Hitting a Nerve

$11.38. What can you buy for that kind of money?

Not much, realistically: an entrée at a casual restaurant, a shirt on sale at Target, a few cases of Ramen noodles in college.

In my case, it was what (per the Internet) bought my time.

About a year ago, a friendly drug rep asked my secretary if he could bring a pizza for lunch. We don’t do rep lunches, but he’d overheard her telling me she’d forgotten lunch at home and was going to go out to McDonald’s.

He told her he wouldn’t stay to sell anything, so she said “Sure, thank you.” He got a small pizza, dropped it off for her, and left. She had a piece and took the rest home to her kids. I didn’t think much of it, although it was the only time in the last 2 years we’ve gotten anything besides samples from a rep.

I wasn’t planning on checking my Sunshine Act disclosure data, since I don’t see reps beyond signing for samples. But then I heard an old partner of mine had a plastic brain listed under his name ($18.36) by mistake when it had actually been given to another doc with a similar name.

So I logged in, and there it was. I’d accepted $11.38 in “food and beverage” (AKA, the pizza I never ate) from a drug company.

I can’t really dispute it, and it’s not that much money. I doubt anyone will think I’m for sale for such a pithy amount, and no reporter looking for a doctor bribery scandal is going to think it’s a story worth chasing.

I support disclosure. There are clearly many instances where the relationship between physicians and pharma has been abused for financial gains. Kickbacks and bribes are as old as society and will always be with us. Having outside scrutiny of our actions, at least in this instance, is likely good at keeping everyone honest. There will always be ways to cheat, but most of us aren’t looking for them.

But still, it irritates me that this seemingly innocent lunch for my secretary could be taken to mean something else.

So, the pizza I didn’t eat becomes an odd milestone in my medical career. I don’t remember when I had my first drug company lunch, but it was likely during my third year of medical school. But now, I, and anyone who wants to look it up, knows when my last one was an $11.38 pizza that I never had on Aug. 29, 2013.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

$11.38. What can you buy for that kind of money?

Not much, realistically: an entrée at a casual restaurant, a shirt on sale at Target, a few cases of Ramen noodles in college.

In my case, it was what (per the Internet) bought my time.

About a year ago, a friendly drug rep asked my secretary if he could bring a pizza for lunch. We don’t do rep lunches, but he’d overheard her telling me she’d forgotten lunch at home and was going to go out to McDonald’s.

He told her he wouldn’t stay to sell anything, so she said “Sure, thank you.” He got a small pizza, dropped it off for her, and left. She had a piece and took the rest home to her kids. I didn’t think much of it, although it was the only time in the last 2 years we’ve gotten anything besides samples from a rep.

I wasn’t planning on checking my Sunshine Act disclosure data, since I don’t see reps beyond signing for samples. But then I heard an old partner of mine had a plastic brain listed under his name ($18.36) by mistake when it had actually been given to another doc with a similar name.

So I logged in, and there it was. I’d accepted $11.38 in “food and beverage” (AKA, the pizza I never ate) from a drug company.

I can’t really dispute it, and it’s not that much money. I doubt anyone will think I’m for sale for such a pithy amount, and no reporter looking for a doctor bribery scandal is going to think it’s a story worth chasing.

I support disclosure. There are clearly many instances where the relationship between physicians and pharma has been abused for financial gains. Kickbacks and bribes are as old as society and will always be with us. Having outside scrutiny of our actions, at least in this instance, is likely good at keeping everyone honest. There will always be ways to cheat, but most of us aren’t looking for them.

But still, it irritates me that this seemingly innocent lunch for my secretary could be taken to mean something else.

So, the pizza I didn’t eat becomes an odd milestone in my medical career. I don’t remember when I had my first drug company lunch, but it was likely during my third year of medical school. But now, I, and anyone who wants to look it up, knows when my last one was an $11.38 pizza that I never had on Aug. 29, 2013.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

$11.38. What can you buy for that kind of money?

Not much, realistically: an entrée at a casual restaurant, a shirt on sale at Target, a few cases of Ramen noodles in college.

In my case, it was what (per the Internet) bought my time.

About a year ago, a friendly drug rep asked my secretary if he could bring a pizza for lunch. We don’t do rep lunches, but he’d overheard her telling me she’d forgotten lunch at home and was going to go out to McDonald’s.

He told her he wouldn’t stay to sell anything, so she said “Sure, thank you.” He got a small pizza, dropped it off for her, and left. She had a piece and took the rest home to her kids. I didn’t think much of it, although it was the only time in the last 2 years we’ve gotten anything besides samples from a rep.

I wasn’t planning on checking my Sunshine Act disclosure data, since I don’t see reps beyond signing for samples. But then I heard an old partner of mine had a plastic brain listed under his name ($18.36) by mistake when it had actually been given to another doc with a similar name.

So I logged in, and there it was. I’d accepted $11.38 in “food and beverage” (AKA, the pizza I never ate) from a drug company.

I can’t really dispute it, and it’s not that much money. I doubt anyone will think I’m for sale for such a pithy amount, and no reporter looking for a doctor bribery scandal is going to think it’s a story worth chasing.

I support disclosure. There are clearly many instances where the relationship between physicians and pharma has been abused for financial gains. Kickbacks and bribes are as old as society and will always be with us. Having outside scrutiny of our actions, at least in this instance, is likely good at keeping everyone honest. There will always be ways to cheat, but most of us aren’t looking for them.

But still, it irritates me that this seemingly innocent lunch for my secretary could be taken to mean something else.

So, the pizza I didn’t eat becomes an odd milestone in my medical career. I don’t remember when I had my first drug company lunch, but it was likely during my third year of medical school. But now, I, and anyone who wants to look it up, knows when my last one was an $11.38 pizza that I never had on Aug. 29, 2013.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

"Do you feel lucky?"

It’s one of Clint Eastwood’s iconic lines (probably a notch below "go ahead, make my day") that wasn’t spoken to a home furnishing. 

But it’s still a question many of us think of late on a Friday afternoon just before weekend call gets rolled over to us.

Weekend hospital call, like an approaching storm, brings foreboding and dread. You have no control over the circumstances that are about to whack you. If it’s busy, you’re out of luck. Whatever comes in, you have to deal with it.

I try to ameliorate the pain by using a quote from a residency attending: "It’s not busy, it’s profitable." I also often repeat Dory’s line from "Finding Nemo" – "just keep swimming, just keep swimming" – as I round endlessly.

But humans, by nature, are superstitious creatures. Our ancestors across the globe created pantheons of deities to explain the sun, storms, ocean, and other natural phenomenon they couldn’t control and prayed to them to try to do so.

