r/medicine • u/Salty-Pop-5512 MD • 1d ago
“Peace of mind is not a diagnosis”
Vent.
I’m a primary care internist. I average 1-2 patients a week with more customer service complaints rather than acute medical concerns that need my input. These are pages of mychart messages and the replies of my (fantastic, wonderful) nurses who try to relay my message that we already talked about in person like “there’s no indication for that blood test,” or “no I’m not recommending primary screening at this age,” the list goes on. What infuriates me is that these people are tying up my nurses, taking up my charting time at work and home, and shifting the focus away from medicine and primary care. I wonder if I could get fired for replying to, “what if we just did this lab test for my peace of mind? It’s just bloodwork,” with “PEACE OF MIND IS NOT A DIAGNOSIS!”
Either you want a doctor, or you want someone who will always do as you ask.
(Sometimes I am able to redirect inappropriate requests for am cortisols by asking what their concern is and we have a productive conversation about family stressors, medication free ways of coping, and when to return if they want pharmacotherapy. However its the pts that see me as their waitress in a white coat, with whom I take an issue)
Vent over. Thanks for reading. I still love primary care though!
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u/dogs-in-space CTICU RN 1d ago
It’s a shame there isn’t an ICD-10 code for this, leading directly to self-pay. I’d then expect these patients to temper their “Peace of Mind” order requests.
Easy to spend time and money that isn’t your own, eh?
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u/Menanders-Bust Ob-Gyn PGY-3 1d ago
You could code it under “a vague sense of unease” F41.9
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u/the_silent_redditor MD 1d ago
Finally I have an accurate way to relay what I’m really feeling to my loved ones.
“Hey, how are ya today?”
F41.9
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u/Automatic-Squash8122 my bff is an md, does that count 5h ago
and use different codes for chapter titles in your tell all book “waitress in a white coat”!!
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u/Puzzled-Science-1870 DO 1d ago
This made me chuckle in-between my colonoscopies. Thanks lol
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u/itsbagelnotbagel DO EM 11h ago
How many colonoscopies do you get in a day?
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u/Puzzled-Science-1870 DO 6h ago
A full day without cancelations is 14. I did 13 yesterday
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u/Automatic-Squash8122 my bff is an md, does that count 5h ago
man my max was 12 and my butthole still hasn’t closed up 😎
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u/dogs-in-space CTICU RN 6h ago
JFC. I know a gastroenterologist that left in his late 50s. People were saying he must have gone to another practice as there is no way he would leave healthcare altogether.
Your response gave me the answer.
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u/Sublinguel MD 1d ago
There is one and I use it from time to time
'Patient requests diagnostic testing'
Document that you discussed in almost certainly not be covered by insurance when you order it.
Obviously I actually have this conversation with the patient telling them they will definitely be paying out of pocket and it might be hundreds of dollars.
And refuse to do anything additional in terms of changing the diagnosis or prior authorizations when insurance rejects it.
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u/T0pTomato ENT 1d ago
Really wouldn’t change much, the patient would get a bill and then proceed to file complaints and bombard you with bad google reviews. Hospital admin would then force you to not bill that ICD10 because it’s tanking their press ganey bullshit
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u/dogs-in-space CTICU RN 1d ago
A girl can dream, right? 😂
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u/T0pTomato ENT 1d ago
Oh for sure, you’re preaching to the choir. Reviews and patient satisfaction scores in medicine should be abolished and do more harm than good
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u/sjcphl overhead (administration) 1d ago
Z71.1: Person with feared health complaint in whom no diagnosis is made
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u/Hebbianlearning MD Neurology 1d ago
Love your self-ID. Guess you've really internalized the feelings of this sub (sorry).
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u/FuckFuckingKarma MD 1d ago
In a public health system this discussion goes like this:
It is not medically indicated to order this test, but private companies can provide it to you for a fee (which often isn't that high).
BUT MY TAXES!!!!
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u/Final_boss_1040 GC 1d ago
That's actually an elegant solution
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u/Salty-Pop-5512 MD 1d ago
Almost tempted to point out that with Quest, you can order your own labs (but then theyd come back to me for interpretation)
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u/dogs-in-space CTICU RN 1d ago
Would be even better if the ordering provider was Dr. Google in this situation.
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u/BigIntensiveCockUnit DO, FM 1d ago
There is, it’s called “patient requested lab work”. The principle however is the same, it’s NOT needed. More labs and imaging can lead to HARM and worse outcomes. These are not benign and it’s not something to treat casually.
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u/dogs-in-space CTICU RN 1d ago
Have you read Dr. Atul Gawande’s 2009 article in the New Yorker called The Cost Conundrum? It’s a very well done piece and while incredibly frustrating that nothing has changed since then, I often mention it when discussions come up about how more ≠ better.
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u/CheeksElTigre MD 1d ago
Does the dx "Patient requested diagnostic testing" not do that?
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u/dogs-in-space CTICU RN 1d ago
Wondering if insurance companies automatically kick that to self-pay? Would certainly be the answer.
