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Money, Medical Practice, and the Patient

So you’re no doubt all on the edge of your seats: WHAT did the Mayo say about the endless blood-pressure conundrum, in the wake of the Affair of the Phantom Heart Attack?

Mwa ha ha!

Friday morning I stock up the covered wagon, yoke the oxen, climb into the seat, snap the bull-whip, and head across-country to that fine organization’s doctor’s offices — from my house, about halfway to Payson. Traffic isn’t bad, for a change — it’s the tail end of rush hour — and I get there in less than an hour.

That notwithstanding, they call me right in. I present the current three months’ worth of twice-daily blood-pressure measures called up by my cardiologist “in the wild” (this is what we call doctors who practice outside the coveted Mayo system), explain why I thought I needed to make a fast run on the ER at 2 a.m. the other morning, and fork over a long list of questions and observations:

The main question/proposal: We need to treat the causes of this supposed elevated BP, not the results.

Factors: There appears to be a correlation between what I tag “annoyance” (comprising annoyance, frustration, anger, and related negative emotions) and higher numbers. A correlation also exists with hot flashes. And another factor appears to be pain: headache, musculo-skeletal, dental, etc.

  1. Hot flashes: These episodes occurred before I started on the amlopidine & they continue, but it wasn’t until after I started taking it that they began happening with some frequency. Whatever is causing them, they clearly are directly connected to BP spikes. BP is elevated every time I test during or shortly after a flash.

What is causing these hot flashes? Could there be an ovarian problem? Can we address this issue?

  1. “Annoyance”: I seem to have developed a problem coping with minor (and major) daily aggravations, such as computer hassles, urban driving, work stress, bureaucratic bullshit, & the dog yapping. Unclear whether a causal relation exists between mild anger or irritation and spikes: the “annoyance” tag also appears many times in the absence of a spike — often when numbers are in the low 120s and 110s.

Some of these issues cannot easily be dispensed with:

  • To live in the city, I have to drive.
  • My business partner declines to fire the infuriating client.
  • I can’t do business or function socially without dealing w/ a computer.
  • I am not getting rid of the dog.

What can be done to address a physiological reaction to frustration, annoyance, and anger?

  1. Pain. This is a constant: at my age, you just hurt as part of life. Chronic sources of pain:
  • Headache. Probably sinus; occasionally migraine. Sometimes stress.
  • Hip pain. Undoubtedly related to osteoporosis.
  • Mastectomy scars.
  • Dental pain of unknown etiology.

Recently learned that pouring cool or cold water over your head can stop a stress or migraine headache, and this drops BP reading rapidly. Otherwise: I can’t take acetominophen, ibuprofen, or aspirin.

Got any other ideas? Is there a way to determine whether I actually am allergic to OTC pain-killers? Or to desensitize me to at least one of them?

  1. Supposed” elevated BP. There appears to be a great deal of controversy over what is dangerous and what is not.
  • Mayo’s ER doc called me, three times, a “very low-risk patient.”
  • British NHS guidelines differ from US guidelines.
  • HALO-3 researchers (Lonn et al.) found BP-lowering drugs led to no change in mortality & morbidity after 5 years.
  • New AHA guidelines have been criticized on several grounds.
  • Pharmaceutical companies fund the American Heart Assn., confounding the issue with an obvious financial motive
  • Other studies (e.g., Diaou et al, BMJ) suggest guidelines are too low and many people are overtreated

What, really, is the science-based, proven significance of BP spikes that occur in response to external stimuli? Is an average BP in the mid-120s/high-70s to mid-80s something that needs to be treated? Show me the science that proves it!

To my astonishment, the woman they assigned to me — a P.A. who specializes in cardiology — actually sat down and read all this bullshit! Instead of just glancing at the figures I’d compiled for the cardiologist (which is what he does: gives a cursory glance at the overall average), she sat there and studied the spreadsheet. She read my questions and thought about them. (I hafta ask you: when have YOU had a doctor behave like this?)

