Choices

When more than one doctor can be seen for a problem, deciding which one to call can be tricky.  What matters most?  Skill?  Bedside manner?  Convenience?  Cost?

It probably depends on the situation.  In this case, I need a cortisone injection.  Okay, I’m not a doctor.  Maybe I’m not qualified to make such a decision.  In the past, though, when my shoulder has felt like this, I’ve gotten a steroid shot, and it’s helped.  Whom should I call?  Rheumatologist, orthopedist, or family physician.

My rheumatologist might be able to do it at my next appointment.  That would be simplest.  No extra appointments, no extra time required.

Another option is to see the orthopedist.  Last summer he said that he suspects I’ll need surgery on the shoulder within a year.  I’d like to prove him wrong.  If he’d said he could fix my shoulder, I might be interested, but that’s not what he said.  There’s only a 50/50 chance of surgery helping, and those odds aren’t nearly good enough.  A better plan is to resume the exercises that have helped in the past (and not stop once my shoulder is better).  Steroids would make the PT exercises a lot more doable.

I’d rather have my family physician do the injection.  His cortisone shots seem to work better and hurt less than steroid injections I’ve gotten elsewhere.  I don’t know if it’s individual skill, or if it’s the fact that he uses kenalog and everyone else has used depo-medrol on me.  It doesn’t matter.  That’s where I’d prefer to go.  The drawback is that if I go see him about my shoulder, he might tell me to go back to the orthopedist.

That’s my choices of whom to see.  Then there’s the financial aspect.

My old insurance policy covered injections at 100%, so cost wasn’t really a factor.  New insurance only covers 80% so expense is now a consideration.  Add in the fact that under this will be entirely out-of-pocket since I haven’t yet met my annual deductible.

Steroid injections vary widely in price.  Looking back through my old EOB’s, I found:

  • My rheumatologist charged $172 when I got a depo-medrol injection from her.  Insurance allowed $128.51.
  • My orthopedist charged $269 for the exact same thing.  Insurance allowed $168.33.
  • My family physician has charged $134 for the kenalog injections (plural) that he’s given.  Insurance allowed $41.18.

That means I can pay $128.51 for the convenience of getting a cortisone injection at my next rheumy appointment, or I can pay $41 plus a $30 co-pay and get the shot from my PCP.  Although this reduces my costs, my insurance company will be out an extra $70 since they’ll be stuck with the tab for an extra office visit.  For a savings of $57, it’s worth making an extra appointment to have my PCP be the doctor jabbing a needle into my shoulder.

When you have a choice, how do you choose?

Who’s The Patient?

It’s odd making the transition to observer instead of active-participant in a growing child’s doctor appointments.  I’m accustomed to being the one to provide information when I’m in an exam room with my children.  Kids grow up, though, and things change.

My daughter’s rheumatologist talks to her, not so much to us.  When my daughter shrugs her shoulders and says, “I dunno,” the doctor doesn’t turn to me or my husband for our input; she rephrases the question and pushes my daughter for an answer.

As we sat on the sidelines and eavesdropped while the rheumatologist talked with our daughter a few weeks ago, I reflected back over the years.  Our other daughter was only three when I took her to an allergist.  I remember interrupting him as he was explaining the scratch-test to me, and asking if he would please explain it to my daughter instead of me, since she was the patient.  He looked quite startled and turned his head to look at her, but only got two sentences out before his head gravitated back to me.  He just couldn’t do it.

My daughter’s rheumatologist is definitely different.  I love how she treats my daughter like an intelligent person capable of explaining what’s going on in her body, but it’s weird to not be included in the dialog.

It was interesting, this new way of doing things, when the doctor asked if our daughter thought her prescription was helping.  My husband and I have both seen a difference:  less pain, better appetite, more activity, happier kid.  It hasn’t brought complete pain relief, but it’s definitely an improvement.  We weren’t asked, though.  Our daughter – the person who was asked – wasn’t sure if the medication was helping.

The rheumatologist suggested that she stop taking it.  Give it two weeks.  If there was no change, no need to continue a med that wasn’t making a difference.  If she did notice a difference, then after two weeks a different NSAID might be better.

That seemed like a sensible plan.  My daughter (who hates taking pills) was delighted to have the doctor tell her not to take her prescription and looked forward to her two-week reprieve.  The day after her appointment, she loved not taking a pill with her breakfast.  The following day, she came downstairs and announced dejectedly, “The medicine was helping more than I realized.”

My husband and I recommended that she take her medicine, but she’d heard that she should wait two weeks before making a decision and didn’t want to go against what the doctor had said.  It was Saturday, so we couldn’t call.  Monday morning, first thing, I phoned and left a message.  When the nurse called back, she told me of course your daughter doesn’t need to suffer for two weeks!

The kid even got to pick whether she stuck with the existing prescription or switched.  Of course she stuck with a once-a-day pill instead of going to twice-a-day, but the particular med she’s taking isn’t that important.  The point is that she chose.  She’s the patient, and she’s learning to make her own decisions regarding her health.

Given the awful day she had earlier this week, my daughter came to me and asked if I thought it might help to try the other prescription.  Although I’m tempted to phone my daughter’s rheumatologist, I don’t think it’s time to do that yet.  It was a one-day problem, not a definite worsening of symptoms.  Trying a different medication seems like a reasonable first step.

A few months ago, my dear daughter announced that we could make her go to the doctor now, but once she turns eighteen she’s never going again.  I suspect that was an expression of frustration with the cards she’s been dealt, not her true intention, but I need to realize that it’s not too long until she’ll be autonomous.  She could choose to never see another doctor.  Instead of imposing my opinions and decisions on her, I’m trying to guide her in making good choices (healthcare and otherwise) so that when she has the legal freedom to make her own decisions, she chooses wisely.

Autoimmune Research

Stem Cell Transplant Benefits Severe Lupus - what an exciting possibility! 

Sometimes it seems like the drug companies are coming up with more expensive treatments, but there isn’t much progress made towards a cure.  Don’t get me wrong, I’m grateful for the drugs that enable me to get out of bed in the morning, and walk (even if people watching me ask if I’m sore, or if I hurt my feet.  At least I’m on my feet).  It’s just that I’d rather have a cure than a lifetime of medications that cost thousands of dollars every month.

It’s wonderful to see visible progress in the search for a cure of an autoimmune disease, even in a small, preliminary study!

 (you might have to register to read the linked article)