While we were discussing these issues, I read my progress notes. At his last visit, he had a skin lesion at the base of his nose that I thought was a skin cancer. Since the cancer was in the center of his face, I thought he should have this removed by a plastic surgeon. It turned out that the lesion was a basal cell carcinoma. The plastic surgeon had removed the lesion very skillfully, and without leaving a scar. I was impressed, and I told my patient that the plastic surgeon had done a fabulous job. Perhaps on some subconscious level I was fishing around for a compliment or a thank you. Many times patients come back after I have referred them to a cardiologist or some other specialist. They thank me profusely for saving their life, even though sending someone with crushing chest pain to a cardiologist or the emergency department is a real "no brainer." In my opinion, this judgment call seemed a little bit more sophisticated. While I was wrapped up in this self-congratulatory reverie, my patient rudely brought me back to reality. He conceded that the plastic surgeon had done a great job, but with his $3,000 deductible, he whined that his out-of-pocket costs were $2,800. I guess it would have been cheaper to cut his nose off, but I didn’t say so, because I didn’t want to give him any ideas on how he might save money in the future.
Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. This column, "Inside Rheum," appears regularly in Rheumatology News, a publication of Elsevier.