As you know. Or maybe you don't, I'm a primary care physician. Our office is obviously not your typical doctor's office, we are a Direct Primary Care (DPC) office. Here's the quick and dirty on how it works.
We file no insurance claims. You may have insurance (and about half of our patients do), but we won't file a claim for your visit, you have to pay it out of pocket. There are 2 choices for that:
--You can pay as you go: Our current price for an office visit is $68 for non members. It doesn't matter if you're a new patient or established patient, if you're not a wellness member, then it's $68 plus whatever labs or procedures you may require. Most of our labs are either $34 or $68 (we try to keep it pretty simple).
--You can become a wellness plan member. Wellness plan members pay a $20 scheduling fee for their office visits and get a number of services that are discounted or included in the price of membership. This includes the lab work for the complete physical, strep test, urinalysis, ECG, cryotherapy (freezing skin lesions), annual flu shot, etc. We also often waive other fees associated with shots or biopsies or laceration repairs, etc. We're awesome like that. Patients can buy the plan either by paying a monthly fee or paying a lump sum (the latter is a better value, by the way). The current 2015 price is $45/month or $499.
You may have already heard of offices doing something like this, and you know it as concierge medicine. This is not the same as concierge medicine. It's more like concierge medicine's younger, less expensive cousin. Concierge medicine usually costs several thousand dollars a year, gives you unfettered access to your physician at any hour by phone or email, and your physician only has a very very small number of patients that she cares for (maybe 200 or so, instead of 1500 to 2000 in the standard physician office). There are some aspects of either type of care that cross over: email interactions, telemedicine visits, longer visits, etc. But a concierge practice often will file insurance claims for visits, in addition to the monthly or annual fee (the average is around $200 per month, but some high end practices can charge up to $20,000 per month or more). In direct primary care (DPC), there are no insurance claims filed by the provider for visits.
Now, I tell you all of that so I can tell you this: once you're an adult, you might want to stop calling your doctor's office to schedule a "check up."
The problem with this line of thinking is that, other than for a child, I have no idea what a "check up" is. Certainly with small children and infants, there are a number of well-child checks that are indicated at 2, 4, 6, 9, 12, 18 and 24 months, and then annually through adolescence and puberty. Those are often referred to as check ups, which makes sense, as you're checking in to make sure a child is hitting all of his benchmarks for development (and getting vaccinations). We also take the opportunity at those visits for anticipatory counseling: talking about bike and water safety, risks associated with smoking and alcohol, answering questions about reproduction and STDs, reviewing possible dangerous behaviors.
However, for an adult, we're not developing anymore, so to speak. We've finished puberty and we're adults. That isn't to say that we don't change or develop problems as we age. We start encountering new issues like blood pressure, diabetes, cholesterol, reflux, arthritis, not to mention the various acute infections and injuries we all may sustain at some time or another in our life.
In my experience, patients often call our office for a "check up" because they either want to be seen for one of two things:
--There's a new problem, one that's usually been going on for a while (belly pain, headaches, skin changes, fatigue, etc). It's a new problem, but not exactly acute, like a sinus infection.
--The other thing people asking for a check up really are asking for is a physical. In these cases, especially for someone who hasn't been to the doctor in years, often it's because a friend became ill, an uncle had a heart attack, a parent was diagnosed with cancer, or a life insurance physical showed an abnormality and the person wants to be checked out. Something has spurred that person to make an appointment to make sure that he is "okay."
Most people don't realize that the differentiation matters, but to your doctor, it does. For a problem or sick visit, we're going to focus on the problem at hand. This may require lab or xrays, but it's very focused on that one problem. For a physical, the approach is more broad and the questions are going to be aimed and screening for common problems or chronic illnesses. Our approach is different, the visit goals are different.
In our office, I am pretty convinced that most people who call saying that they want a "check up" but not a physical are trying to avoid the price difference ($68 for a single office visit vs. $499 for a physical/wellness program). In a traditional office that files insurance claims, the difference can mean 100% covered preventative visit (your physical) versus a visit where the patient pays a copay or even the cost of the visit if she has a high deductible plan.
What's my point? Well, my point is that when you call your doctor's office and want to be seen, be clear about what you want. Are you ill? Are you having a problem you want addressed? Make that clear when you make the appointment. Or are you just more interested in general screening for things like cholesterol, sugar, blood pressure, kidney and liver function? If that's the case, then schedule a complete physical. This differentiation means that you and your doctor both have the same goals in mind for your visit.
