Patient Advocacy

I had an interesting patient encounter this week.   She is an older woman I have only seen once before. She is new to our clinic because of a change in insurance. She has already developed quite a reputation at our clinic for being a little “difficult”.   She made a complaint against Barbie Nurse.   Barbie Nurse is blonde and cute and sweet as pie.   Patients LOVE her. For this lady to make a complaint against Barbie Nurse, something must really be wrong with her.

So, as I sit down to speak with her, The Complainer says, “Sweetheart, could you speak up a little bit? You speak really softly.”

I almost laughed out loud at this statement. This is something that I have NEVER been accused of.   I am loud to a fault, but to humor her, I start speaking louder.   She asks me several times, “Huh?” and “What?”

I speak louder and louder to the point I am yelling at her. I suddenly recollect that the complaint against Barbie Nurse was that she was “yelling at her”.   A light bulb goes off in my rather dense brain.

“Ma’am, do you think you may need to see an Audiologist?” I inquire in my sweetest, most diplomatic tone.

“Sweetheart, there ain’t nothin’ wrong with my heart.   I don’t need to see no Cardiologist,” she replies.

Houston, we have a problem. I now understand why she complained that I “didn’t tell her anything” at our first patient encounter, and why the last two doctors she had “just couldn’t communicate.”     I wonder how many other interactions she is missing out on because she can’t hear.   I wonder how many other people have dubbed her as a “mean-old-lady” because of this.   I suddenly felt ashamed. Of course, I have scheduled an appointment for her with an Audiologist.

As I was reflecting on this, a student who is doing a research project with patients with lung disease at our clinic comes to speak with me.   She has seen one of my patients.   He is elderly and requires twenty-four hour care.   She informs me that he has no complaints about his lungs currently, but he is not on “the best medications for his condition.” She lets me know that the best choice would be two pricey inhalers

I pretty sarcastically look at her and say, “Oh really?   I had NEVER thought of that.   Why do you suppose I don’t have her on those?

She looks at me skeptically, clearly she doesn’t speak sarcasm, “Well I guess you are worried about his coordination and ability to use these, but I can help with teaching him.”

Great I think, glad she can do that for me since I am incapable of teaching a patient to use an inhaler.   I realize that I may be being a little hard on her.   I try to soften my approach. I patiently explain to her,

“The average retail price of the combined medications you suggested is $350 monthly. That is $4200 yearly. After $2850, Medicare patients are responsible for their own drug costs until they reach $4500.   The medications I have him on, although not the best for his condition are free under Medicare and won’t count toward this.   He is also on medications for his blood pressure, diabetes and blood clots. What do you expect he will do about these medications in August of each year when he runs out of money? And that is only if he only pays for the medications you are suggesting.”

I stop my speech confident that I have conveyed to her a new concept in patient care that was not introduced in her lecture classes. I am self-confident and assured that this will have opened her eyes to a new world of patient care and a different way of thinking.

She looks at me and said, “Well, will you at least put him on the $50 medication?”

Ok, she is a little more concrete-thinking and dense than I thought. Maybe we will take a different approach,

“Ok, I will put him on that medicine if YOU call him and tell him that you would like me to start a $50 medication for a condition he is not complaining about and that it will cost him $600 annually AND that it may very well put him in the Medicare Donut Hole so that he will have much greater out of pocket expenses.”

Oooooppps.   I forgot that she doesn’t speak sarcasm. She looked at me somewhat confused and wondered off.

These two incidents highlight to me what an awesome responsibility being an advocate for my patients first is. I am not to be an advocate for the pharmaceutical companies, or a government agenda or even my place of employment. I am to be an advocate of THE PATIENT.   I am really fortunate to work at a clinic where this is the priority and not the bottom line, but other places this is not the case.   I hope maybe this student will reflect on this conversation with some common sense and change her strategy. Maybe getting a hearing aid for my “difficult” patient will change her life. I hope so.


  1. Some people just don’t get sarcasm :-/ I think most people I know are really concrete thinkers. I have to watch myself and use sarcasm with people that will appreciate the art. Please let us know if you get any feedback from the elderly lady that has a hearing problem. I loved that part of the story!

  2. Many people simply don’t realize what a hardship high medical co-pays can be, until they’ve faced them, too. Good for you for not trying to talk your patients into medications they can’t afford. And good for you for realizing the costs of certain medications – my doctors haven’t a clue until I tell them that, gee, I really can’t afford $450 a month, please prescribe something else.

  3. All I can say is AMEN! My grandfather was a family practitioner and felt the same way about his patients. Yours is a noble profession, and I admire your dedication. 🙂

  4. I think the person doing the study could have just been ignorant about the cost of the medication and how that could affect compliance. It is great that you are taking that into consideration. I can remember when I was working as a Nurse that often times meds were ordered for patients who were unable to afford them. Some MDs just did not take the time to be aware of that. I used to go the extra mile to help my patients many times and I know it takes extra time and effort that often goes unnoticed. I am glad you discovered the older woman’s problem. She could of easily fallen through the cracks.

    • I agree… I think the student had no idea about the costs of the medications and the realities of this. What I found a little disturbing is that even after I explained it to her, she seemed unconcerned. I hope she will consider this in the future. Everyone has someone they love who is on a fixed income and needs the lowest cost medications

  5. That student conversation sounds like many of the conversations I have with my reps when they rattle off words like, “Lowest Branded Co-Pay.” Oh, gee, thanks for that! Alas, I still allow them to fill my sample closet and take up my already-behind-my-schedule time because of those patients I need to load up on samples. Miss you!

    • Miss you too Dawn, but it looks like your clinic is running great! It is a hard balance. I actually laughed out loud at the Qsymia rep trying to explain to me why I would want to write two generic meds as a branded med…

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