Door of St. Patrick's Cathedral in New York City

“Your mammogram shows an area the radiologist is recommending that we biopsy. I am going to put in a referral for you to see a breast specialist to get that done.”

“Um. I already have the biopsy scheduled. The radiologist said they could do it. It has been approved by my insurance and everything.”

I glanced at the time stamp on the mammogram report. She’d had the mammogram done just that morning. The report summary said “suspicious calcifications concerning for malignancy….”

“I would really rather we get you hooked up with a breast specialist to do this.” 


Who do they think they are, scheduling my patients for procedures that I have not even authorized yet?

“I’d rather just get it done. It’s already scheduled for next week.”

“Look, I can get you in with the specialist in just a few days. This is not going to delay care in any way.”

Suspicion began to creep into her voice. “I really don’t want to,” she said firmly. What exactly had they said to her? 

How do you say, “I think you might have cancer,” without causing panic? How do you remain professional when you are seething inside?

If it were me, if it were my mother, I would want to have the biopsy done by a breast specialist, not a radiologist. They have surgical training but more importantly, they know what to do if god-forbid-it-turns-out-to-be-cancer. Instead of waiting to see someone that can take the next step, I would be already plugged in. I have seen it too often. The panic, fear… the rage… 

My patients deserve the same care I would get, the same care I would demand for my loved ones.

I knew how it was going to go, though:

“If you don’t stop doing this, I am going to stop sending my patients there for mammograms.”

The manager laughed at me through the phone. “You have to send patients to our facilities. We are in the same system. You know they track that sort of thing.” 

And she’s right….

The suit squinted at me from across the table.

“So, in analyzing the data from your mammogram referrals we see that you are sending about 52% of your patients to outside facilities. Care to elaborate on why that is?”

“Is it required that I send patients to only system facilities?”

“Oh, no. No. It’s not required.” 

That would be illegal.

“So why are you here talking to me about this again?” I could feel the pricks of anger rising under my skin.

“We can’t require you to do that but in the interest of managing costs for patients…” He trailed off. 

In the interest of keeping more money in the system…

I held back a laugh. 

It was an interesting thing, how much more frequently my patients getting mammos at system facilities seemed to end up getting biopsies compared to those facilities outside the system that did not do biopsies as part of their services. Did they track that, I wondered? Was my perception about this correct or merely a projection, tainted by the animosity I felt? I resolved to start keeping a tally.

“While we are on the subject, your referrals to system specialists is below the system average for primary care. Why?”

“The why depends on the patient. Some prefer to stay in the area. Driving downtown is a hardship for a lot of them, not to mention the cost of parking. Some need a physician with a certain set of skills or a certain personality. Some have experience with a physician through a family member or have been seeing this specialist for years and need a referral each year because of their insurance.” 

Why am I justifying this to you?

A month ago they added a button on external referral orders that requires me to provide an excuse so they can better track such things. If there was a “bite me” option on the choice list, I would use that. 

Previously they had only loaded the contact info for physicians within the system. If they were not a system specialist they had to be loaded manually by filling out a form that went to the practice manager then to a practice administrator and then to a VP and then to someone to add them in. It took weeks.

Provide us with a list of the specialists you would like to use and we will contact them to try to get them to join the system.”

“I’m not doing that. I’m not letting you use my name to convince them to join anything. If they want to join, they can look you up. Meanwhile, I will continue to refer in a way that keeps the best interests of my patients as a priority.”

Technically they could pull those names from electronic health record. Maybe they already had.

“Oh, we always want you to keep the interests of your patients as a priority. We would never ask you to do otherwise.”

Except that is not how it feels…


128 thoughts on “Needled 

  1. Business do not like these unknown variables. They should like to control all the possibilities. I can imagine your frustration, but I most identify with the anger under your skin.
    We plebs are just trying not to die, Mr Suit.

    Liked by 3 people

    • Money drives speedier referrals to some degree. It does affect quality. If patients cannot go elsewhere there is no drive for the system to change behavior or to improve quality. But we also have to shine a light on the negative….