The problem is that if a patient calls for a "check up" appointment, the implication is that there are no problems or concerns and it's just a screening visit. I've even had appointments with patients where they made it clear it was just a "check up" and then called back a week later to complain that I hadn't fixed their back pain or their belly pain that they did not tell me about. Be upfront with your doctor about your concerns and your goals. We can't read your mind, and as much as we want to remember every detail you've told us, sometimes we just don't.
Look, most of us are busy and we're on a budget. We don't like to waste time or money, or at least most people I know don't. So make the most of your time with your doctor. When you request an appointment, be honest about your expectations: are you concerned about a specific problem? If you are calling because you want a "check up" be honest with yourself and with the scheduler. Because that's what you're probably really asking for and calling it by a name may seem to give you a cheaper price, but it won't be the same thing, and ultimately you will be disappointed.
Monday, April 27, 2015
Saturday, April 4, 2015
Losing your friends
I got hit with a sledgehammer this week. I didn't realize it when it happened. Sort of like when you knock your arm on the door handle and don't realize how much it hurt you until a few days later when you see a really, really ugly bruise. Or no bruise appears but that place on your arm is unreasonably tender.
That's what happened to me.
My mom called me this week. Granted, I get a little nervous when I see a Montana area code on my phone. My dad had a stroke 5 years ago. We've had ups and downs since then, and secretly whenever my phone rings and it's a 406 number, I fear that it's "the call." If you're an adult, you know: that call when your mom calls to tell you that your dad is in the hospital. Or worse.
This time it was worse, but it wasn't my dad.
If you have known me for any significant period of time, you know that when I was 13, my 15 year old sister, Kate, died. In the wee hours of a February morning in 1985, my brother woke with a sore belly, asking my mom for help. She went to the kitchen to get him some Pepto Bismol, the universal remedy for all sick children everywhere in the 80s. While she was in the kitchen, she heard something in our garage. She walked through the kitchen door that led to the garage, and she saw something that I can't even imagine: the car running, the garage door dow, and her 15 year old daughter in a heap near the open driver door. My heart catches in my throat just writing that. As a mother, I can't imagine it.
She hit the garage door opener button to open the door, and she ran to the car, turning it off, all the while yelling for my dad. Before she could tend to her unconscious daughter on the floor, she passed out. My father called 911. He moved my mother inside the house and tried to revive my sister. EMS providers arrived.
In the meantime, I was downstairs, sleeping on a pull out couch bed with my best friend at the time, Amy, who had come to spend the weekend. Amy and I had become friends when our family lived in Laurel, MT, about 20 miles from Billings, where we lived at the time. When we moved from Laurel to Billings when I was in 4th grade, we would often spend weekends at one another's homes. This weekend, Amy was spending the weekend at our house. I was roused from sleep by an EMS worker who was checking my vital signs. He was telling me my sister was sick and that we needed to wake up and come upstairs. I stumbled on the stairs (probably because it was 4am and I had just been shaken from a dead sleep), so I got carried up the stairs and set on our living room couch and placed on oxygen. From my vantage point, I could see the lights from ambulances, I could hear large fans blowing in the garage. More importantly, I could hear my mother from her bedroom down the hall yelling and crying. "She's dead, isn't she? I know she's dead. Oh, God."
I had no idea what was happening. None.
To make an already too long story shorter, my sister died that night.
But this isn't about her. It's about her best friend. Marge Nicholson. She lived about 2 and a half blocks over if you took the trails. Kate and Marge were friends through junior high and high school Marge had an awesome Ford Cobra. It had a badass stereo. No, seriously, it was badass. Marge loved bands like Twisted Sister and Bon Jovi, and Ratt. She had all of their albums on cassette and blasted their music from that green sports car daily.
Kate rode to school with Marge every day. When I started junior high as a 7th grader, Kate and Marge were in 9th grade. True to form, I wasn't allowed to be seen with them. But I still got to ride to school with them. I think my mom made them take me along: if Kate didn't have to ride the bus, then neither did I. Once they moved into the high school, my junior high was literally on the way. So I still got to ride with them. I went from being the "stupid little sister" who should keep her distance to the cool kid getting a ride to school with high school kids in a badass car with a very very loud stereo. It was, I felt at the time, the one cool thing about me as an 8th grader. I had older friends who were awesome
Then, that night happened. Kate died. Everything changed. After a week of being out of school, when I came back people looked at me differently. I'm not sure if it was real or imagined, but I was different. Something was gone. I was that girl whose sister died. The 'cool kids' who had tortured me for being fat, for being a nerd, for being smart? They laid off. But the weight of being the girl whose sister had died, maybe even killed herself, was worse. I'd rather be the fat, smart nerd, somehow.