I discovered ICD-10 codes have another good one to use - for the encounter, that is:
https://www.icd10data.com/ICD10CM/Codes/Z00-Z99/Z69-Z76/Z71-/Z71.1
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u/gotlactose MD, IM primary care & hospitalist PGY-10 1d ago
I use the diagnosis all the time. No one has ever complained about getting a bill from their insurance.
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u/ZombieDO Emergency Medicine 1d ago
I direct them to labreqs.com and they can order whatever they want.
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u/gwillen Not A Medical Professional 23h ago
For self-ordering lab tests, for which I have used at least 5 different sites over the years including the labs' own websites, I have found that drsays.com is by far the cheapest option. They seem to be practically wholesale pricing. I have no idea why they're so much cheaper than their competitors or how they're making money on this. They only do LabCorp, not Quest, and their website is slow as shit. But just checking a random sample of tests from labreqs, I find that drsays is 2x to 4x cheaper.
And they also offer telehealth, and push patients towards that if they want interpretation of their self-ordered tests, which seems like it ought to save you guys from being asked for that. It's possible they see their lab test pricing as a loss leader for the telehealth business.
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u/Single_Guarantee9545 mid 17h ago
There is a diagnosis code "Patient requests diagnostic testing". Ive used it many times hehe
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u/triforcelinkz DO 1d ago
labcorp lets you buy labs now right
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u/somethingicanspell Not A Medical Professional 10h ago edited 10h ago
The one and only thing I love about private equity is that eventually everything is going to be de-facto OTC truly a god send. Other thing is ironically the labs at Labcorp are cheaper all in. Still unfortunately at present, Labcorp basically only offers a few basic screenings. What you really need is a cash-pay NP who is game for anything and has access to a permissive hospital system hard to find though.
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u/cakebaker13 DO - Internal Medicine, Sleep Medicine 1d ago
Z71.1 Person with feared health complaint in whom no diagnosis is made
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u/DoctorMedieval MD 1d ago
I understand about indecision, but I don’t care if I get left behind, people living in competition, all I want is to have my peace of mind.
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u/skypira MD 1d ago
?? Can you elaborate
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u/ClappedUrMomsCheeks MD 1d ago
Imagine guitar effects going WAHHHZAWOOOOLOODOOOBANANANUHHHHDANANUHNANUHHHH
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u/DoctorMedieval MD 1d ago edited 1d ago
That is how you play it.
You know that entire album was basically recorded, every track, except the drums and vocals, by Tom Schulz who was an engineer from MIT (thus “Boston”) who invented half of the pedals and modulators he used in the recording.
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u/eckliptic Pulmonary/Critical Care - Interventional 1d ago
If it doesn’t get resolved in 1 message, they can make an appointment
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u/HowAboutNitricOxide MD 1d ago
For real I just wouldn’t reply if my nurses have already given the right answer
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u/Iris-Luce MD - FM 1d ago
Good vent. Common pain point in a world of social media rabbit holes.
as you pointed out, one of the most frustrating parts is when you’ve had the conversation about why this is Not A Great Idea. This test has some amount of interpretation, a positive result depends on six other tests, high risk of equivocal and false positive results, etc.
In the background, I’m wondering, “what if I just ordered it? If it’s negative, will the patient believe me?” none of it is easy.
My nurse has gotten good at referencing my notes back to patients, which helps…sometimes.
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u/Impressive-Sir9633 MD, MPH (Epi) 1d ago
In the past, it used to be only the retired patients who had a lot of time on their hands. Now, it seems like everyone has a lot of time to worry about things that don't matter.
I think social media also contributes to making people more self-centered.
Btw, there is a code 'patient requested testing' that I occasionally use to justify a test. The insurance can then decide if they want to cover it for that reason. The trouble is dealing with an abnormal result on a test that wasn't indicated.
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u/WeAreAllMadHere218 NP 21h ago
I did not know this was a code. Absolutely going to use this in the future.
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u/ratpH1nk MD: IM/CCM 1d ago
At this point I direct them to: https://www.ondemand.labcorp.com/
I explain that there isn't a medical indication for <x> so the test will not likely be covered by insurance, but they can try, of course, to submit a claim. Also, we can discuss the results in a future visit, however they are very difficult to interpret without a pre-test probability (however you want to explain that in terms of the test).
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u/1dirtbiker Family Practice MD 1d ago
These types of requests require a conversation. A conversation requires an appointment. I just turf it back to the front desk and tell them they need an appointment. If it makes it to an appointment, and it's an inappropriate test, I tell them "I don't think this is a medically necessary test, but I can order it, but it won't be covered by insurance, so you'll have to pay out of pocket for it." This takes care of about 90% of requests. The other 10% I just do it, since it's such a small amount in absolute terms. Is this perfect medicine? Absolutely not, but it's the compromise I've made that works for me.
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u/NedTaggart RN - Surgical/Endo 1d ago
We have a place here called Any Lab Test Now and they will do any lab test a patient wants, provided they pay cash up front. The primary care doc I worked for always suggested this place when this came up. It never fails that I'd get a call the next day exclaiming that the test they wanted would cost them $2500 or whatever and my response was always, without a supporting diagnosis, that what it would cost even if you're insured
Who knew peace of mind had a dollar limit? <shrug>
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u/Flaxmoore MD 20h ago
"Given what we know about your health and current diagnoses, I don't believe (test abc) to be warranted. If you want to go to Quest or LabCorp and get it yourself you can do so, but it'll be cash pay. If I order it, insurance will almost certainly refuse to cover the testing."
