Hi, I’m a clinician out in America. I’ll be writing a series of essays about how capitalism makes my practice less effective, and my job suck overall. It’s an effort to analyze the internal dynamics of working in healthcare in America.

Upselling Health or "A Wealth of Care"

“Hey [patient name], one more thing I thought I'd mention. We can also set up a telehealth appointment, if you feel that would be beneficial. It'd be a good opportunity to touch base.”

I sit there in front of my computer, and I debate adding the last phase to the text message.

“Up to you.”

That one’s key, it’s the one I want to add because I want the patient to consider it, to develop an internal locus of control, a feeling that we’re working as partners, not that he’s coming to see a guru without whom he won’t heal. I sigh, look at my schedule in the upcoming week, see some openings that my boss wants filled, and leave it out.

I work in rehabilitation in a rural setting for a private clinic. It’s, frankly, not as bad as it could be. I see a moderate number of patients per day (but higher than most hospitals/non-profit settings). Some clinics are more like >20 patients per day on the 20 min. My schedule’s much more manageable. That said, the pressure to bill more units and patient visits that are wholly medically unnecessary is immense.

One place where this hits the road is scheduling appointments per week for a client. My boss expects me to push for 3 visits per week for 12 weeks for nearly every diagnosis. For a post operative patient, this makes sense. There’s lots of variables in play. Things to manage that are critical, like wounds, infection risk, and inflammation. There’s also rapid tissue remodeling, so tons of gains in function can be made in this period. Same goes for, say, a frail balance patient. They can need that many visits to address all the factors that can lead to a fall, optical prescription, inner ear dysfunction, strength, urinary incontinence, cognition, home setup, medication, etc, as well as practice balance exercises that are highly effective and too risky to do at home.

Your classic chronic low back pain? Fuck no. Maybe 2 visits per week for week or so, rapidly tapering. Why? Well, to be frank, chronic back pain takes time, and so it makes sense for visits to be spaced out once some progress is being made. Tons of visits close together won’t have much meaningful difference between them in terms of patient status, and won’t foster a sense that the patient is there to learn skills to take control of their condition. The patient associates you with their recovery, not their own effort and learning.

Obviously, in ideal communism, you should get care that meets you where you’re at, but the rehab lit supports that fostering patient independence is essential as well. The most effective regimes pair a supportive and available-if-necessary clinician who isn’t a guru, or a miracle worker, but kind of a teacher or (gulp) consultant. Someone who helps the patient develop skills to manage their own condition to meet the goals the patient wants, while providing the occasional skill that patient’s can’t do for themselves, as well as knowledge and perspective to help patients understand their condition.

It’s not uncommon for patients in my clinic to have been seen 50 times, 3x weekly, with little-to-no status change for something that should have taken less than 20 visits to resolve over the same period, just with some more spacing and occasionally periods of more frequent visits to manage flare-ups, but ultimately helping the patient get more independent and return to normal life.

So…after an evaluation or progress note, you kinda have to put the screws on people, kinda get them to buy in to the fact that you’re giving them something that they can’t get anywhere else, and that if they don’t come in all they time, they won’t progress. Essentially, you’re selling them a sense of powerlessness. This is profitable, sometimes extremely so. My boss likes to call this "providing a wealth of care."

The patient texts me back, he’s out of town and is not interested, but wants to come in after he's back. I breathe a sigh of relief, since I can at least tell my boss I tried.

If there's more interest in these, I'll keep going.