6 nonbillable events that paid me handsomely

A consultant urged the author to avoid doing anything he couldn't bill for. His response: Those encounters can be the most rewarding kind.

By Richard E. Waltman, MD
Family Physician/Tacoma, WA

Our medical group recently hired a billing expert to help us improve coding and increase charges. He urged us to avoid "nonbillable encounters" and to charge for whatever we did. "Keep the meter running at all times," he said. "You are highly trained professionals, and deserve to be paid for what you do."

This consultant does a very good job. He knows his material and presents it clearly. I picked up a few tips from him that will probably help my bottom line, and I am grateful for that.

But he missed a key point. Some of the most gratifying moments we physicians enjoy have nothing to do with money. Making a great diagnosis, intervening quickly and seeing a patient recover, having a patient come back to see us in the office after a difficult hospitalization, providing support to a dying patient—experiences like these give us compensation that cannot be measured in dollars and cents.

Here are some recent earnings of mine that won't appear in my paycheck but are, simply put, priceless.

Sara Reilly (I've changed all the names) is an 80-year-old woman, relatively new to our practice, with controlled hypertension and advanced arthritis. As I stood to leave the exam room after a recent visit, she asked whether I could answer a "stupid" question for her. She wanted to know whether a man who is dying of a stroke experiences pain.

I sat down again, realizing my morning schedule was now shot, and she told me how she had cared for her husband at home after his stroke. She felt she had done a good job, but she was upset because "I wasn't there at the end."

She explained that she was sitting next to his bed, kissed him, told him she loved him, and then fell asleep in her chair. When she woke up, he had passed on. She told me that in the six years since his death she had felt that she'd failed to comfort him in his last minutes. She worried that he might have felt pain that she didn't help him with.

I explained that he likely hadn't experienced any pain, but had had a comfortable passing. I also reminded her that the last words he'd heard in his life were "I love you" and that the last person he'd seen was his wife of so many years at his side. I told her she had provided him a loving and gentle death, the way we all want to go, and that she had done a great job for him.

Mrs. Reilly cried, then smiled and asked if she could give me a hug. And a great hug it was. A week later I received a note from her. She said she still hated taking her blood pressure medications and still had a lot of pain from her arthritis, but that what I had told her had eased her mind and made her feel so much better. She told me she would never forget my kindness. And I won't forget her.

Mary Richardson is an 88-year-old woman with advanced arthritis that forces her to use a walker. Her great-grandson invited her to his wedding in Hawaii, and though she was hesitant to make that long trip alone, I persuaded her to go.

She made the preparations, but then fell at home and fractured her pelvis a week before the trip. I hospitalized her for pain control and asked the physical therapists to give her double sessions each day. When she said she was still too ill to fly, I told her, "You'll be on that plane if I have to drive you to the airport."

We were able to get her well enough to use a wheelchair, and the airline agreed to help her. She made the trip. In the office two weeks later, back in her walker, Mrs. Richardson told me how glad she was to have been there for the ceremony, and thanked me for making her go.

A week later, I received a thank-you note from the groom. He told me that having his great-grandmother at the wedding was a wonderful blessing and that he would be eternally grateful for my concern. "You really must be a good doctor to be so concerned about our family," he wrote.

Ted Rosen is a 41-year-old man with primary sclerosing cholangitis. He had been doing well, but then his liver functions began to worsen. He was seeing his gastroenterologist, and I was not involved in his day-to-day care.

I did, however, see his father, Al, who's also our patient. He has hypertension and GERD, and this day his blood pressure was unexpectedly high. So I asked him, "What's up, Mr. Rosen? Is something bothering you today?"

Al told me he was very upset because his son was going in for an ERCP biopsy, and possibly stenting, the next morning. We talked a lot about the procedure, about the disease itself, and what was likely to happen.

A very strong and private man, Mr. Rosen was able to open up and say how fearful he was for his son. We talked as two dads as well as patient and doctor, and we acknowledged how our job is to protect our kids and how inadequate we feel when we seem powerless.

I pointed out that by supporting Ted and being emotionally available for him and his family, Al really was doing something very important—being there in a way that only a father or mother could be. Al thanked me for my words and interest, and he told me, "With your help, Doc, we're going to get through this thing."

I thought about Ted for the rest of the day, and after patients, evening rounds, charting, and reviewing labs and reports, I pulled Ted's cell phone number off the computer and called. "It's 8:15, Doc. What the heck are you doing in the office?" he asked.