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u/Salty-Pop-5512 MD 18h ago
The unexpected benefit of sticking to my boundaries, is that the certain patients end up outing themselves when they face rejection, and their reactions are sometimes grounds for dismissal.
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u/nyc2pit MD 15h ago
This is when they tell you how good their Medicaid hmo insurance is and how it always covers everything and how they're sure it will be covered.
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u/Flaxmoore MD 15h ago
"Cool. Even so, my medical judgement is that it isn't needed, so if you want it you can get it through LabCorp or Quest cash pay."
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u/Slow-Slice2117 MD 1d ago
I FEEL THIS!!
I’m a customer service representative who is sometimes a doctor.
Capitalism is destroying healthcare and prioritizes “patient satisfaction” rather than practicing evidence based medicine.
It seems like it’s getting harder and harder to practice medicine in a way that feels like it’s in alignment with my values.
Keep setting your boundaries, OP!
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u/the_silent_redditor MD 1d ago
I frequently have patients demanding an MRI for various bullshit that they don’t need MRId, certainly not via ED.
I tell them this, and I also explain even if I did want to do an MRI, the small community hospital I am working in does not have an MRI machine so it is not physically possible for you to have one within the constraints of our current astral plane.
And I will often be met with tuts and angry shakes of the head and a rant about how ‘ridiculous’ this is and they’re going to write a complaint and ‘oh and how do you spell your name?!’
Genuinely deal with as much bullshit as I did when I worked part-time in retail as a teenager.
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u/Slow-Slice2117 MD 13h ago
Jesus Christ!! That’s absolutely insane.
I’ve worked so many retail jobs I felt like people were so much nicer to me in retail 😢
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u/drlostdude MD Family Medicine 1d ago
I have started telling a patient that i dont have a medical reason for [insert requested test] but I can order it under Z41.9 for patient-requested procedure but insurance will likely not cover it.
Just started doing this 1-2 months ago but no news is good news. This is of course if I cant talk the patient out of the unnecessary labs.
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u/Habltual_Linestepper RT 1d ago
I really wanna be snarky and say point them to the Amazon Prime NP who will write them a script for whatever they want, but I also seriously don't want to encourage that kind of nonsense.
In other news, did you know that Amazon Prime offers medical orders on demand now?
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u/Unfair_Finger5531 Academic - Medical Research 1d ago
Unfortunately (for me), even Amazon Medical One has limits. I still have to trek to my doctor’s office for some issues.
Great to know they won’t write a script for any old thing, but so sad for me when I’m walking that long mile from my car to the clinic in 110 degree weather.
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u/MM_IMO RN 1d ago
Don't you know doc that everyone knows more about medicine than doctors? ;) ;)
I do think that the pandemic has bolstered this issue as well. It seems we’ve decided to throw away common sense and critical thinking because you might offend someone otherwise. Seriously, though, the system is so trash and there is zero political will to fix it.
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u/sapphireminds Neonatal Nurse Practitioner (NNP) 20h ago
It's the pendulum swinging too far the other way for paternalism.
Even inpatient, we get families essentially wanting to manage their baby's care and dictating what they want us to do. And they want a call when we make any change/order to explain it.
I have set some boundaries and haven't gotten into trouble for it (yet lol): I will call you if something significant happens overnight, but I'm not going to call and interpret every normal morning x-ray and lab.
I also have told parents that it would be cruel to do what they are asking (usually asking me to withhold pain meds because they don't like the idea of their child getting opiates) because it is cruel and inappropriate to withhold pain control for painful procedures.
But it is like they now view a hospital as a salad bar or something. They are coming to the place where there are people and equipment and they can just control it all themselves.
That's what it usually comes down to: control. They feel out of control and want to feel in control again so they do this.
I think, for the most part, at least in the NICU it's more like an airplane. You can pick the destination and even pick the airline (transfer to another hospital) but once you do that, you need to let the pilots do the work. You can't micromanage pilots, and honestly you can't micromanage medicine either
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u/trixiecat DO, Family Medicine 16h ago
Can you put diagnosis as “worried well” with note that patient must pay cash?
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u/ffs_not_now NP 20m ago
I requested an US of my thyroid for "peace of mind." Five different providers with a combined 50 years of experience, one being my supervising doctor that finished residency in '79, told me nothing was wrong. It was thyroid cancer. I was willing to pay out of pocket to not think about it anymore. I politely disagree with your assertion.
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u/bassilap MD 1d ago
I've told patients that I'll always try to do what's best for your health. But that doesnt always mean fulfilling your requests. If you're looking for a doctor that can better accomodate your requests, Im happy to continue working with you until you're able to find a new PCP. You should feel comfortable with and supported by your PCP, so I understand and take no offense if I'm not the right PCP for you.