Now we fear a nebulous group of beings named the "call gods."

It’s always plural, and it’s never been established how many there are or if they have individual names. But they’re feared by all who take hospital call. Amongst physicians, I find they’re universal. Doctors who are Christians, Jews, Hindus, Muslims, atheists ... all know and fear them.

The rules of this medical religion have never been put down and are passed on by verbal tradition. The main theme is that you never, ever, ever do anything to make them angry. This primarily involves not saying things like "it’s quiet so far" or "gee, my phone hasn’t rung all day," for doing so will most assuredly bring their wrath down upon you.

Likewise, even if things are quiet, you never say that until 7:01 on Monday morning, when it’s been rolled back over to your call partner. If someone asks, "how’s your call going?" – even if nothing has happened – you still say "steady" or "hopping" just to avoid challenging the unseen deities.

Of course, the call gods aren’t the only ones we fear. There are specialty-specific, and even procedure-specific, deities. Any neurologist attempting a bedside lumbar puncture on a large person will likely say a quick prayer to the LP gods.

Medicine has come a long way, over time, but even a field with a hefty base in science can’t overcome human nature and our inherent fear of forces beyond our control.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

"Do you feel lucky?"

It’s one of Clint Eastwood’s iconic lines (probably a notch below "go ahead, make my day") that wasn’t spoken to a home furnishing. 

But it’s still a question many of us think of late on a Friday afternoon just before weekend call gets rolled over to us.

Weekend hospital call, like an approaching storm, brings foreboding and dread. You have no control over the circumstances that are about to whack you. If it’s busy, you’re out of luck. Whatever comes in, you have to deal with it.

I try to ameliorate the pain by using a quote from a residency attending: "It’s not busy, it’s profitable." I also often repeat Dory’s line from "Finding Nemo" – "just keep swimming, just keep swimming" – as I round endlessly.

But humans, by nature, are superstitious creatures. Our ancestors across the globe created pantheons of deities to explain the sun, storms, ocean, and other natural phenomenon they couldn’t control and prayed to them to try to do so.

Now we fear a nebulous group of beings named the "call gods."

It’s always plural, and it’s never been established how many there are or if they have individual names. But they’re feared by all who take hospital call. Amongst physicians, I find they’re universal. Doctors who are Christians, Jews, Hindus, Muslims, atheists ... all know and fear them.

The rules of this medical religion have never been put down and are passed on by verbal tradition. The main theme is that you never, ever, ever do anything to make them angry. This primarily involves not saying things like "it’s quiet so far" or "gee, my phone hasn’t rung all day," for doing so will most assuredly bring their wrath down upon you.

Likewise, even if things are quiet, you never say that until 7:01 on Monday morning, when it’s been rolled back over to your call partner. If someone asks, "how’s your call going?" – even if nothing has happened – you still say "steady" or "hopping" just to avoid challenging the unseen deities.

Of course, the call gods aren’t the only ones we fear. There are specialty-specific, and even procedure-specific, deities. Any neurologist attempting a bedside lumbar puncture on a large person will likely say a quick prayer to the LP gods.

Medicine has come a long way, over time, but even a field with a hefty base in science can’t overcome human nature and our inherent fear of forces beyond our control.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

"Do you feel lucky?"

It’s one of Clint Eastwood’s iconic lines (probably a notch below "go ahead, make my day") that wasn’t spoken to a home furnishing. 

But it’s still a question many of us think of late on a Friday afternoon just before weekend call gets rolled over to us.

Weekend hospital call, like an approaching storm, brings foreboding and dread. You have no control over the circumstances that are about to whack you. If it’s busy, you’re out of luck. Whatever comes in, you have to deal with it.

I try to ameliorate the pain by using a quote from a residency attending: "It’s not busy, it’s profitable." I also often repeat Dory’s line from "Finding Nemo" – "just keep swimming, just keep swimming" – as I round endlessly.

But humans, by nature, are superstitious creatures. Our ancestors across the globe created pantheons of deities to explain the sun, storms, ocean, and other natural phenomenon they couldn’t control and prayed to them to try to do so.

Now we fear a nebulous group of beings named the "call gods."

It’s always plural, and it’s never been established how many there are or if they have individual names. But they’re feared by all who take hospital call. Amongst physicians, I find they’re universal. Doctors who are Christians, Jews, Hindus, Muslims, atheists ... all know and fear them.

The rules of this medical religion have never been put down and are passed on by verbal tradition. The main theme is that you never, ever, ever do anything to make them angry. This primarily involves not saying things like "it’s quiet so far" or "gee, my phone hasn’t rung all day," for doing so will most assuredly bring their wrath down upon you.

Likewise, even if things are quiet, you never say that until 7:01 on Monday morning, when it’s been rolled back over to your call partner. If someone asks, "how’s your call going?" – even if nothing has happened – you still say "steady" or "hopping" just to avoid challenging the unseen deities.

Of course, the call gods aren’t the only ones we fear. There are specialty-specific, and even procedure-specific, deities. Any neurologist attempting a bedside lumbar puncture on a large person will likely say a quick prayer to the LP gods.

Medicine has come a long way, over time, but even a field with a hefty base in science can’t overcome human nature and our inherent fear of forces beyond our control.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

No matter how hard we try to run on-schedule, most patients usually experience some down time in our waiting rooms. So, in the honored tradition of our ancestors, we supply magazines to read.

These days – the era of iPads – many bring their own reading material, but a good percentage still don’t and leaf through the glossies out there.

I try not to subject them to much. You won’t see drug rep pamphlets in my lobby. I get a free subscription to a celebrity gossip rag (thanks, pharma), but it goes straight to recycling on arrival. Many of my patients are seriously ill, and the last thing I want to do is have them read about people who think the worst thing in the world is to have make-up with the wrong foundation color. If professional celebrities want to see real problems, they can hang out at my office, or (better yet) an oncologist’s.

So what do I put out? I get a local parenting magazine, and my mother’s friend donates recent issues of Sunset and Good Housekeeping (thanks, Nancy). People are okay with them.

My dad once got me a big coffee table book about the history of medicine. He found it at a garage sale for 25 cents. On a whim, I put it out, and it’s been surprisingly popular. I even have a patient who makes a note of where he left off when called back, so that he can resume at his next visit.

Six months ago, while straightening up a home bookcase, I found a few "Far Side" collections, and put them out in my lobby. They quickly passed the magazines in popularity, and cemented my already solid reputation as an eccentric.

I don’t know how many other doctors have done this. I’ve heard there’s a doc on the west side of town who only has the complete P.G. Wodehouse "Bertie & Jeeves" series in his lobby. I think that would be perfectly fine, too, but takes longer to read, and I try to minimize waiting room time.