But in the coming weeks, some things happened. They were things that I didn't realize were important to helping me recover, to feel normal. Marge still gave me a ride to school every day. She asked me to come over and hang out with her occasionally (something she'd never done outside of Kate being there).
She took me with her to cruise the strip, as everyone who has lived in a small town has done on Friday or Saturday nights. She was interested in how I did in school. She asked me to come with her to clean out Kate's locker. We sat on the floor of that high school in the middle of the day. We cried over papers, pictures, books. We hugged. On the drive home, we saw him: the downtown Roller Skater. There was this guy in my home town who would put on brightly colored clothes (usually short shorts and a tank top), his headset and his skates and would just skate. He skated on the sidewalks, often doing dance routines to songs only he could hear. Stopped at a red light, he skated up past the car we were sitting in. We were raw, and I mean raw. We had cried our eyes out, were emotionally spent to the point where we could do nothing but ride in silence, ever aware of the box of Kate's high school experience in the back seat like a boulder weighing down the car and slowing our lives as we drove home. And the Skater flowed past us, arms and legs putting on his own gorgeous ballet for no one's benefit but his own. He reached up and grabbed the "Don't Walk" sign bar, and pulled himself up, while still dancing, and Marge and I? We lost it. We laughed, we watched, we missed the light turning green, but we couldn't bring ourselves to hit the gas: we had to watch this man literally dancing to the beat of his own drummer. He lifted us out of our mire into laughter and joy.
Over the next few years, Marge was my friend. She took me to my first 'R' rated movie, the Breakfast Club. She let me have my first real glass of wine (not the sips I got of my parents' glasses at holidays, but a whole glass poured just for me). She just loved and accepted me. I never, ever, not once in a million years would have accepted it or understood it. If you had asked me who my best friends were in junior high and high school were, until recently, I wouldn't have even thought to name her as one. It never occurred to me how much she anchored me, healed me, accepted me in ways none of my other friends could. They hadn't lost someone like I had. But Marge did. She understood. She'd lost a sister, too.
I regret every day that I never told her how integral she was to me staying sane for so long after Kate died. Every. Single. Day.
I regret it more now because of that call I mentioned earlier: Marge died earlier this week. Cancer. Fucking, goddamn cancer. Not only that, but the 2nd time for her. Seriously, what the actual fuck? Marge was a mother, a foster mother, a sister, an aunt, a wife, a friend. She was amazing. She loved in such a deep and wild and unabandoned way. She was, in a word, amazing.
And now she's gone. And the world is less, so very very much less for losing her.
And so am I.
So, Marge, I hope you get Wi-Fi in heaven, because I need you to know this one thing: you kept me sane, you loved me, you made me feel normal in a time when no 8th grade girl feels normal. Thank you, a million times over. Thank you. Rest well, dear friend, and I know when you meet God, he will say to you, "well done, my good and faithful servant."
To read her obituary, please click here
That's what happened to me.
My mom called me this week. Granted, I get a little nervous when I see a Montana area code on my phone. My dad had a stroke 5 years ago. We've had ups and downs since then, and secretly whenever my phone rings and it's a 406 number, I fear that it's "the call." If you're an adult, you know: that call when your mom calls to tell you that your dad is in the hospital. Or worse.
This time it was worse, but it wasn't my dad.
If you have known me for any significant period of time, you know that when I was 13, my 15 year old sister, Kate, died. In the wee hours of a February morning in 1985, my brother woke with a sore belly, asking my mom for help. She went to the kitchen to get him some Pepto Bismol, the universal remedy for all sick children everywhere in the 80s. While she was in the kitchen, she heard something in our garage. She walked through the kitchen door that led to the garage, and she saw something that I can't even imagine: the car running, the garage door dow, and her 15 year old daughter in a heap near the open driver door. My heart catches in my throat just writing that. As a mother, I can't imagine it.
She hit the garage door opener button to open the door, and she ran to the car, turning it off, all the while yelling for my dad. Before she could tend to her unconscious daughter on the floor, she passed out. My father called 911. He moved my mother inside the house and tried to revive my sister. EMS providers arrived.
In the meantime, I was downstairs, sleeping on a pull out couch bed with my best friend at the time, Amy, who had come to spend the weekend. Amy and I had become friends when our family lived in Laurel, MT, about 20 miles from Billings, where we lived at the time. When we moved from Laurel to Billings when I was in 4th grade, we would often spend weekends at one another's homes. This weekend, Amy was spending the weekend at our house. I was roused from sleep by an EMS worker who was checking my vital signs. He was telling me my sister was sick and that we needed to wake up and come upstairs. I stumbled on the stairs (probably because it was 4am and I had just been shaken from a dead sleep), so I got carried up the stairs and set on our living room couch and placed on oxygen. From my vantage point, I could see the lights from ambulances, I could hear large fans blowing in the garage. More importantly, I could hear my mother from her bedroom down the hall yelling and crying. "She's dead, isn't she? I know she's dead. Oh, God."