After I’d had time to calm down (nothing makes me more miserable or more nervous than going into a doctor’s office or a hospital, except possibly a face-to-face encounter with a home invader), she took my blood pressure and pronounced it non-alarming. She was familiar with the HOPE-3 study and knew about its five-year finding that blood-pressure-lowering drugs had exactly zero effect on mortality and morbidity among its large sample population.

And finally she opined:

• 108/75 is too low for me. This is why I have been feeling so dragged out I can barely haul myself down to the bathroom.
• The occasional spikes into the 140s are not very out of the ordinary, nor are they anything to get hysterical about.
• I should quit taking the drug ASAP. (Beat her to that one!)
• I should knock off tracking my blood pressure every damn day, for godsake.
• She was ordering a stress test and a full blood panel. Go downstairs now, please, to get the latter done.
• Make an appointment, please, for the stress test. Seeya soon!

It was pretty clear that she did not think I needed to be on a $125/bottle calcium-channel blocker — or anything else. Nor did she think there was really much of a problem. The average BP compiled over the past three months of 123.4/81.9 struck her as within the safe range.


When I staggered out of her office and bounded down the fire-escape to my car, I felt more like crying than celebrating.

Sumbiche. I’ve been through two years of this torture, with doctors in the wild trying to pressure me onto these drugs by repeatedly telling me that if I don’t take them I’m going to drop dead of a stroke or heart attack.

One hesitates to state the obvious: that I was gratified when her opinion echoed my own. But yes: I was gratified that her opinion echoed my own. But that is because my opinion is grounded fairly solidly in science: I do know how to read a research report, and I certainly can distinguish between science and woo-woo. Those traits follow naturally on several years as a technical editor.

* * *

Some years ago, my beloved, long-time, and much trusted GP, Tim Daley, quit his private practice and went to work for the Mayo. He had done his residency at the Mayo in Minnesota and was delighted when they opened for business here in Arizona. Despite the pleading and dismay of his partners, LIKE A ROCKET he shot out of downtown Phoenix and off to Outer Scottsdale.

Naturally, I followed him. One does not easily let go of a competent, intelligent doctor imbued with experience and common sense. Getting insurance that would cover the Mayo was sometimes challenging, but in the occasional years that My Beloved Employer dropped the ball, I would go out on the open market and buy my own.

Eventually, Tim retired.

His parting shot to me was this: Never hire a doctor who relies on a private practice to make a living. Get yourself a doctor who is paid a salary. All other doctors are motivated to “discover” reasons that you need treatment and medications that will keep you coming back to their office for endless consultations and further rounds of treatment.

“Holy shit!” said I. “Where does one find a doc who gets paid a salary, this side of Luke Air Force Base?”

“In Arizona? Your only choice is the Mayo. Or,” he added, “doctors who have ’boutique’ practices, whereby you pay a stiff annual fee for the privilege of becoming one of the limited number of patients they see.”

Toward the end of my tenure at The Great Desert University, the state offered PPO coverage that included the Mayo, so I was able to stay on their rolls that way. (Wander off, and the Mayo will dump you: especially if you’re on Medicare, whose bureaucracy they prefer not to deal with). Once I got on Medicare, I was a legacy patient and so they could not gracefully boot me out.

I hadn’t thought much about Tim’s advice in recent years. But now on reflection it comes back to me. Get a patient with BP in the 120s or low 130s believing she has “high blood pressure,” slap her on the smallest dose of BP meds you can prescribe, and you’ll get her locked in to coming back every three months for a consultation, now and forever. And that will be a consultation for which you can charge Medicare and her Medigap insurance, to the max. She will, in a word, represent your bread-and-butter.

So, my friends. Bear in mind that medical practice is not a religious calling. It is a business. You are a cash cow, no less for doctors and hospitals than for vendors of televisions, communication systems, real estate, and cans of beans. In America, you have to be an alert and aware consumer of medical treatments, same as you need to be an alert and aware consumer of anything else.