One of my strangest discoveries about private practice is that my most popular lobby magazines aren’t magazines at all. And I found them on my own bookshelf.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

No matter how hard we try to run on-schedule, most patients usually experience some down time in our waiting rooms. So, in the honored tradition of our ancestors, we supply magazines to read.

These days – the era of iPads – many bring their own reading material, but a good percentage still don’t and leaf through the glossies out there.

I try not to subject them to much. You won’t see drug rep pamphlets in my lobby. I get a free subscription to a celebrity gossip rag (thanks, pharma), but it goes straight to recycling on arrival. Many of my patients are seriously ill, and the last thing I want to do is have them read about people who think the worst thing in the world is to have make-up with the wrong foundation color. If professional celebrities want to see real problems, they can hang out at my office, or (better yet) an oncologist’s.

So what do I put out? I get a local parenting magazine, and my mother’s friend donates recent issues of Sunset and Good Housekeeping (thanks, Nancy). People are okay with them.

My dad once got me a big coffee table book about the history of medicine. He found it at a garage sale for 25 cents. On a whim, I put it out, and it’s been surprisingly popular. I even have a patient who makes a note of where he left off when called back, so that he can resume at his next visit.

Six months ago, while straightening up a home bookcase, I found a few "Far Side" collections, and put them out in my lobby. They quickly passed the magazines in popularity, and cemented my already solid reputation as an eccentric.

I don’t know how many other doctors have done this. I’ve heard there’s a doc on the west side of town who only has the complete P.G. Wodehouse "Bertie & Jeeves" series in his lobby. I think that would be perfectly fine, too, but takes longer to read, and I try to minimize waiting room time.

One of my strangest discoveries about private practice is that my most popular lobby magazines aren’t magazines at all. And I found them on my own bookshelf.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

No matter how hard we try to run on-schedule, most patients usually experience some down time in our waiting rooms. So, in the honored tradition of our ancestors, we supply magazines to read.

These days – the era of iPads – many bring their own reading material, but a good percentage still don’t and leaf through the glossies out there.

I try not to subject them to much. You won’t see drug rep pamphlets in my lobby. I get a free subscription to a celebrity gossip rag (thanks, pharma), but it goes straight to recycling on arrival. Many of my patients are seriously ill, and the last thing I want to do is have them read about people who think the worst thing in the world is to have make-up with the wrong foundation color. If professional celebrities want to see real problems, they can hang out at my office, or (better yet) an oncologist’s.

So what do I put out? I get a local parenting magazine, and my mother’s friend donates recent issues of Sunset and Good Housekeeping (thanks, Nancy). People are okay with them.

My dad once got me a big coffee table book about the history of medicine. He found it at a garage sale for 25 cents. On a whim, I put it out, and it’s been surprisingly popular. I even have a patient who makes a note of where he left off when called back, so that he can resume at his next visit.

Six months ago, while straightening up a home bookcase, I found a few "Far Side" collections, and put them out in my lobby. They quickly passed the magazines in popularity, and cemented my already solid reputation as an eccentric.

I don’t know how many other doctors have done this. I’ve heard there’s a doc on the west side of town who only has the complete P.G. Wodehouse "Bertie & Jeeves" series in his lobby. I think that would be perfectly fine, too, but takes longer to read, and I try to minimize waiting room time.

One of my strangest discoveries about private practice is that my most popular lobby magazines aren’t magazines at all. And I found them on my own bookshelf.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

What’s in a name? A lot, if you’re a doctor.

"Doctor" is our formal title, although technically it means anyone with a higher educational degree. We’re also called physicians, or healers. In other times, we may have been medicine men, witch doctors, or shamans. Or we may prefer a more specific name based on our chosen field: neurologist, internist, or surgeon, for example.

Recently, though, we’ve had specific (and less flattering) names hung on us – health care providers, primary care physicians, gatekeepers – not to mention the alphabet soup that longer names bring (HCP, PCP).

It kind of puts us in a semantic identity crisis. Especially with all the HCPs out there who aren’t MDs or DOs.

But no matter what title they hang on me, I know what I do. I care for people who need me. I provide treatment for those I can help and support to those I can’t. I hold hands. I write prescriptions. I discuss test results. I talk, and I listen. I fill out forms. I argue with insurance companies. I go home each night and in the morning come back and do it all over again.

Somehow saying I’m an HCP doesn’t seem to do the job description justice.

I remember a residency meeting I attended in the mid-90s. I was in training, and the meeting was held to introduce all the residents to the hospital’s new health plan. The insurance lady running it told us not to use the word "patients" but instead call them "lives." Doctors, in her doublespeak, were "providers" unless you were in internal medicine or family practice, in which case you had the even less flattering name of "gatekeeper."

The meeting got increasingly acrimonious, and the insurance lady looked more and more uncomfortable. Finally, a family practice resident named Barb stood up and said, "You can change words all you want, but here’s the truth. We are not providers, or PCPs, or gatekeepers. We are doctors. And we do our best to care for people, even when your company won’t."

Barb stood up, turned on her heel, and walked out with her long skirt swirling. The insurance company lady was obviously angry and left through the exit behind her.

It’s now 20 years later, Barb, and I don’t think anyone could have said it better, then or now. It still holds true.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

What’s in a name? A lot, if you’re a doctor.

"Doctor" is our formal title, although technically it means anyone with a higher educational degree. We’re also called physicians, or healers. In other times, we may have been medicine men, witch doctors, or shamans. Or we may prefer a more specific name based on our chosen field: neurologist, internist, or surgeon, for example.

Recently, though, we’ve had specific (and less flattering) names hung on us – health care providers, primary care physicians, gatekeepers – not to mention the alphabet soup that longer names bring (HCP, PCP).

It kind of puts us in a semantic identity crisis. Especially with all the HCPs out there who aren’t MDs or DOs.

But no matter what title they hang on me, I know what I do. I care for people who need me. I provide treatment for those I can help and support to those I can’t. I hold hands. I write prescriptions. I discuss test results. I talk, and I listen. I fill out forms. I argue with insurance companies. I go home each night and in the morning come back and do it all over again.

Somehow saying I’m an HCP doesn’t seem to do the job description justice.

I remember a residency meeting I attended in the mid-90s. I was in training, and the meeting was held to introduce all the residents to the hospital’s new health plan. The insurance lady running it told us not to use the word "patients" but instead call them "lives." Doctors, in her doublespeak, were "providers" unless you were in internal medicine or family practice, in which case you had the even less flattering name of "gatekeeper."

