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October 27, 2015

Patients Who Travel a Long Distance for Care

Image courtesy of tigger11th at FreeDigitalPhotos.net
In 2014, our practice made the difficult decision of no longer accepting new patients who live outside the Virginia region of the United States (specifically VA, WV, DC, and MD) with the exception of a few conditions. The reasons are many in spite of what many (upset) patients felt to be an unwarranted geographic limitation. This blog tries to explain why we have taken this step which is still in effect today.

There are certain conditions that patients have travelled hundreds if not thousands of miles to our practice for help... conditions that patients felt were not adequately treated nor understood by their local doctors. To name a few such conditions:


We still accept new patients for spasmodic dysphonia and Zenker's no matter how far away they live, but for the other conditions, we only do so in very rare and exceptional circumstances.


Why?

Generally speaking, patients who travel a long distance justifiably want any and all testing and procedures to all be done ASAP (i.e., same or next day) while they are in town. After all, if they paid $1000 for a round-trip plane ticket, $500 for hotel stay, and $200 for car rental, than by golly they want to get their money's worth. And that means our office better be able to deliver...

Unfortunately, we can not accommodate these understandable demands for several reasons.

Our office is a small 2 physician practice. We do not belong nor are we affiliated with a large medical center. Unlike a place like Mayo Clinic or Johns Hopkins Hospital, we are not able to perform every single test under the sun in our office on the same day of visit. There are some tests we CAN do in our office same day of visit like allergy testing, bloodwork, cultures, FeNO, esophagoscopy, laryngoscopy, etc. 

However, we are NOT able to perform any same-day radiological studies like barium swallows, CT scans, MRI scans, etc. These studies are scheduled at our SMALL hospital after insurance authorization. Coordinating a day/time when a scanner is available at our small hospital after insurance authorization typically results in a scan being scheduled days later. Keep in mind, the hospital we are affiliated with is a SMALL hospital with only a few CT scanners and only one MRI scanner. Unless the problem is an emergency, appointments are scheduled next available which may be days later.

We are NOT able to schedule a surgery for the same or next day... any surgeries recommended will occur during the next available OR time slot which may not be for 7 or more days. The hospital we are affiliated with has only 4 operating rooms which are shared with orthopedics, ophthalmology, OB/GYN, general surgeons, etc and ENT time blocks for surgery is reserved for during very specific days/times which may already be filled with other patients.

Certain specialized testing we often order to evaluate the rare conditions listed above often require an appointment with yet another doctor/facility we work with because we do not offer such testing and they do. Such testing include SELSAP for laryngeal sensory neuropathy or 24 hour multichannel pH impedance testing with manometry to evaluate for silent LPR. In other words, if our office recommends one of these tests, there may not be an appointment available during your stay in the area to get this done in one visit.

The same is true for "other" appointments such as any referrals to specialists, most commonly pulmonary and gastroenterology.

Remember, there are other patients on the schedule and squeezing one patient in would often necessitate cancelling another patient's appointment.


Why not schedule everything prior to visit?

Some patients may than ask why not get all these tests/procedures/appointments scheduled prior to a visit? The two main reasons are:

1) What tests/procedures/appointments should be scheduled?
2) Who is going to order and than get insurance authorization for any tests/procedures? Our office can not do this without an office visit (same reason why medical offices can not prescribe any medications without an office visit first).

Follow-up frustrations

Although most patients who have travelled great distances for us to see have been grateful for the care we have provided that nobody locally was able to provide, many have also expressed some level of frustration (and perhaps even anger) due to the above-stated issues.

And this frustration often continues beyond the initial office visit if there's any follow-up required, especially if a health concern/question pops up. For example, globus is a condition where a person has a lump sensation in the throat. Sometimes, this sensation can get so bad, the patient can barely swallow. It is not uncommon that we get a panicked phone call from a patient suffering from severe globus stating they choked on some food and can barely eat anything now without coughing/gagging... except we are located in Virginia and the patient is located in Wisconsin. Any response we make in this situation will be met with some resentment because unfortunately there's not a whole lot we can do to treat/evaluate/manage this problem over a phone line.

1) Our normal response offering an appointment to see us is understandably not reasonable given the huge geographic distance separating us.
2) Go to the ER... Most patients have done this enough times before seeing us to know there's not much an ER can do for their specific problem.
3) Go see their local ENT... except they've already done that without results which is why they have come to see us in the first place.
4) We don't know what else to offer at this very moment over the phone beyond the above 3 options... which is the honest truth.

The typically unsatisfying response we end up making is to reassure that we need to complete the workup initiated at the last office visit to determine what is causing the symptoms and once a correct diagnosis is obtained, to than follow through on a treatment course to hopefully "cure" them.

In Summary

After being on the receiving end of verbal tirades from angry, frustrated patients who spent hundreds if not thousands of dollars to see us because we literally and truly can't accommodate to get everything done while they are here... our office has decided to stop seeing patients who live more than a reasonable car drive's away.

Of course, our policy may change as circumstances change.

So why do we see spasmodic dysphonia and Zenker's, but not the other conditions? It's because these are conditions that we can potentially treat in one visit with minimal testing and minimal follow-up with near universal success.
Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids. Google+ Christopher Chang, MD Bio

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