I told him I'd heard about his tests and wanted to know how he was feeling. Ted tearfully told me that he was "scared as hell." He wasn't concerned for himself, but for his wife and two young children.

We talked for about 30 minutes, both about his illness and about family, and at the end of the conversation, both of us were tearful. Ted thanked me for my concern. He told me he was determined to keep going and would hope for the best. "It's not my time, Doc," he said. And then he added, "I can't tell you how much better I feel after talking with you. I still can't believe you called me."

Sam Eaton is a 79-year-old man in excellent health. I've seen him just once or twice a year, but I saw his wife more frequently until she died two years ago.

I had Mr. Eaton come in for an appointment to discuss his wife's death. He had a lot of questions, but I wasn't able to get him to grieve. So I had him come back again in a month, and once again he talked a lot about his wife, still without expressing much emotion. "You want to make me cry, don't you?" he asked.

I said Yes. He needed to express his grief and loss. "I'm doing fine, Doc. I appreciate your concern, but I don't need your help."

Two months later, Mr. Eaton was on the schedule for a flu shot. I asked my nurse to put him in an exam room when he came in, and I followed in right behind. I told him that I was concerned about him and his reluctance to express his sadness. He looked at me with a profoundly sad face and asked, "Well, how would you feel if someone drove a machete into your heart?"

And then the tears came. Mr. Eaton said it was the first time he had cried, told me how much he missed her, how lonely he was. We had a good talk, and we met once a week for the next few weeks. I hooked him up with a survivor support group and encouraged him to open the lines of communication with his children and some friends.

It was a very tough course for Mr. Eaton, but he is doing much better now. At his recent checkup, he told me that he felt he was able to cry that day when he'd come for the flu shot because he knew I was going to keep after him until he did, and because he knew I was worried about him. "You don't care about my insurance or my bank account, Doc. You care about me. Thanks."

Peggy Hawthorne is a 56-year-old patient with poorly controlled diabetes, worsened by overeating, inactivity, and smoking-related lung disease. I'd made many efforts to get her to stop smoking and take better care of herself.

She called for an appointment and said she needed tranquilizers. A week earlier, the local newspaper had reported that two people were killed in a drug deal gone bad. I was surprised to hear from Peggy that her 31-year-old son was one of the two. Even though I knew they were estranged and that he'd been in trouble before, I was shocked by the news.

I was also disturbed to hear from Peggy that she wasn't getting much sympathy. She said that the police officers who came to her home to inform her of her son's death told her that "this is usually what happens to these guys," and her minister had suggested a quiet burial without a formal service "under the circumstances."

I told Peggy how sad I was to hear about her loss, and encouraged her to let out her feelings. "He may have been a drug addict and a criminal, but he was my son," she said. "I'm devastated. I miss him terribly."

She cried, I became tearful, and we talked about his early years, the happier and simpler times. I told her that her loss was huge and her sadness was just and understandable. "You lost your son, Peggy. You must grieve as a mother must." I encouraged her to call me if she needed to talk, and sent her a sympathy card.

Several weeks later, she said that "things are still tough," but added, "I really appreciate what you said. It helped me a lot."

Betty Hancock is a 47-year-old woman who came to see me with a palpable breast mass that appeared just a few months after a normal mammogram. A needle biopsy was positive, and she was scheduled for surgery.

Thinking about her one night, I sent her a card that arrived the day before surgery. In it, I told her that although it was going to be very tough, I really felt that we could cure her. I promised that I would get the very best people involved in her care and that I would do everything I could to help and gain a good result for her.

I saw Mrs. Hancock in her room the evening after surgery. She was surrounded by family, and the note I had written was on her bedside cabinet. Still clearly in pain, she took my hand and said, "Thank you for the wonderful card. I was afraid, but when I read what you wrote, I felt so much better. I am so fortunate to have you as my doctor."

Six very special moments. My patients all thanked me. But I feel I should thank them for letting me into their lives and for sharing their deepest feelings and thoughts with me. What a privilege that is.

I agree fully with our billing consultant that within ethical bounds we should bill correctly and try to maximize our incomes. But he's wrong if he thinks that's why I go to work. Sure, the money is good. But it's the sense of worth and accomplishment I gather from interactions like these that is my real payoff. In the currency of making a difference every day in the lives of so many people, no profession pays better than being a physician.

 

Richard Waltman. 6 nonbillable events that paid me handsomely. Medical Economics 2002;1:67.