Here is the inside scoop on the REAL reason some Doctors do not prescribe Pulmonary Rehabilitation or Lung Cancer Rehabilitation:
The number one question we get every time we meet a new Pulmonary Rehab (PR) or Lung Cancer Rehab (LCR) patient is: Why didn’t my Doctor send me to you sooner?
Hold onto your seats this is going to cause quite a bit of controversy and ruffle some feathers, but it needs to get addressed. This question can not be easily summed up in just one answer. The reasons are divided: it is really ½ the Doctors responsibility and ½ the Patients responsibility.
Let’s look at few factors that create a scenario in which Patients do not get referred to Pulmonary Rehabilitation or Lung Cancer Rehabilitation, then finally we can offer some solutions:
• Today’s typical doctor office visit
• Today’s Doctor/Patient relationship
• The Doctor types that do not refer PR
• The Patient types Doctors do not want to refer to PR
*I can not emphasize this enough- This article does not represent the majority of the excellent Physicians practicing today as well as the excellent Patients, just the ones that don’t get it.
I truly believe that once some light is shed on this topic Doctors and Patients will both benefit greatly!
Here are 2 Rules to keep in mind as we continue:
Rule #1: You don’t know what you don’t know
Rule #2: You can only utilize the tools that you have in your toolbox of life
The typical office visit of today
I really believe that to start to find the answer we first have to look at a typical Doctor’s office visit and how this contributes to Patients not getting referred to PR or LCR.
Tell me if your typical Doctor office visit sounds like this:
- You arrive at the office and walk into the waiting room and sign in – You are short/shortness of breath (SOB)
- You sit, rest, and recover in the waiting room, while you wait to be called into the exam room (Notice that Your Doctor never witnesses your SOB)
- You walk to exam room- Now you are SOB again- You sit, rest, and recover in the exam room -you wait until Dr comes in. (Again, notice that Your Doctor never witnesses your SOB)
What is the most important piece of information to take from all of this?
Hint: See Rule #1 (Your Doctor usually never actually sees you short of breath!)
You have probably been in the office anywhere from 30 to 90 minutes at this point and want to get the heck out of there. The Doctor has likely allocated you only 10 minutes. You probably also have lots of questions but you both keep getting sidetracked and interrupted…your time is up, your visit is over, see you in 3 months…ugh!
The Doctor/Patient Relationship
Just like any relationship, both parties need to have a mutual interest and investment in this venture. In short, both parties need to have some “skin in the game.”
The Doctor Patient relationship has evolved so much over the last 20 years. Back in the day, Patients never questioned Doctors. You did what he told you period. Now in the Information Age, Patients are using the internet to diagnose and plan a course of treatment all before they even go in to see the Doctor. This is really unfair to do to your Doctor. There really is a fine line between being informed and thinking you know it all. Also, since lots of patients are not even compliant with a simple task such as taking a pill, or an inhaler, Your Doctor is not going to waste time, energy and effort to refer to PR…and I agree with them. Too many times we have spoken to patients to schedule their initial evaluation and they tell us that that did not really want to do PR, they just said yes to appease their Doctor at their last visit.
Common Doctor types that do not prescribe Pulmonary Rehab:
• The 4 minute Examiner– This Doctor is over-worked, overbooked and feels underpaid from reduced reimbursement, he/she has to quadruple book to make up for any possible cancellations that day. Unfortunately, you only get a 4 minute exam.
Primary tool in tool box: Referral for more tests and postponement
Problem: They never see you short of breath and not enough time to discuss it
• Dr. Set in My Ways– “They didn’t teach me that in Medical School, I only know how to prescribe meds, I don’t know enough about PR or LCR, I’m not changing my ways”
Here’s one of my LEAST favorite responses that Doctors give:
“You have a disease…you should rest and take it easy”
Believe me, nothing is further from the truth!