The meeting got increasingly acrimonious, and the insurance lady looked more and more uncomfortable. Finally, a family practice resident named Barb stood up and said, "You can change words all you want, but here’s the truth. We are not providers, or PCPs, or gatekeepers. We are doctors. And we do our best to care for people, even when your company won’t."

Barb stood up, turned on her heel, and walked out with her long skirt swirling. The insurance company lady was obviously angry and left through the exit behind her.

It’s now 20 years later, Barb, and I don’t think anyone could have said it better, then or now. It still holds true.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

What’s in a name? A lot, if you’re a doctor.

"Doctor" is our formal title, although technically it means anyone with a higher educational degree. We’re also called physicians, or healers. In other times, we may have been medicine men, witch doctors, or shamans. Or we may prefer a more specific name based on our chosen field: neurologist, internist, or surgeon, for example.

Recently, though, we’ve had specific (and less flattering) names hung on us – health care providers, primary care physicians, gatekeepers – not to mention the alphabet soup that longer names bring (HCP, PCP).

It kind of puts us in a semantic identity crisis. Especially with all the HCPs out there who aren’t MDs or DOs.

But no matter what title they hang on me, I know what I do. I care for people who need me. I provide treatment for those I can help and support to those I can’t. I hold hands. I write prescriptions. I discuss test results. I talk, and I listen. I fill out forms. I argue with insurance companies. I go home each night and in the morning come back and do it all over again.

Somehow saying I’m an HCP doesn’t seem to do the job description justice.

I remember a residency meeting I attended in the mid-90s. I was in training, and the meeting was held to introduce all the residents to the hospital’s new health plan. The insurance lady running it told us not to use the word "patients" but instead call them "lives." Doctors, in her doublespeak, were "providers" unless you were in internal medicine or family practice, in which case you had the even less flattering name of "gatekeeper."

The meeting got increasingly acrimonious, and the insurance lady looked more and more uncomfortable. Finally, a family practice resident named Barb stood up and said, "You can change words all you want, but here’s the truth. We are not providers, or PCPs, or gatekeepers. We are doctors. And we do our best to care for people, even when your company won’t."

Barb stood up, turned on her heel, and walked out with her long skirt swirling. The insurance company lady was obviously angry and left through the exit behind her.

It’s now 20 years later, Barb, and I don’t think anyone could have said it better, then or now. It still holds true.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Like most doctors, I have a few patients without insurance.

Raj is a hard-working guy who, like me, has his own business and a family to support. He pays his bills, but really can’t afford insurance.

Recently, he tripped over his dog and suffered a back injury. I tried to manage it conservatively, but things kept getting worse and it became obvious that an MRI was needed. I found a decent place that gave him a cash discount and got the study.

Unfortunately, he had a pretty bad disk herniation with severe canal stenosis and radicular impingement. It was obvious he needed surgery.

He made some calls around the state, looking to get a decent surgical package put together. The best he was able to get, including surgery, anesthesia, and a few hospital days, was $60,000. This didn’t include any costs that might arise from complications.

Raj, like most of us, didn’t have that kind of money lying around. Nor was he going to go to an emergency department to make the rest of us pay for it.

But he also was having increasing problems walking. He and I had a few phone calls trying to find a solution, without any clear ideas.

His answer was to contact his grandparents, who live in India. They were able to get him names of established spine surgeons in the country. He flew there with his MRI disk, saw the surgeon, had a successful operation, and was back home after 10 days. He’s now back at work, without any complications, and doing fine.

Total cost (not including plane fare): $4,000.

I have nothing against the American health care system. I’m a part of it. But I’m left wondering why a successful back surgery would have such a dramatic cost difference between two countries. I’m sure malpractice issues are part of it, but not the whole issue. Are equipment and drug costs lower in India? Labor?

There are probably a lot of factors, which I won’t pretend to understand. But it raises a question. In an era when American medicine is trying to do more with less, what can we learn from other countries? A lot of major breakthroughs are made here that travel elsewhere, but that doesn’t mean we have all the answers.

I may be naive, but if we can learn ways to improve our system by looking elsewhere, we have to. Our patients deserve it.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Like most doctors, I have a few patients without insurance.

Raj is a hard-working guy who, like me, has his own business and a family to support. He pays his bills, but really can’t afford insurance.

Recently, he tripped over his dog and suffered a back injury. I tried to manage it conservatively, but things kept getting worse and it became obvious that an MRI was needed. I found a decent place that gave him a cash discount and got the study.

Unfortunately, he had a pretty bad disk herniation with severe canal stenosis and radicular impingement. It was obvious he needed surgery.

He made some calls around the state, looking to get a decent surgical package put together. The best he was able to get, including surgery, anesthesia, and a few hospital days, was $60,000. This didn’t include any costs that might arise from complications.

Raj, like most of us, didn’t have that kind of money lying around. Nor was he going to go to an emergency department to make the rest of us pay for it.

But he also was having increasing problems walking. He and I had a few phone calls trying to find a solution, without any clear ideas.

His answer was to contact his grandparents, who live in India. They were able to get him names of established spine surgeons in the country. He flew there with his MRI disk, saw the surgeon, had a successful operation, and was back home after 10 days. He’s now back at work, without any complications, and doing fine.

Total cost (not including plane fare): $4,000.

I have nothing against the American health care system. I’m a part of it. But I’m left wondering why a successful back surgery would have such a dramatic cost difference between two countries. I’m sure malpractice issues are part of it, but not the whole issue. Are equipment and drug costs lower in India? Labor?

There are probably a lot of factors, which I won’t pretend to understand. But it raises a question. In an era when American medicine is trying to do more with less, what can we learn from other countries? A lot of major breakthroughs are made here that travel elsewhere, but that doesn’t mean we have all the answers.

I may be naive, but if we can learn ways to improve our system by looking elsewhere, we have to. Our patients deserve it.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Like most doctors, I have a few patients without insurance.

Raj is a hard-working guy who, like me, has his own business and a family to support. He pays his bills, but really can’t afford insurance.

Recently, he tripped over his dog and suffered a back injury. I tried to manage it conservatively, but things kept getting worse and it became obvious that an MRI was needed. I found a decent place that gave him a cash discount and got the study.

Unfortunately, he had a pretty bad disk herniation with severe canal stenosis and radicular impingement. It was obvious he needed surgery.

He made some calls around the state, looking to get a decent surgical package put together. The best he was able to get, including surgery, anesthesia, and a few hospital days, was $60,000. This didn’t include any costs that might arise from complications.

Raj, like most of us, didn’t have that kind of money lying around. Nor was he going to go to an emergency department to make the rest of us pay for it.

