LOS CABOS, MEXICO Every community dermatologist dreads the phrase, "Oh, by the way … "
It comes, all too often at the end of a harried day, spoken by the young mother with rosacea who waits until the last millisecond to point out her teenager's acne and her 8-year-old's hair loss.
To survive, clinicians often come up with creative, effective, and amusing strategies to cope with real-world dilemmas, but they rarely sit down and compare notes.
That's why Dr. Michael A. Greenberg, a dermatologist in Elk Grove Village, Ill., codirected a workshop entitled, Bring Us Your Office Problems, at the annual meeting of the Noah Worcester Dermatological Society.
The problems raged, but solutions abounded at the lively session. Here are some of the more thorny issues presented, as well as the attendees' suggestions.
"Oh, By the Way …"
All dermatologists who attended the session said they stop what they are doing and take a look only if the last-minute issue involves a black or otherwise suspicious lesion. If not, they delay. Some explain to patients that medicolegal rules require that any visit be documented in a chart. They send the patient and his or her entourage back to the front desk so a chart can be established or retrieved, and then offer to work the new patient into the schedule.
"It may be 5 minutes; it may be an hour," Dr. Charles Zugerman of Chicago tells his patients.
Dr. Lee J. Vesper of Cincinnati emphasized the complexity of what may seem like a simple issue: "There are 52 kinds of hair loss. I need to take a good history."
Dr. Greenberg quipped, "I don't take quick looks. I only take careful looks."
"I Have a List"
"Carpe registrar: Seize the list," advised Dr. Alan M. Ruben of Wheeling, W.Va.
The strategy has two rationales. First, patients often begin with the least important issue first. Second, many of the items on the list may be related to one condition, so reviewing the list may aid in diagnosis and treatment.
If the list is long and complex, prioritize the problems and assign the rest to a new appointment, attendees suggested.
"Why Did I Have to Wait So Long?"
The worst horror story came from Dr. Zugerman, who once faced a revolution in his waiting room when four or five patients united to demand that he come out to explain the "obscene" amount of time they had been waiting.
Many dermatologists said they have had to revise the way they schedule to alleviate waiting times. Dr. Stuart M. Brown of Dallas suggested stretching most appointment slots to 30 minutes and leaving open the last hour of the morning and the afternoon.
"I think it's a sin to keep people waiting a long time, but then act rushed," said Dr. Ruben. As he enters a room, he apologizes, first thing.
Dr. Greenberg keeps a plaque in his waiting room that explains delays, noting that emergencies arise and dermatologic cases sometimes prove to be unexpectedly complex. He also reminds people that they'll receive special attention on the day they need it.
Dr. Brett M. Coldiron of Cincinnati said he reduced his waiting times by dropping his two worst-paying insurance carriers. He also uses his lunch hour to catch up with charting and phone calls.
"Patients don't wait; charts do," he said.
"Can You Remove an Irritated Skin Tag?"
Most dermatologists remove a few skin tags or benign lesions for free. If there are many, and the patient wants them all off, some physicians explain that insurance won't cover their removal and ask if the patient wants to pay cash.
Dr. Ruben asks the patient to sign a note that goes into the chart and to the insurance company. It states the following:
▸ The patient has been reassured all lesions are benign and normal.
▸ The patient has identified lesions that are symptomatic.
▸ Only these symptomatic lesions were treated at the patient's request.
Given this information, some companies reimburse for their removal, he said.
What Bill?!
Sometimes a patient owes a significant amount and it becomes clear that they never intend to pay. Dr. Greenberg offered a possible solution: forgiveness of the debt. The physician writes off the debt. A Form 1099 is issued and referred to the Internal Revenue Service, which will demand that the debtor pay social security, Medicare fees, and taxes on the amount.
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