Over the past few weeks, I’ve presented a parody of family medicine, whereby each character (Mrs. Doctor, Mr. Insurance, Patients) represent the current triad of the most dysfunctional of all American families: that of primary care practice. This week, Mrs. Doctor airs her grievances to her counselor about her evermore demanding and unreasonable spouse, Mr. Insurance).
A week after Mrs. Doctor’s visit to her PCP’s office, she sits in a waiting room, awaiting her first visit with the therapist.
Unlike the chaotic, tense reception at her primary care physician’s office, the therapist’s waiting room is everything but: it boasts relaxing designs and colors, is not crowded, and no noise save the soft bubbling from a Zen water fountain can be heard. A feeling of calm invites Mrs. Doctor to sit and reflect.
The experience works like a well oiled clock. On exactly the hour, her therapist opens the door inviting her into her session:
Therapist: I heard from your PCP that you were coming. I understand that you’ve some radical thoughts about your marriage to Mr. Insurance that could affect others like you in the same position. Why don’t you start by telling me about it?
Mrs. Doctor: (Pulling out a notebook of grievances that is years thick). I have a problem with my husband, Mr. Insurance. He refused to come today. He claims he had an “important” golf game today with a client. I’ve been begging him for years to come with me to counseling, but he refuses constantly saying that everything is my fault.
Therapist: What do you think he means by “your fault.”
Mrs Doctor: When Mr. Insurance and I got married, I signed a prenuptial and a marriage contract. He has a bunch of kids and I agreed to take care of them. The agreement goes that he’ll pay the bills while I tend to the flock and try my best to keep them healthy.
Therapist: Is this your first marriage?
Mrs. Doctor: We both have been married before. Mine ended badly and all my kids, which we call patients, are now adults and stayed with my first husband ,Mr. Blue Cross. None of the kids wanted to come with me, which is discouraging. Then I got together with Mr. UnitedHealth Insurance — but he goes by Mr. Insurance for short. We were happy together at first. He had a bunch of kids under his supervision but desperately needed someone to be responsible for their care, which is something I love to do. At first it was a match made in heaven. We worked together like a real couple trying to do the best thing for our kids.
Therapist: What happened?
Mrs. Doctor: Same thing that happened to my first marriage with Mr Blue Cross; Mr Insurance slowly became abusive. Why do I attract bad apples?
Therapist: How was Mr. Insurance abusive?
Mrs Doctor: It started slowly. He wouldn’t pay the bills for the kids, or stalled to pay me for the things we had agreed that he’d cover. He even stuck me to pay all the vaccines I gave to the kids. By the time I understood what he was doing, I lost $30,000. He plays these games all the time. He’s even sent auditors to our home to make sure that I’m doing a good job taking care of the kids.
Every year he says he’s having a harder time with me and that I should be paid less and less for the care I give the kids. I don’t think he has any idea how hard my job is. I work 12 hour days, 5 days week, not to mention that I take calls at night and some weekends without getting paid. He thinks I should be having more and more kids to take care and thinks I’m wasting time.
He sends me letters telling me that labs or xrays for several of our kids were unnecessary, that the medicines I gave aren’t going to be paid for, that I should get permission from him before setting up a test or a referral for the kids when they need it, or asking why I decided to use a certain drug.
Yet, he’s no idea what going on with the kids. He’s never home, doesn’t know them, and hasn’t watched them grow up like I have. He seems to meddle all the time with their care and tell me how I should be doing my job.
One more thing that infuriates me is that not only does he not know the kids, know their history, know their circumstances, but he thinks he should be making medical decisions. He never went to medical school or residency but has no problem acting like he knows what’s best. It’s like being forced into consulting with Dr. Scrooge for every decision the kids and I make together. He can’t even be sued!
Therapist: What do the kids think?
Mrs. Doctor: We try to keep them in the dark about what’s going on. They know things aren’t right between us, but they wouldn’t understand. Our job is to care for them and pay their bills. We try our best to keep our problems with each other our secret.
Therapist: We’re out of time. I do have an assignment for you. Read this classic children’s story: Thidwick The Big Hearted Moose, and answer this question for next week: Should Thidwick go or should he stay?
And, until next week, I remain yours in primary care,
Alan Dappen, MD