But he also was having increasing problems walking. He and I had a few phone calls trying to find a solution, without any clear ideas.

His answer was to contact his grandparents, who live in India. They were able to get him names of established spine surgeons in the country. He flew there with his MRI disk, saw the surgeon, had a successful operation, and was back home after 10 days. He’s now back at work, without any complications, and doing fine.

Total cost (not including plane fare): $4,000.

I have nothing against the American health care system. I’m a part of it. But I’m left wondering why a successful back surgery would have such a dramatic cost difference between two countries. I’m sure malpractice issues are part of it, but not the whole issue. Are equipment and drug costs lower in India? Labor?

There are probably a lot of factors, which I won’t pretend to understand. But it raises a question. In an era when American medicine is trying to do more with less, what can we learn from other countries? A lot of major breakthroughs are made here that travel elsewhere, but that doesn’t mean we have all the answers.

I may be naive, but if we can learn ways to improve our system by looking elsewhere, we have to. Our patients deserve it.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Have you ever used "The Doctor Trick"?

Of course you have. You probably call it something else, though. Like a light saber, it must be used with respect and care. Overuse will render it worthless, but sometimes you don’t have a choice.

"The Doctor Trick" – as a friend in residency called it – is using your title as an excuse to leave.

I remember the first time I did it. It was in residency, and I’d somehow been dragged to a Halloween party I didn’t really want to be at. Not only that, but it had a $15 cover charge. After getting in and realizing that I’d prefer having my fingernails pulled out, I went back to the door. I showed the cashier my hospital ID and receipt indicating I’d been there less than 5 minutes. I told her I’d been called to the hospital for an emergency. She gave me my money back, and I thanked her and left.

Granted, she was under no obligation to do that, but it didn’t hurt to ask. As my dad would say: "The worst they can do is say no."

So I’ve used it here and there over time, typically as an excuse to leave a party, meeting, or pretty much any event where I’m looking for a way out. I’ve never used it to try and get better seats, or a table by the window. To me, that falls on the entitled side, and usually people will say no anyway.

It’s kept in check by knowing that overuse will, like the boy who cried wolf, render it useless. There’s also a fear that abusing it will bring bad karma from the feared "Call Gods" who will punish you next time you’re on.

That said, it still provides a convenient excuse to get out of, or away from, meetings, in-laws, school boards, and other happenings you’d rather avoid.

Membership, as they say, has its privileges.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Have you ever used "The Doctor Trick"?

Of course you have. You probably call it something else, though. Like a light saber, it must be used with respect and care. Overuse will render it worthless, but sometimes you don’t have a choice.

"The Doctor Trick" – as a friend in residency called it – is using your title as an excuse to leave.

I remember the first time I did it. It was in residency, and I’d somehow been dragged to a Halloween party I didn’t really want to be at. Not only that, but it had a $15 cover charge. After getting in and realizing that I’d prefer having my fingernails pulled out, I went back to the door. I showed the cashier my hospital ID and receipt indicating I’d been there less than 5 minutes. I told her I’d been called to the hospital for an emergency. She gave me my money back, and I thanked her and left.

Granted, she was under no obligation to do that, but it didn’t hurt to ask. As my dad would say: "The worst they can do is say no."

So I’ve used it here and there over time, typically as an excuse to leave a party, meeting, or pretty much any event where I’m looking for a way out. I’ve never used it to try and get better seats, or a table by the window. To me, that falls on the entitled side, and usually people will say no anyway.

It’s kept in check by knowing that overuse will, like the boy who cried wolf, render it useless. There’s also a fear that abusing it will bring bad karma from the feared "Call Gods" who will punish you next time you’re on.

That said, it still provides a convenient excuse to get out of, or away from, meetings, in-laws, school boards, and other happenings you’d rather avoid.

Membership, as they say, has its privileges.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Have you ever used "The Doctor Trick"?

Of course you have. You probably call it something else, though. Like a light saber, it must be used with respect and care. Overuse will render it worthless, but sometimes you don’t have a choice.

"The Doctor Trick" – as a friend in residency called it – is using your title as an excuse to leave.

I remember the first time I did it. It was in residency, and I’d somehow been dragged to a Halloween party I didn’t really want to be at. Not only that, but it had a $15 cover charge. After getting in and realizing that I’d prefer having my fingernails pulled out, I went back to the door. I showed the cashier my hospital ID and receipt indicating I’d been there less than 5 minutes. I told her I’d been called to the hospital for an emergency. She gave me my money back, and I thanked her and left.

Granted, she was under no obligation to do that, but it didn’t hurt to ask. As my dad would say: "The worst they can do is say no."

So I’ve used it here and there over time, typically as an excuse to leave a party, meeting, or pretty much any event where I’m looking for a way out. I’ve never used it to try and get better seats, or a table by the window. To me, that falls on the entitled side, and usually people will say no anyway.

It’s kept in check by knowing that overuse will, like the boy who cried wolf, render it useless. There’s also a fear that abusing it will bring bad karma from the feared "Call Gods" who will punish you next time you’re on.

That said, it still provides a convenient excuse to get out of, or away from, meetings, in-laws, school boards, and other happenings you’d rather avoid.

Membership, as they say, has its privileges.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

How often do your patients ask about medical marijuana? I suppose it depends on where you live, but here in Arizona, it’s legal. So they ask about using it for migraines, epilepsy, diabetic neuropathy pain, and others. I hear the question from many patients.

How do I answer it? It gets tricky. I have mixed feelings about it, with anecdotal evidence from patients who have tried it, medical journals, and the usual overhyped stories in the lay press. It’s often hard for doctors to see the answer clearly and even more so for patients.

I suspect a lot of the interest comes from the commonly held belief that if it comes from "natural" sources, it has to be better for you than "chemicals." Never mind that what my dog leaves in the backyard is also "natural" or that THC is a chemical. Pretty much everything in the human body (and universe in general) is technically a chemical.

So I tell them I don’t know for sure. At best, it may help them. At worst, it’s an expensive placebo that could lead to other health issues. I explain the treatments I have to offer and that nothing is 100% successful or completely free of side effects – even "natural" products.

I’ve learned that those who’ve decided to use it won’t be dissuaded by my arguments or any amount of equivocal data, so I try to keep an open mind.

I let them make their own decision and document it carefully. If they want to go find a medical dispensary, that’s their call in the end, not mine. I also tell them that, if it doesn’t work, I’ll still be here to do my best to help them. I don’t take offense at their decision, ever.