      Liked by 3 people

  2. That exact thing happened to me with the biopsy and the breast cancer. The radiologist did the biopsy. Perhaps it was the person I had but I would never let that happen again. It took forever and was quite painful. After the diagnosis, I went to a breast cancer specialist. Fast forward down the road and I had to have a biopsy on the other breast. I dreaded it because of my previous experience. It was nothing. He was quick, no discomfort. Eventually my wonderful breast surgeon was gobbled up by the big box and he retired. Sigh. I trusted him. He referred me to an oncologist outside his system because he thought it would be a better match for me and he was right. Not sure if that would happen now. Not that there’s any pressure…..

    Liked by 6 people

  3. I went through this a lot as a Case Manager for a managed care medical group. If someone needed a referral to specialist outside “the network.” The medical director was pretty good about approving the referrals but someone had to do the work to get the approval, me, and we felt the pressure to stay in network.

    Liked by 1 person

  4. It’ll be a year on the 15th Sept that we found Humphrey. I saw the doc the next day, got a referral to the breast clinic within two weeks, where they did an ultrasound, mammogram and core biopsy. Another two week wait for the results, but I was asked to come earlier than my appointment time as the consultant surgeon was not happy with the results. She did her own biopsy, which was a little more painful, but she was brilliant. She knew what it was and didn’t bullshit us. The results came back towards the end of October, and I had my surgery on the 31st. No chemo (thank goodness) and a course of radiotherapy from December to January. I feel great and am grateful to all the support I had from the medical profession, friends and fellow bloggers. From what we understand, I can come back to the breast clinic here for follow ups if necessary ( about a three and a half hour drive) and will do so for continuance of care. The breast clinic do it all, and I have the utmost confidence in them.

    Liked by 1 person

      • Our small, critical access hospital merged with Behemoth about a year ago. The bean counters have descended upon the fiscal department. They have already outsourced coding. One of the reasons our hospital has loyal patients is that most people hate the “just for business” feel of Behemoth. So, what did the Powers That Be decide to do? Merge with the hated other. Let’s become LIKE them. stupidstupidstupid We did need to modernize (we still have paper EOBs), there was room for improvement, for sure, and things are tight, but instead we just sold out. The community is starting to write such comments on social media now. I fear it is too late. We’ve set the course. Bigger definitely equals worse occurrences of what you are writing about.

        Liked by 1 person

  5. I having a complete set of films, discs & reports. I am my own advocate.
    I am high risk, do accept. advice of my physicians. Breast MRI’s alternate
    6 mos is not fun.
    When it comes to surgeons, I pick them on advise of docs I trust.
    Thankfully I am not beholding to any healthcare facility.

    Liked by 1 person

  6. You bet! I have had to move my doctors a few times. It makes life much easier
    to walk into a radiology facility with a comprehensive set of reports,
    and all! A nurse friend impressed on me awhile ago that I needed to do

    Liked by 1 person

  7. I want to scream. Well, you do, too. My PCP is much like you (fortunately), and he sometimes shares with me his similar frustrations. Business and paperwork first, patients second. Terrible. Dr. Folsom made house calls when I was a child. I remember his white hair, deep voice, and warm smile. Patients were his only concern. Back then he had to deal with terrible diseases. You may find this interesting: I never had my tonsils removed as a child, even though I constantly had tonsillitis. The reason being there was a window of time in the early and mid ’50’s when doctors feared that removing tonsils left a patient more susceptible to polio. True doctor trivia.

    Liked by 1 person

  8. Please tell me that the corporate monopolies are still distant in U.S. healthcare.

    Obamacare is in part still present despite the current administration. Thing is when you get corporate monopolies only the wealthiest can actually choose and the less wealthy are forced to obey their healthcare provider. Healthcare should not be about greed.

    Liked by 1 person

    • The healthcare systems are trying to grow as fast as possible into huge monopolies, controlling as much market share as possible. Obamacare is not the cause of that. Greed is. Fear is. Government regulations are the cause of a whole host of other absurdities, though. Like the depression screens you get asked before your blood pressure is taken and the weight loss handouts that automatically print at the end of visits.

      Liked by 1 person

  9. This reminds of the way management looks at “key performance indicators” in pharmacy – things like how many scripts we dispense, how many add-on sales we do, etc, etc. They look at numbers and percentages, and it would be impossible for us to explain/justify all the lagging figures and missed opportunities. Sure, they know that patient care is important, but the bottom line is still the bottom line…
    I hadn’t realised doctors undergo this sort of numerical/statistical scrutiny too. Some expectations are simply absurd.