Primary tool in tool box: Medications
Problem: Pulmonary Rehab is never even considered-Patients suffer
• Dr. “Try This” – “Let’s try this new medication.” Realistically, almost all the “New” medications are derivatives of drugs that have been around for the last 30 years… Sometimes if it’s not broke, don’t fix it!
Primary tool in tool box: Medications du jour- whatever the latest drugs are on the market
Problem: Too many changing variables
• Prednisone Pusher– Making a deal with the devil- (I am referring only to the Doctors that put Patients on high doses of steroids and leave them on that high dosage for years).
Primary tool in tool box: Prednisone
Problem: You feel good temporarily for a short time, but then eventually need higher and higher dosage to get the same effect. Also, let’s also not forget the paper thin skin, the bruising, increased blood sugar, increased appetite, weight gain, feeling wired and brittle bones.
• Dr. Oxygen – “I don’t know what to do for you, I’ve tried every tool I have. You have shortness of breath, so you must need oxygen…at 2 lpm” Again, another supposed “miracle cure” except for the fact mostly everyone on oxygen is still short of breath and usually always placed on 2 LPM without anyone ever actually determining the correct dosage for the patient.
Primary tool in tool box: Oxygen
Problem: These Doctors aren’t educated properly on usage and dosage of oxygen. They usually order 2Liters nasal cannula on every patient that is newly placed on oxygen. Remember, oxygen is a drug. Let’s make proper dosing a priority!
• The Monopoly Doctor– This Doctor wants and needs a financial incentive to refer patients. Some of the greedier ones go so far as to create and hide their relationship with therapy offices just to make a few extra bucks.
(One day I will tell you the story of how we got first hand information on these highly questionable business practices.)
Primary tool in tool box: Self referral- Aren’t there Self referral (Stark Laws) in place to prevent this?
Problem: Greed clouds judgment
Now that we have identified some of the Doctor types that don’t prescribe Pulmonary Rehab, let’s look at what role the Patient has in not getting referred.
Common Patient types that prevent Doctors from prescribing Pulmonary Rehab or Lung Cancer Rehab:
• King or Queen of Denial -“I don’t have shortness of breath”- No accountability and lots of denial… “I don’t have a problem climbing stairs” Spouse says “Oh really why did we move our bedroom to the first floor where the dining room was because you can’t climb stairs?” “I have shortness of breath, but It doesn’t affect me (as I’m panting and almost falling over)”.
• Vain & Shy – “I don’t have shortness of breath”- (I am too embarrassed to admit it, I try to hide it in every possible way.)
My question to you is: What will draw more attention to you? Wearing a clear tube in your nose that lots of people have or writhing around on the floor of a store or restaurant in Respiratory or Cardiac arrest waiting for the ambulance to get there?
• Vanity & Stubborn – “I don’t have shortness of breath”- “I don’t want to wear oxygen although it may help me, I won’t wear it.”
• The Minimizer – I have SOB, but when I get to the Doctor’s office I “forget” to mention it. “I’m not that bad.”
• Non-Compliance Officer– “I don’t take my medications consistently if at all, so I’m definitely not going to exercise.”
Now be honest. If you were a Doctor, wouldn’t it be frustrating trying to spend precious minutes begging and pleading with someone who does not want to help themselves? How many times would you continue to suggest a healthier choice or treatment option (only to have it refused) before you would stop trying? All I can say is God bless the dedicated Doctors, Respiratory Therapists, Nurses and other great medical professionals that keep trying tirelessly every single day!
Luckily, for the Patients that aren’t motivated, most of us refuse to give up on them.
So how do we change this situation?
About the author:
David Junga, RRT is a Nationally Board Certified Registered Respiratory Therapist and Program Director at Pulmonary Rehabilitation Associates, LLC and PulmonaryRehab.com. David has been in private practice since 1999 and loves teaching patients how to overcome their shortness of breath.
David is also a Postural Alignment Specialist certified by the Egoscue University and Program Director at CtPainFree.com. His other passion is teaching people how to eliminate chronic pain through simple yet powerful corrective exercises.