At our best, doctors are only advisers. We can’t make anyone do anything they don’t want to.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

How often do your patients ask about medical marijuana? I suppose it depends on where you live, but here in Arizona, it’s legal. So they ask about using it for migraines, epilepsy, diabetic neuropathy pain, and others. I hear the question from many patients.

How do I answer it? It gets tricky. I have mixed feelings about it, with anecdotal evidence from patients who have tried it, medical journals, and the usual overhyped stories in the lay press. It’s often hard for doctors to see the answer clearly and even more so for patients.

I suspect a lot of the interest comes from the commonly held belief that if it comes from "natural" sources, it has to be better for you than "chemicals." Never mind that what my dog leaves in the backyard is also "natural" or that THC is a chemical. Pretty much everything in the human body (and universe in general) is technically a chemical.

So I tell them I don’t know for sure. At best, it may help them. At worst, it’s an expensive placebo that could lead to other health issues. I explain the treatments I have to offer and that nothing is 100% successful or completely free of side effects – even "natural" products.

I’ve learned that those who’ve decided to use it won’t be dissuaded by my arguments or any amount of equivocal data, so I try to keep an open mind.

I let them make their own decision and document it carefully. If they want to go find a medical dispensary, that’s their call in the end, not mine. I also tell them that, if it doesn’t work, I’ll still be here to do my best to help them. I don’t take offense at their decision, ever.

At our best, doctors are only advisers. We can’t make anyone do anything they don’t want to.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

How often do your patients ask about medical marijuana? I suppose it depends on where you live, but here in Arizona, it’s legal. So they ask about using it for migraines, epilepsy, diabetic neuropathy pain, and others. I hear the question from many patients.

How do I answer it? It gets tricky. I have mixed feelings about it, with anecdotal evidence from patients who have tried it, medical journals, and the usual overhyped stories in the lay press. It’s often hard for doctors to see the answer clearly and even more so for patients.

I suspect a lot of the interest comes from the commonly held belief that if it comes from "natural" sources, it has to be better for you than "chemicals." Never mind that what my dog leaves in the backyard is also "natural" or that THC is a chemical. Pretty much everything in the human body (and universe in general) is technically a chemical.

So I tell them I don’t know for sure. At best, it may help them. At worst, it’s an expensive placebo that could lead to other health issues. I explain the treatments I have to offer and that nothing is 100% successful or completely free of side effects – even "natural" products.

I’ve learned that those who’ve decided to use it won’t be dissuaded by my arguments or any amount of equivocal data, so I try to keep an open mind.

I let them make their own decision and document it carefully. If they want to go find a medical dispensary, that’s their call in the end, not mine. I also tell them that, if it doesn’t work, I’ll still be here to do my best to help them. I don’t take offense at their decision, ever.

At our best, doctors are only advisers. We can’t make anyone do anything they don’t want to.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I see other doctors as patients. Granted, other doctors also see me as a patient.

Seeing another doctor always adds an extra layer of challenge to the job. Even if they’re not in my field, I worry they’re secretly criticizing what I’m doing and thinking I’m clueless. Odds are favorable that they did a neurology rotation at some point, and so are at least somewhat familiar with the history and exam.

I suspect other doctors get bigger work-ups than nondoctors. Some of it may be for legal reasons, but I think most of it is that we figure they expect it from us (although, realistically, I’m not looking for a bunch of tests when I go to the doctor). As a result, more MRI scans and labs are ordered to search for both horses and zebras.

I can’t say that I’ve found weird or scary stuff in other doctors any more than what I’ve found in the general population, but somehow I worry more about missing something. Maybe some of it is the feeling that we’re all part of the same family, so I need to take care of brethren. Or a nervous feeling that they’re inwardly rolling their eyes and thinking that I’m an idiot if I don’t order a certain test. It might be more likely that they’re sitting there wondering why the hell anyone would want to be a neurologist because they hated their rotation in it.

When it comes to treatment, similar thoughts come up. Other doctors know the meds – although so does anyone with a smartphone these days – and I worry that, inwardly, they’re secretly criticizing my choice of poison or are going to argue with me about side effects.

Like any doctor, I want to give equal care to all. But human nature means different circumstances can change our mindset, and we have to overcome that. Good or bad, it’s part of the job.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I see other doctors as patients. Granted, other doctors also see me as a patient.

Seeing another doctor always adds an extra layer of challenge to the job. Even if they’re not in my field, I worry they’re secretly criticizing what I’m doing and thinking I’m clueless. Odds are favorable that they did a neurology rotation at some point, and so are at least somewhat familiar with the history and exam.

I suspect other doctors get bigger work-ups than nondoctors. Some of it may be for legal reasons, but I think most of it is that we figure they expect it from us (although, realistically, I’m not looking for a bunch of tests when I go to the doctor). As a result, more MRI scans and labs are ordered to search for both horses and zebras.

I can’t say that I’ve found weird or scary stuff in other doctors any more than what I’ve found in the general population, but somehow I worry more about missing something. Maybe some of it is the feeling that we’re all part of the same family, so I need to take care of brethren. Or a nervous feeling that they’re inwardly rolling their eyes and thinking that I’m an idiot if I don’t order a certain test. It might be more likely that they’re sitting there wondering why the hell anyone would want to be a neurologist because they hated their rotation in it.

When it comes to treatment, similar thoughts come up. Other doctors know the meds – although so does anyone with a smartphone these days – and I worry that, inwardly, they’re secretly criticizing my choice of poison or are going to argue with me about side effects.

Like any doctor, I want to give equal care to all. But human nature means different circumstances can change our mindset, and we have to overcome that. Good or bad, it’s part of the job.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I see other doctors as patients. Granted, other doctors also see me as a patient.

Seeing another doctor always adds an extra layer of challenge to the job. Even if they’re not in my field, I worry they’re secretly criticizing what I’m doing and thinking I’m clueless. Odds are favorable that they did a neurology rotation at some point, and so are at least somewhat familiar with the history and exam.

I suspect other doctors get bigger work-ups than nondoctors. Some of it may be for legal reasons, but I think most of it is that we figure they expect it from us (although, realistically, I’m not looking for a bunch of tests when I go to the doctor). As a result, more MRI scans and labs are ordered to search for both horses and zebras.

I can’t say that I’ve found weird or scary stuff in other doctors any more than what I’ve found in the general population, but somehow I worry more about missing something. Maybe some of it is the feeling that we’re all part of the same family, so I need to take care of brethren. Or a nervous feeling that they’re inwardly rolling their eyes and thinking that I’m an idiot if I don’t order a certain test. It might be more likely that they’re sitting there wondering why the hell anyone would want to be a neurologist because they hated their rotation in it.