    Liked by 1 person

    • It gets worse as technology improves. The EHR doesn’t get better but the data they think they glean from it does. Well. It doesn’t improve per se. They can measure a lot more numbers but whether or not those numbers are truly meaningful is something else entirely.


  10. Dear Doc…. I hope you hold your ground. Nothing will change unless there is push back from the providers and patients. Yes, it is all about the money. But when you burn out your clinicians and turn them off to their calling, you won’t have anyone to MAKE the money. And what will happen is there will be only pond scum working as clinicians. I see this coming in our own agency. We have lost just about all our senior nurses. They have left because the reason they do home care…direct care for patients and families… is getting lost in the documentation, restrictions, overloaded, and lack of support from the higher ups. And as much as I teach compassion self-care, patient compassion and other hand-holding skills, the bottom line is that it does not make money. It is lip service to say we do it.
    Yes, I am a bit disgruntled as well with working in a “system”

    Liked by 4 people

  11. While I don’t entirely understand the American system, I do understand and know that where there is beaurocracy, humanity tends to lose out. Too much ‘system’ and not enough concern for individual needs.

    Liked by 1 person

    • Size has good and bad things, just like everything else in the world, I suppose. Good in that I do not have to negotiate contracts with insurance contracts. Bad as in what I wrote about here. Sometimes I ask myself if the good outweighs the bad. The truth is this is the story everywhere and being on your own is just too hard anymore.

      Liked by 2 people

      • Are there single-handed medical practices in the USA? I’d assumed that all had some degree of staffing, apart from the doctor. My father was a single-doctor practice and the only help he ever had was an occasional locum and later on a receptionist. Everything was done from his practice outward – referrals to specialists he knew at local hospitals or, further afield if necessary. But the system got too big for him and he was glad to retire when he did.

        Liked by 1 person

    • (I don’t know in what order this will appear but this is to Victo’s reply about solo practitioners.) The system is making it impossible for solo practitioners. Just the cost of the computer software was enough to drive the podiatrist I worked for into an early retirement (starting my long bout of unemployment). He and I could not have been further apart in our political leanings, but he had some very accurate and valid points about how the health care system was devolving. The age of the solo practice is over. It just isn’t economically feasible. That’s just wrong.

      Liked by 1 person

  12. I really think by sharing your stories with us you do two things: warn us and inform us. And I guess give us hope that there are still doctors who really do care about their patients first. Thank you! Unfortunely I am not sure about my own doctor……

    Liked by 2 people

  13. Wow! It seems like Physicians in the US and I wouldn’t be surprised if here in Canada too have their hands tied in so many ways and sadly for the sake of money more often than not. How sad. Where you able to convince that patient to see a specialist instead?

    Liked by 1 person

  14. When the “system” evolvles into a computer program that calculates diagnosis and treatment based on tests, that calls you with its disagreement and starts spitting questions you answer by “press 1 for yes”, its time to run for the hills and hang your shingle for people who pay with food or goods..
    I don’t envy your heart vs corp at all..

    Liked by 1 person

      • I think my typing needs to evolve 😂

        Yep, insurance companies have done this for years for denying benefit claims and predeterms..
        In my opinion “we”, the collective of insured are to blame.. Instead of demanding fairness in pricing from pharma, insurance and service providers, we pitted them all against each other and us.. This was started by 3 letters.. HMO.. People fell for the snake oil salesmen that peddled this crap company to company.. I didn’t join one until the mid 90s and that was only because it was the only company option.. Today we have many different acronyms but they all branched off the original rotten trunk.. Health providers had little choice except to accept these types of insurances.. The biggest losers in all this is the insured, in my opinion.. and we did it to ourselves..

        Liked by 1 person

  15. I can’t stand to read about the business end of this. I’m conditioned to think that medicine is pure and altruistic. That it exists for the good of humanity. But I force myself to take this stuff in. It’s naive of me to think the world of medicine is any different than any other business.

    St. Patrick’s on 5th Ave. That’s an easy one.

    Liked by 1 person

  16. I wish more people REALLY understood how broken the system is. Sadly, it is more people saying/thinking (voting) like, “I like the ACA but hate Obamacare.”