And good luck to you…

8 thoughts on “Money, Medical Practice, and the Patient”

    • Thanks. It’s sublimely annoying, though, to realize that I’ve been put through all this stress so that a couple of doctors could make a dime off Medicare…

  1. Hmmm….Man….the thing that bothers me is that the medical community does not realize what a “burden” seeing them every 90 days can be….financially, emotionally and a BIG “time suck”….When DW goes to her Doc she must shower, dress, prepare the list of meds she is taking, a list of questions and sometimes be “fasting”. Then the trip to and from the Doc….the wait in the office….the examination…It takes a bite out of half a day.
    Glad you seem to be getting to the bottom of this. But will disagree about Medicare…IMHO no one is getting rich on servicing Medicare patients. The fees that Medicare pays and what the practice originally bills are A LOT lower. My retired Doc of 30 years shared that he actually lost money on “seeing” a Medicare patient and that with Medicaid it was actually worse. And went on to share that SOMETIMES it would take him over a year to get paid. He considered it his “duty” to see ALL patients….I still miss that guy!
    It’ll be interesting to see what your “blood panel” shows….

    • You could be right about that. The Mayo does NOT want you if you’re on Medicare. If you’re not already on their rolls, they won’t accept you; if you are when you turn 65, they’ll keep you, but they require that you show up once a year. If you don’t, you’re off.

      Also, they do not accept “Medicare assignment,” which means it’s up to you to collect from Medicare. They will send a bill to your Medicare and to your Medigap provider, Medicare & Medigap then send the reimbursement to you, and then YOU have to pay the Mayo.

      This is a hassle — it means I have to have an extra savings account into which to gather a slew of piddly little deposits, because neither outfit will just say, “OKAY, here’s the bill, let’s pay it.” You get a string of payments, and you never know when they’re done paying. Sometimes you end up with a small outstanding bill, which you then just give up and pay — but usually the entire amount is eventually covered.

      Medicaid, I guess, is pretty awful for providers. And I have the impression that private insurance isn’t necessarily much better — they also will try to avoid paying when they think they can get out of it. Friend of mine, a psychiatric nurse practitioner, shut down her successful private practice and took on a salaried job because of the difficulty of getting paid by government and private insurers.

      LOL! I guess those facts put the lie to the theory that docs are trying to extract payment by making you trot into the office every three months. At least, if you’re on Medicare or Medicaid.

      As a practical matter, though, diabetes is something you need to right herd on carefully. But given the dubiousness of the claim that calcium-channel blockers will protect you from cardiovascular events — and the questionable claim that everyone of all ages and all conditions must drive their BP below 120 — I am relieved to be freed from this particular slab of paranoia. And I do think Americans are subjected to a lot of unnecessary “care.”

  2. I, too, am gratified to hear that the PA’s opinion echoed your own, especially as my own was in line with both of them. 😀 And glad to hear that your BP is just fine, after all the stress you’ve been put through about it.

    I’ve had great luck with PAs and NPs, so much so that I’d rather see them than MDs and ODs. In my experience, the former actually *listen,* consider patient concerns and come out with helpful information/suggestions far more often than the latter.

    Tomorrow we are scheduled to appear in Chapel Hill for MrH’s surgical follow-up. This means a four-hour drive, whatever amount of time the appointment(s) consume, and a four-hour drive back–a whole day lost, not to mention the discomfort, aggravation and expense of the drive. I hope further follow-up care can be handled by our local docs!

    • Yes, the PAs and NPs don’t seem to have the time pressure suffered by regular docs. When I remarked that what I had to say would take a few minutes to explain, she remarked that was not a problem: she had 50 minutes (!! NOT the usual 15?!?) to talk to me.

      That drive sounds like a killer — even worse than the journey to the Mayo! You wonder: could they not instruct a provider closer to your home on what to look for and have you traipse across the country less often? Hope all goes well and the surgical dust has settled this time!

  3. That’s wonderful news! We should all do research on any diagnosis we’re given but, really, can the average Joe understand what they’re reading like you can? It sounds intimidating, to say the least.
    That’s some chilling, if useful, advice that your old GP gave you. Sobering and depressing.

    • There ya go… I’ll try to write a post — maybe two of ’em — on how to recognize a credible “scientific” publication (vs. woo-woo) and on the easy way to read a research paper. It looks one helluva lot harder than it is!

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