When it comes to treatment, similar thoughts come up. Other doctors know the meds – although so does anyone with a smartphone these days – and I worry that, inwardly, they’re secretly criticizing my choice of poison or are going to argue with me about side effects.

Like any doctor, I want to give equal care to all. But human nature means different circumstances can change our mindset, and we have to overcome that. Good or bad, it’s part of the job.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Discharge summaries have become my pet peeve recently.

It’s not uncommon for a patient to be referred to me for outpatient follow-up, or for one of my own patients to be treated where I’m not on staff and then sent back to me afterward. When that occurs, I used to get a copy of the discharge summary to get an idea of what happened. (Note the "used to.") I certainly wouldn’t rely on it entirely, but it was helpful. Not anymore.

The modern discharge summary is worthless and sometimes downright dangerous. It’s often nonspecific and typically full of errors. Not minor errors, either, but big ones. I commonly see patients listed as having had procedures they didn’t undergo, test results that were someone else’s, and diagnoses and medications that aren’t even close.

Here’s a recent example (I’ve removed some information, but this is the basic idea): "The patient was admitted for dizziness. She was seen by neurology and had a brain MRI and labs. Discharge diagnosis is dizziness. Her medications were not changed."

That was it – a few sentences in one paragraph.

How much valuable information did you get from that? Absolutely none. All I see is that I need to get the MRI report and/or films, and possibly the other neurologist’s notes.

In years past, the summary was done by the patient’s own physician, who knew he or she would be referring to it in a few weeks when the patient came in for follow-up. So there was a vested interest in it being thorough and useful.

But today the reports are typically dictated by hospitalists. They may provide good care, but it’s often the case that they just picked up the patient for the first time. They likely have 18 other people to see, five admissions, and three discharge summaries to do and don’t have the time to do more than glance through the H&P and last few scribbled notes. As the day goes on, patients also tend to blur together, causing more errors.

The hospitalists simply don’t know patients as well as do the outpatient physicians who have been seeing them for years, and so fewer errors will be caught. I admit I’m guilty of turning some of my own patients over to inpatient physicians. All of us are busy. And I’m not knocking hospitalists, who do an often difficult part of medicine. But the loss of communication between these two branches of medicine is a sad loss for all of us – especially for our patients.

Perhaps the most irritating part is the generic statement I see at the bottom of many summaries: "This discharge summary may contain errors and omissions. Please refer to the full chart for complete information." This, sadly, is an admission that the document is worthless (which I doubt will stand up in court). I don’t often have access to the full chart, or time to comb through it in detail, when the patient comes in. Although I wouldn’t put all my faith in the summary, it’s nice when it give me a general idea of what I’m dealing with.

Once, a discharge summary was something useful – a succinct statement of events for the next doctor to use for guidance. Today, it’s become the kitchen mess piled up after a party. No one wants to do it, so a hurried, sloppy job is done, making more work for everyone else later.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Discharge summaries have become my pet peeve recently.

It’s not uncommon for a patient to be referred to me for outpatient follow-up, or for one of my own patients to be treated where I’m not on staff and then sent back to me afterward. When that occurs, I used to get a copy of the discharge summary to get an idea of what happened. (Note the "used to.") I certainly wouldn’t rely on it entirely, but it was helpful. Not anymore.

The modern discharge summary is worthless and sometimes downright dangerous. It’s often nonspecific and typically full of errors. Not minor errors, either, but big ones. I commonly see patients listed as having had procedures they didn’t undergo, test results that were someone else’s, and diagnoses and medications that aren’t even close.

Here’s a recent example (I’ve removed some information, but this is the basic idea): "The patient was admitted for dizziness. She was seen by neurology and had a brain MRI and labs. Discharge diagnosis is dizziness. Her medications were not changed."

That was it – a few sentences in one paragraph.

How much valuable information did you get from that? Absolutely none. All I see is that I need to get the MRI report and/or films, and possibly the other neurologist’s notes.

In years past, the summary was done by the patient’s own physician, who knew he or she would be referring to it in a few weeks when the patient came in for follow-up. So there was a vested interest in it being thorough and useful.

But today the reports are typically dictated by hospitalists. They may provide good care, but it’s often the case that they just picked up the patient for the first time. They likely have 18 other people to see, five admissions, and three discharge summaries to do and don’t have the time to do more than glance through the H&P and last few scribbled notes. As the day goes on, patients also tend to blur together, causing more errors.

The hospitalists simply don’t know patients as well as do the outpatient physicians who have been seeing them for years, and so fewer errors will be caught. I admit I’m guilty of turning some of my own patients over to inpatient physicians. All of us are busy. And I’m not knocking hospitalists, who do an often difficult part of medicine. But the loss of communication between these two branches of medicine is a sad loss for all of us – especially for our patients.

Perhaps the most irritating part is the generic statement I see at the bottom of many summaries: "This discharge summary may contain errors and omissions. Please refer to the full chart for complete information." This, sadly, is an admission that the document is worthless (which I doubt will stand up in court). I don’t often have access to the full chart, or time to comb through it in detail, when the patient comes in. Although I wouldn’t put all my faith in the summary, it’s nice when it give me a general idea of what I’m dealing with.

Once, a discharge summary was something useful – a succinct statement of events for the next doctor to use for guidance. Today, it’s become the kitchen mess piled up after a party. No one wants to do it, so a hurried, sloppy job is done, making more work for everyone else later.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Discharge summaries have become my pet peeve recently.

It’s not uncommon for a patient to be referred to me for outpatient follow-up, or for one of my own patients to be treated where I’m not on staff and then sent back to me afterward. When that occurs, I used to get a copy of the discharge summary to get an idea of what happened. (Note the "used to.") I certainly wouldn’t rely on it entirely, but it was helpful. Not anymore.

The modern discharge summary is worthless and sometimes downright dangerous. It’s often nonspecific and typically full of errors. Not minor errors, either, but big ones. I commonly see patients listed as having had procedures they didn’t undergo, test results that were someone else’s, and diagnoses and medications that aren’t even close.

Here’s a recent example (I’ve removed some information, but this is the basic idea): "The patient was admitted for dizziness. She was seen by neurology and had a brain MRI and labs. Discharge diagnosis is dizziness. Her medications were not changed."

That was it – a few sentences in one paragraph.

How much valuable information did you get from that? Absolutely none. All I see is that I need to get the MRI report and/or films, and possibly the other neurologist’s notes.

In years past, the summary was done by the patient’s own physician, who knew he or she would be referring to it in a few weeks when the patient came in for follow-up. So there was a vested interest in it being thorough and useful.