I had no idea what was happening. None.
To make an already too long story shorter, my sister died that night.
But this isn't about her. It's about her best friend. Marge Nicholson. She lived about 2 and a half blocks over if you took the trails. Kate and Marge were friends through junior high and high school Marge had an awesome Ford Cobra. It had a badass stereo. No, seriously, it was badass. Marge loved bands like Twisted Sister and Bon Jovi, and Ratt. She had all of their albums on cassette and blasted their music from that green sports car daily.
Kate rode to school with Marge every day. When I started junior high as a 7th grader, Kate and Marge were in 9th grade. True to form, I wasn't allowed to be seen with them. But I still got to ride to school with them. I think my mom made them take me along: if Kate didn't have to ride the bus, then neither did I. Once they moved into the high school, my junior high was literally on the way. So I still got to ride with them. I went from being the "stupid little sister" who should keep her distance to the cool kid getting a ride to school with high school kids in a badass car with a very very loud stereo. It was, I felt at the time, the one cool thing about me as an 8th grader. I had older friends who were awesome
Then, that night happened. Kate died. Everything changed. After a week of being out of school, when I came back people looked at me differently. I'm not sure if it was real or imagined, but I was different. Something was gone. I was that girl whose sister died. The 'cool kids' who had tortured me for being fat, for being a nerd, for being smart? They laid off. But the weight of being the girl whose sister had died, maybe even killed herself, was worse. I'd rather be the fat, smart nerd, somehow.
But in the coming weeks, some things happened. They were things that I didn't realize were important to helping me recover, to feel normal. Marge still gave me a ride to school every day. She asked me to come over and hang out with her occasionally (something she'd never done outside of Kate being there).
She took me with her to cruise the strip, as everyone who has lived in a small town has done on Friday or Saturday nights. She was interested in how I did in school. She asked me to come with her to clean out Kate's locker. We sat on the floor of that high school in the middle of the day. We cried over papers, pictures, books. We hugged. On the drive home, we saw him: the downtown Roller Skater. There was this guy in my home town who would put on brightly colored clothes (usually short shorts and a tank top), his headset and his skates and would just skate. He skated on the sidewalks, often doing dance routines to songs only he could hear. Stopped at a red light, he skated up past the car we were sitting in. We were raw, and I mean raw. We had cried our eyes out, were emotionally spent to the point where we could do nothing but ride in silence, ever aware of the box of Kate's high school experience in the back seat like a boulder weighing down the car and slowing our lives as we drove home. And the Skater flowed past us, arms and legs putting on his own gorgeous ballet for no one's benefit but his own. He reached up and grabbed the "Don't Walk" sign bar, and pulled himself up, while still dancing, and Marge and I? We lost it. We laughed, we watched, we missed the light turning green, but we couldn't bring ourselves to hit the gas: we had to watch this man literally dancing to the beat of his own drummer. He lifted us out of our mire into laughter and joy.
Over the next few years, Marge was my friend. She took me to my first 'R' rated movie, the Breakfast Club. She let me have my first real glass of wine (not the sips I got of my parents' glasses at holidays, but a whole glass poured just for me). She just loved and accepted me. I never, ever, not once in a million years would have accepted it or understood it. If you had asked me who my best friends were in junior high and high school were, until recently, I wouldn't have even thought to name her as one. It never occurred to me how much she anchored me, healed me, accepted me in ways none of my other friends could. They hadn't lost someone like I had. But Marge did. She understood. She'd lost a sister, too.
I regret every day that I never told her how integral she was to me staying sane for so long after Kate died. Every. Single. Day.
I regret it more now because of that call I mentioned earlier: Marge died earlier this week. Cancer. Fucking, goddamn cancer. Not only that, but the 2nd time for her. Seriously, what the actual fuck? Marge was a mother, a foster mother, a sister, an aunt, a wife, a friend. She was amazing. She loved in such a deep and wild and unabandoned way. She was, in a word, amazing.
And now she's gone. And the world is less, so very very much less for losing her.And so am I.
So, Marge, I hope you get Wi-Fi in heaven, because I need you to know this one thing: you kept me sane, you loved me, you made me feel normal in a time when no 8th grade girl feels normal. Thank you, a million times over. Thank you. Rest well, dear friend, and I know when you meet God, he will say to you, "well done, my good and faithful servant."
To read her obituary, please click here
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