sound like a doctor who has watched too many ER or Grey's Anatomy episodes? If so, this is not the doctor for you.

All in all, trust your instincts and be persistent in your goals to find a great doctor. You will know whether a doctor is a good fit for you. Also, if you suspect something is wrong and a doctor does not give you a satisfactory answer or solution, then continue advocating for yourself. Don’t accept answers like, “You are too young to get cancer.”

Demand to be treated with respect and, if need be, be difficult to those who treat you unfairly. You have an amazing power to demand to be treated with respect – whether from doctors, nurses, and office personnel. If someone treats you with disrespect, such as rudeness, talk back.

You are nobody’s doormat, and they need to know it.