But today the reports are typically dictated by hospitalists. They may provide good care, but it’s often the case that they just picked up the patient for the first time. They likely have 18 other people to see, five admissions, and three discharge summaries to do and don’t have the time to do more than glance through the H&P and last few scribbled notes. As the day goes on, patients also tend to blur together, causing more errors.

The hospitalists simply don’t know patients as well as do the outpatient physicians who have been seeing them for years, and so fewer errors will be caught. I admit I’m guilty of turning some of my own patients over to inpatient physicians. All of us are busy. And I’m not knocking hospitalists, who do an often difficult part of medicine. But the loss of communication between these two branches of medicine is a sad loss for all of us – especially for our patients.

Perhaps the most irritating part is the generic statement I see at the bottom of many summaries: "This discharge summary may contain errors and omissions. Please refer to the full chart for complete information." This, sadly, is an admission that the document is worthless (which I doubt will stand up in court). I don’t often have access to the full chart, or time to comb through it in detail, when the patient comes in. Although I wouldn’t put all my faith in the summary, it’s nice when it give me a general idea of what I’m dealing with.

Once, a discharge summary was something useful – a succinct statement of events for the next doctor to use for guidance. Today, it’s become the kitchen mess piled up after a party. No one wants to do it, so a hurried, sloppy job is done, making more work for everyone else later.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

How often do you fire patients? I do it here and there, maybe a few times a year, but certainly not as often as patients fire me.

Contrary to popular belief, I don’t get some sort of perverse thrill out of it. I am maybe relieved, knowing that I’m (hopefully) done with a difficult relationship. But it’s a pain, always requiring a trip to the post office to send the registered letter. There’s also the fear that they’ll report me to the board for it, and I’ll have to defend my actions. And I certainly can’t guard against the one-sided Yelp reviews.

What tips you over the edge? I consider myself pretty tolerant. In long-standing patients, I’ll generally let the occasional no-show slide. For drug abusers, I’m actually willing to continue with many of them, but will let them know that I’m not going to give them controlled substances anymore. Most of them leave at that point anyway.

I have zero tolerance for malicious behavior. Abuse my staff, and you’re out of here. I’m more willing to put up with someone who’s nasty to me than one who treats my staff the same way.

What other things do I fire them for? Occasionally noncompliance, especially if it’s putting their own safety in danger. Only once have I fired someone for refusing to have tests done. That was after, literally, 5 years of him repeatedly showing up annually to ask me to order them for his symptoms, then never following through and showing up a year later to start over again. At some point, my patience for that type of thing runs out, and I consider myself fairly patient.

Like most doctors, I’ve had more patients fire me than I’ve fired patients. For most, you don’t realize they’re gone. They just never come back. Occasionally, you get a release from another doctor, but more often you don’t.

Rarely, someone sends a nasty letter telling me why they went elsewhere and what they think of my medical skills/fashion sense/office décor ... whatever. The first time I got one of those, it hurt. Nowadays, I just don’t care.

Part of growing up as a doctor is realizing you’ll never make everyone happy or be able to help them all. Trying to do so will only lessen your sanity, so it’s a message best learned early.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

How often do you fire patients? I do it here and there, maybe a few times a year, but certainly not as often as patients fire me.

Contrary to popular belief, I don’t get some sort of perverse thrill out of it. I am maybe relieved, knowing that I’m (hopefully) done with a difficult relationship. But it’s a pain, always requiring a trip to the post office to send the registered letter. There’s also the fear that they’ll report me to the board for it, and I’ll have to defend my actions. And I certainly can’t guard against the one-sided Yelp reviews.

What tips you over the edge? I consider myself pretty tolerant. In long-standing patients, I’ll generally let the occasional no-show slide. For drug abusers, I’m actually willing to continue with many of them, but will let them know that I’m not going to give them controlled substances anymore. Most of them leave at that point anyway.

I have zero tolerance for malicious behavior. Abuse my staff, and you’re out of here. I’m more willing to put up with someone who’s nasty to me than one who treats my staff the same way.

What other things do I fire them for? Occasionally noncompliance, especially if it’s putting their own safety in danger. Only once have I fired someone for refusing to have tests done. That was after, literally, 5 years of him repeatedly showing up annually to ask me to order them for his symptoms, then never following through and showing up a year later to start over again. At some point, my patience for that type of thing runs out, and I consider myself fairly patient.

Like most doctors, I’ve had more patients fire me than I’ve fired patients. For most, you don’t realize they’re gone. They just never come back. Occasionally, you get a release from another doctor, but more often you don’t.

Rarely, someone sends a nasty letter telling me why they went elsewhere and what they think of my medical skills/fashion sense/office décor ... whatever. The first time I got one of those, it hurt. Nowadays, I just don’t care.

Part of growing up as a doctor is realizing you’ll never make everyone happy or be able to help them all. Trying to do so will only lessen your sanity, so it’s a message best learned early.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

How often do you fire patients? I do it here and there, maybe a few times a year, but certainly not as often as patients fire me.

Contrary to popular belief, I don’t get some sort of perverse thrill out of it. I am maybe relieved, knowing that I’m (hopefully) done with a difficult relationship. But it’s a pain, always requiring a trip to the post office to send the registered letter. There’s also the fear that they’ll report me to the board for it, and I’ll have to defend my actions. And I certainly can’t guard against the one-sided Yelp reviews.

What tips you over the edge? I consider myself pretty tolerant. In long-standing patients, I’ll generally let the occasional no-show slide. For drug abusers, I’m actually willing to continue with many of them, but will let them know that I’m not going to give them controlled substances anymore. Most of them leave at that point anyway.

I have zero tolerance for malicious behavior. Abuse my staff, and you’re out of here. I’m more willing to put up with someone who’s nasty to me than one who treats my staff the same way.

What other things do I fire them for? Occasionally noncompliance, especially if it’s putting their own safety in danger. Only once have I fired someone for refusing to have tests done. That was after, literally, 5 years of him repeatedly showing up annually to ask me to order them for his symptoms, then never following through and showing up a year later to start over again. At some point, my patience for that type of thing runs out, and I consider myself fairly patient.

Like most doctors, I’ve had more patients fire me than I’ve fired patients. For most, you don’t realize they’re gone. They just never come back. Occasionally, you get a release from another doctor, but more often you don’t.

Rarely, someone sends a nasty letter telling me why they went elsewhere and what they think of my medical skills/fashion sense/office décor ... whatever. The first time I got one of those, it hurt. Nowadays, I just don’t care.

Part of growing up as a doctor is realizing you’ll never make everyone happy or be able to help them all. Trying to do so will only lessen your sanity, so it’s a message best learned early.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.