Just a Check Up

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.

Infection control

If we're wondering why we're failing at protecting health care staff from Ebola, take a look at this picture:

Aren't they cute? Can you imagine the number of bacteria they carry from patient to patient?

  Check out all of those adorable stethoscope covers.  There are patterns you can get, you can make them your own. I even saw a super cute alligator one.
And don't worry, I'm sure every nurse, doctor, medical assistant, and tech takes them off between patients and washes them, right?  I mean, they do that, right? (No. They don't. And good hospitals have made it clear that these covers are nothing more than infection magnets, but they are still sold to clinicians in health departments, surgery centers, and clinics across the country.)

Here's the scary part of the game, kids: very few medical staff actually are enforcing good infection control in the average clinic or hospital.  Most staff got a quick OSHA training on it and then just do what they're told by their supervisor.  We couldn't control infections enough to prevent MRSA from becoming a household name. It's not that medical staff are stupid.  It's not that they're malignant.  It's that we are complacent.  We haven't seen a truly terrifying plague like Ebola in the US since HIV/AIDS. (To be clear, I do not consider Ebola a plague or even an epidemic in the US.  I'm comparing it to HIV/AIDS only in the level of fear among US citizens, not in its scope or reach or impact on the actual health of the population.)

It was the HIV epidemic that introduced us to the idea of universal precautions against blood and body fluid exposure in the first place. But then more people were tested, treatments improved, and we realized that the people at risk were generally gay men and injection drug users.  So, well, we stopped worrying.  Magic Johnson got it and he didn't die, what's the big deal?  I mean, does the guy who gives me my flu shot really need to wear latex gloves anymore?
According to a 2010 article in the NY Times,  in the United States, the Centers for Disease Control and Prevention estimated roughly 1.7 million hospital-associated infections, from all types of microorganisms, including bacteria, combined, cause or contribute to 99,000 deaths each year.

The problem here isn't that we don't have the technology or the sophisticated medical care or access to great treatment.  It's that we rely entirely on those things, and we have become complacent.  I've witnessed in my career numerous blood draws done where the phlebotomist took off his gloves because the patient was "a hard stick" and the vein was hard to feel through the gloves.

 I've seen vaccines administered by nurses and medical assistants without gloves where the syringes were then stuck into the table to prevent a needle stick, rather than the clinic paying for the safety needle systems, pictured to the right, that are so readily available.  I've accidentally stuck my own finger a few times.  Luckily for me, it was only in the stage where I was drawing up the medications I was about to use, and the needle hadn't been used on any one else.  I've seen dirty gloves removed in the course of treatment and tossed casually aside on a counter top or even the floor, only to be picked up by cleaning crew or other staff, who were sometimes wearing gloves and sometimes were not.  I've seen simple procedures, such as incision and drainage of an abscess or removal of a skin lesion performed without eye protection.  And, I'll admit, I'm guilty of that last one.

I'm not saying these things to say that doctors, nurses and medical assistants are lazy or malignant.  I'm saying them because we're complacent.  But it's not limited to just clinicians. There's an entire community of complacent parents out there who have never seen a case of polio or measles or whooping cough outside of a movie or a historical documentary.  Those parents have decided that their non-scientific based fears are more important than some imaginary or historical disease, and refused to vaccinate.  And now, the epidemic we should be fearing and working to stop isn't Ebola, but rather measles.

Look, no medical system is perfect.  No individual is perfect.  But if medical systems (clinics, health departments and hospitals) don't take this opportunity to review their infection control models, don't put into place aggressive hand washing programs and don't take the time to update their processes for dealing with communicable diseases as they present, then this is a lost opportunity that may cost people lives.  Those lives won't be lost to Ebola, as the chances of getting Ebola in the US right now is less than the chances of winning the lottery or being struck by lightning.  Those lives will be lost to MRSA, to nosocomial infection, to influenza.  And that will be the policy fail that is unforgivable, not that a nurse got on a plane or that we allowed a man who had recently traveled to west Africa to leave the ER with symptoms.