Lesson No. 1 for Physicians: The Customer Is Always Right

I have a new-found love in practicing under the simple notion that the customer is always right.

I didn’t always believe this, of course. I had to gradually learn it over time. It’s my ongoing CME.

The intense knowledge of the structure and functioning of the human body coupled with the prestige of medical education in the United States breeds a sentiment of hubris amongst graduates that often thwarts their best intentions with patients. Almost no one experiencing the gauntlet of medical education is immune to this process. I certainly wasn’t. I remember the warm anesthetic feel of describing to my patients the danger of continued high blood pressure. With it came the reassurance that, through adherence to the right medication combination, we could mitigate their risk and prevent harm. It made sense to me.

I had the belief that my role was an educator, and their enlightenment would deliver them from an inevitable end point. For some patients this worked-some who believed in a young physician like me. Some who could trust comfortably in others. Some who had the resources to recall and organize recommendations, enact them on a daily basis, and return for another round of assessment. Heck, some seemed to love the fact that a doctor would spend time with them and explain things, and I seemed to love hearing myself talk. After all, health is exciting!!  In retrospect, that excitement may have been lost on most.

After my training was complete, I took a job working in a safety net setting providing primary care. Jim, one of my first “new patient encounters” to establish care, arrived on a sunny afternoon in Seattle, which is a rarity. Jim had come to the appointment because he had heard there was a new clinic in the area, he hadn’t seen a doctor for some time, and was having some concerns about his feet. Overall, he felt fine.

A quick review of his chart indicated that he was on several antipsychotics (one long-acting injectable form), a mood stabilizer, and a blood pressure medication. His problem list from a mental health provider indicated that he suffered with schizoaffective disorder, high cholesterol, a history of diabetes, and was frequently seen at a local emergency room for chest pain evaluations where he was well known for being loud, intrusive, and intoxicated. It made no mention of his poor dentition, smoking habits, or poor hygiene, and neither did Jim.

Standard operating procedure for a new patient encounter to establish care dictates that one obtain a thorough medical history, social and family history, list of current medications and allergies and perform a thorough review of systems and high-quality physical exam. Medical billings require a certain number of categories in each section of the medical evaluation be properly documented to satisfy coding requirements and, ultimately, ensure reimbursement. Unfortunately, those thoughts were parading through my head as Jim informed me he was already late for his bus and took off his shoes. He pointed to his discolored toenails and expressed his concern that he wouldn’t be able to wear sandals on sunny days such as the one he was currently missing while stuck in my clinic. He was embarrassed the ladies would not find him attractive, which I couldn’t refute.

There was nothing else wrong with his feet, other than his poor sensation, weak pulses and little hair below the mid-point of his calves. His skin was dry, cracked, and begging for a diabetic ulcer to establish residence and fester.

His billing sheet required a medical diagnosis and a corresponding ICD-9 code to be filled in. Out of many possibilities, Jim received one that sunny day: 110.1. Toenail fungus. And he got treatment with a lacquer that stood a better chance of curing his concerns than curing his nails. He left the clinic late for his bus-before I could examine his heart and lungs, or ask about his chest pain, or reconcile his medication list. After his visit, veteran clinic staff noted they hadn’t seen Jim for years and were surprised he had come in at all. I felt the totality of my medical education had been squandered.

They kindly reminded me it had just begun.