    The other day, while trying to unfry my brain after looking at too many bizarre Explanation of Benefits reports, in my job in the billing end of hospital care, I grazed some of the articles that popped up on my monitor from the MSN splash screen that our computers default to on the Internet. One was an article about the biggest industry in each state. By far the most common was either health care of some sort or insurance of some sort. That just ain’t right.

    Liked by 1 person

    • People are generally very uneducated about healthcare and partly that is due to the depth of complexity. Hell, I don’t even understand it all. Partly it is because we have isolated them from it, protecting patients from the ugliness.

      Liked by 1 person

  17. The American healthcare system always looks scary and complicated to us in Australia. As if it is a system that would willingly let people die on the hospital doorstep if they didn’t have the right insurance. I got hooked on the TV series Nurse Jackie for a while. I don’t think it was a comedy. And now, this week’s news about the nurse in Utah being manhandled by a police officer. Followed by his bodycam discussion about his concern that his actions would affect his second job with Gold Cross, and his threat to only bring transients to that particular hospital in future and take the “good ones” to another hospital. Good ones? Is that people with the right insurance? Right address? Right clothes? Not the homeless, the drug or alcohol addicted, or those living on the poverty line, I suppose.

    With regard to breast cancer, we have a system here where women of a certain age or predisposition are called every two years to attend a free mammogram. Sometimes there may be a “call-back” if there is any doubt it is all clear. Otherwise, any irregularities are immediately put through to the specialists for biopsy, and then on to the oncologist if that is malignant. I have several friends who have had that experience. They report it is all done with such calm and timeliness that they have no time to stress over the diagnosis. They just focus on treatment and recovery.

    Liked by 1 person

    • What happened to that nurse is horrifying. And yes, the threat about good vs bad patients does have to do with insurance coverage and probably, to some degree, personality. I like how your system is set up for breast concerns. We could do a lot better here with seamless care on that front.

      Liked by 1 person

  18. Our hospital system bought out a 26 person cardiology group last year.
    Two years earlier they bought out Physicians Associates, a multispecialty group of over 100 doctors.
    I read your blog and my mind starts spinning. I recall how long it took for my lumbar stenosis to be diagnosed. I think about how often my labs, pharmacy, and radiology tests are automatically done ‘in house’.
    I think about the ‘harmless’ nodules on my thyroid.
    I need to wake up!
    Thank you.

    Liked by 2 people

  19. The system is a nightmare and I don’t know how these people live with their conscious- that is if they have one. I was a victim of the this crap via my 25 year association with my ophthalmologist. He refers to a specialist in Austin and one in Round Rock for glaucoma/cataract surgery. I chose the female surgeon in Round Rock and had to enlist a good friend to drive me. (Not allowed to drive ones self post surgery).
    Prior to my surgery being planned, asked Dr..L for a local referral. Well, he said he did not know anyone in the Baylor Scott and White system. I figured then that he was lying through his teeth.

    After my surgery I asked Dr. J if she knew of a specialist in the Baylor/Scott and White System and without hesitation she gave me the name of Br B. who is located in Temple and only 30 miles from my town. I will be using him for the next surgeries. I liked Seton Williamson in Round Rock but it is/was too far away.

    Needless to say, am more than ticked at my log time eye MD. He only wanted to refer me to the MDs that he and his fellow doctors used and apparently they get a percentage of every patient who are referred. I know of no other motive.

    Liked by 1 person

    • The area I work in has hundreds of specialists in every field you could imagine but I don’t know who most of them are. Add to that the fact that physicians come and go all the time. I will often get patients asking me for a referral in a certain part of town or a certain hospital system but I have to tell them that I don’t know of anyone. It does not mean that they don’t exist. I just don’t know them and I don’t know their work or their personality. In those cases I tell patients to check to see who is covered in that area by their plan and call me with a name and I will be happy to do a referral. Also, we don’t get kick backs from referrals. Ever. Highly illegal.

      Liked by 1 person

      • Hmm well that is good to know. My eye doctor has one eye surgeon that comes to the clinic(( 2x monthly) to see new referrals made by my MD, The name of her clinic is on the wall outside of my MDs clinic. So is there no benefit to any MD of either practice. Do they pay each other for facility usage?

        Sorry to have a terrible assumption!

