A Far Too Typical Visit

Mrs. Carignan was in my schedule this morning for her one-month follow-up. Three months ago I had requested a psychiatric consultation for her, but I had not heard back about any appointment date from RPA, Rural Psychiatric Associates. They had lost both their regular doctors a year or two ago, and had been getting by with locum tenens physicians since then. I had referred Mrs. Carignan because I needed help with both diagnosis and treatment in her case. I was hoping the newly hired permanent psychiatrist could help her.

She had been hospitalized twice, once for a “breakdown” in her forties, and again about ten years ago for what sounded like a manic episode. Since then she had been on several mood stabilizers and a few antidepressants. When her old psychiatrist, Dr. Andrews, left the area, she stopped her medications.

Several months ago, she came to see me about her nerves. She was anxious and depressed, and on top of it was exhibiting symptoms of mild dementia.

My usual armamentarium of medications for someone like her proved useless, and I had finally convinced her she needed a psychiatric reevaluation. After the first month of waiting to hear back from RPA’s appointment staff I decided to put in for a Prior Authorization from Wellcare, her Medicare D prescription insurer, for a more expensive agent for refractory and bipolar depression.

My heart sank when I saw her name in my schedule this morning. There had been no word from Rural Psychiatric Associates and there, right in front inside her paper chart, was the fax we sent off to Wellcare more than a month ago. There was no indication of any reply in her chart. I searched our new electronic medical record. She had no clinical notes in it yet, nothing about any response from Wellcare, and there was nothing in the referral module about a psychiatric appointment.

I checked the time – five minutes into her allotted fifteen minute visit. I called Wellcare with some trepidation. This was likely to take time, but I felt I owed Mrs. Carignan this, since the system – actually three different systems – had failed her.

After only a minute or two on hold I told Wellcare’s customer service representative my errand:

“I am a physician. I faxed you a coverage request more than a month ago and have not had any response yet.”

She politely promised to put me in touch with someone who would be able to help me.

Two minutes later, a young man with a heavy accent offered to help me. I had to spell Mrs. Carignan’s name twice, and he double-checked her birthdate and policy number. He put me on hold and I listened to the same music I had already become familiar with.

“I apologize, Doctor, could you give me your patient’s birthdate and policy number again”, the young man said. I obliged, and he excused himself again. I glanced at the clock above my desk. Five minutes left of her visit, I noted with more than a little concern that I might not be able to do much for her today.

“I am sorry, Doctor, we have a client with the same name, different spelling and not quite the same birth date”, the young man announced when he finally came back on the line.

“This is her Social Security number…”, I offered.

“Let me look her up that way, then, Doctor. Would you mind holding for just one minute?”

I looked at the clock again. Two minutes left.

“Thanks for holding, Sir. I am sorry but we have no client with that Social Security number.”

“I see”, I said. “Well, I have already spent her entire appointment speaking with you on the phone. Thank you very much for looking into this. Good-bye.”

I grabbed her paper chart and my laptop and entered Room 1.

“I’m sorry to keep you waiting, Mrs. Carignan. I have just spent the last fifteen minutes talking to Wellcare, your prescription insurance, about that medication I wanted to prescribe for you. They claim they never heard of you.

“But I’ve been with them for years.”

“Let me call your pharmacy”, I said as I pulled out my cell phone.

A minute later Sandy, the new pharmacist at Williams’ Rexall answered my question:

“Wellcare is paying us just fine for her medications, but the policy number we have is different. It’s 596 0059.”

I wrote down the number, wondering when I would ever get the time to call them back.

Opening my laptop, I said:

“So we have no word from the psychiatry office and your insurance company don’t know who you are.”

She looked puzzled.

“Should I go on taking this”, she asked, reaching into her zippered toiletry bag with all her pill bottles. She produced a small bottle with an antidepressant I had not prescribed for her.

The name of the doctor on the bottle was Mary Meyerer, the new chief at Rural Psychiatric Associates. The fill-date of the prescription was almost three weeks ago.

“Oh, you did get an appointment with the psychiatrist!”

“Yes, and I’m going back next week again…”

“Great. I’m glad you finally got an appointment. You see, some specialists, particularly psychiatrists, don’t tell us when they make an appointment for someone we refer to them.”

“That seems silly…”

“Well, yes.” I paused. “At least you got in.” Looking quickly through her chart I added:

“I see it’s been a while since you had your bloodwork done for your cholesterol. Let me put an order in the computer for that…”

The task bar on my laptop informed me that I was 30 minutes behind, with two patients waiting in exam rooms and a third in the waiting room.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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