        Liked by 1 person

      • I have a GI specialist that comes from downtown twice a month and they pay a small facility fee. It is not very much at all, considering it is only two days a month. I used that person before they started coming (they are not part of the same healthcare system) but they are not the only GI specialist that I refer to. Sometimes the patient’s illness or personality is better suited to someone else. 🙂

        Liked by 1 person

  20. How did a “free nation’s” medical system get this way, where even the good doctors don’t have a say about their own patients? I hate always using my “bygone days” for a reference, but why did the family doctor with the black bag coming up your front steps lose its appeal? Was he not still the wealthiest man in town? Wasn’t he our best friend too? At least we got the top quality care back then. Good care was concluded with a cup of coffee or just a chat on the front porch. ❤

    I keep reading news articles about Medicare fraud, Veterans Administration fraud and on and on. Where are the honest people who used to genuinely care about sick people?

    Liked by 1 person

    • Keep in mind that there are criminals everywhere. Medicine does not have them at a higher rate than anything else but they get more press because of the scope and the horror of it. The vast majority of physicians are plugging away doing their best for patients.


  21. I’ve noticed this myself; my long-standing eye doctor takes my insurance, yet they always give me a hard time about a referral because he is not in the system. The same with mammograms. I do hope doctors stand up to all this garbage sooner or later. It will never change unless they do. (K)

    Liked by 1 person

    • Some insurance requires only a one time referral. Some don’t require a referral at all. Others require a new referral to the same physician done every single year. Some only need a paper referral. Others need a prior authorization number that requires my staff to enter into into a website or to spend some time on an automated phone system. Keeping it straight is a nightmare because it is constantly changing. If we screw up on our end, the patients get stuck with the bill. We now employ two full time employees just to manage the referrals.

      Liked by 1 person

      • I can see that…it is a nightmare. I was thinking that when I started working 40 years ago all my doctors took my insurance…I think they took all and any insurance. No referrrals needed…what happened? It isn’t that long ago. I think referrals are definitely a wedge to keep people from getting treatment. If you are truly sick (and maybe old too) you don’t have the energy or ability to keep after them. Even I put off stuff because it takes so much energy to even be able to see a doctor or get a test…(K)

        Liked by 1 person

  22. I am cheer-leading you right now!!!! Go Victo, Go Victo! I have a good PCP but I would prefer you to be my doctor. This is what drives me crazy about our health system. One of my excellent specialists discovered I am cystic (with cysts in the lung cavity and bile duct, WTH?) and said I will have to tell every radiologist/surgeon that I am. You go girl!!! 🎆🎆🎇

    Liked by 1 person

  23. Some of your posts do frighten me, my dear Victoria…
    A man seems to think he can rule the US (thus the world) in 140 characters.
    But your “suits” are pushing the control to its extreme.
    The combination of statistics (tally) with computers is beginning to scare me.
    Is everyone experiencing that in the US medical system, or is it the “organization” you seem to be affiliated with?
    Profit is fine, but greed?

    Liked by 1 person

  24. Oh, and I have read some of the 110 comments on this post. Some seem to come out of a Stephen King story. I was thinking, could you copy and edit some of the comments along with your posts and make a book? (Under an assumed name, otherwise you might lose your practice…)
    God, this all makes me so angry.

    Liked by 1 person

  25. I hate that you’re constantly forced to push back, but I love that you do push back. Listening to Bad Pharma here and there as I drive, I feel so sad for everyone who’s being squeezed by a few industries’ drive to maximize profits. It’s easy for healthy non-medics to feel like what’s being squeezed is an abstraction, but it’s not.

    It’s lives for profit: lives of patients who make insurance-approved choices that may well cut years (or even decades) off their lives, lives of patients who participate in research under the assumption their participation will improve outcomes for others (versus being shoved in a file cabinet and forgotten for “wrong” study results), the lives of doctors who want to see their patients live full and healthy lives, the lives of those who will someday be but have not yet been impacted by this squeeze, the lives of everyone who love all these people. So, pretty much, all of us.

    Hope for better is in the pushing-back against both the practices and idea that profits are worthier of protection than people, and so … you give me hope. Thanks.

    Liked by 1 person

  26. Pingback: Between books and life | The Monster in Your Closet

  27. I always type a snide comment when the EMR asks me to put a reason for something I have just done… I wonder when it will bite me in the ass.
    So far my favorite is “because I said so.” It’s the only place that line still works.

    Liked by 1 person

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