04 December 2012

No, You Kiss My...

According to the results of 10 patient surveys conducted by HealthGrades.com, Dr. Larry M. Greenbaum's patient satisfaction marks are below the national average. A board-certified rheumatologist who graduated from SUNY Downstate Medical Center in 1984 and did both his internship and residency at Winthrop University, Greenbaum has been with Indiana Internal Medicine Consultants in Greenwood, IN since 1993.

His practice's office staff seems fine enough. For the ease of appointment scheduling, office environment and office friendliness the survey indicates that patients find these services to be "good" or, just marginally, "very good." But when it comes to wait time, things don't look so good. HealthGrades.com shows that patients are reporting a 16 to 30 minute wait while the national average is 10 to 15.

Perhaps patients spend this extra time waiting doing a bit of personal reflecting. Rather than reading old magazines, cleaning out their purses or checking their voicemail, the patients dwell on persistently aching hips, a recurring rash or the crippling joint pain of rheumatoid arthritis.

One such patient was a 75-year-old man in for his first appointment. Diagnosed with rheumatoid arthritis for about a year and half, the man was struggling to adjust to his treatment's side effects. Greenbaum describes the case in his article "Kiss My ...," which appeared online in Rheumatology News on Nov. 30, 2012.

"When his treatment commenced with 20 mg of prednisone a day, he felt like 'Superman,' but by the time he was down to 2 mg a day, he felt as if he had been 'hit by a truck'," Greenbaum writes. "He claimed that an arthrocentesis by his first rheumatologist caused his left index finger MCP joint to permanently dislocate the day after the procedure. 'He took too much out,' he complained. He was on methotrexate, but he was dreadfully worried about dire side effects. A recent string of sinus infections were clearly due to his medications, in his opinion. He didn’t think that his long history of smoking could possibly have contributed to his problems."

Greenbaum's condescension is clear as he mocks the man's attempts to describe his condition and its effects on his life. The man—like most patients—did not use medical terminology. He spoke in the manner to which he was accustomed. He related his story from his perspective, illustrating the tenant of cognitive behavior therapy that an event does not cause our emotions, rather how we perceive an event and what meaning we give to it thereby defines it.

Greenbaum defines his own philosophy of care. "Trying to keep the mood light, I used one of my favorite quips: 'If all else fails, examine the patient,'" he writes.

Greenbaum's "quip" is not amusing; however, it is certainly enlightening—only when lab results and a headful of institutional knowledge fail to produce a solution, should a doctor deign to rely on information given by the patient—the person—who actually has experience living with the condition and living with the condition under the specific circumstances of being himself. It's a belief as antiquated as using a mallet to the head for anesthesia. It is an affront to the concept of patient-centered care. It is a failure to care at all. 

Of course, caring doesn't seem to be what Greenbaum's in it for. 

"If your practice is like mine, you probably don’t bill for 'consult level 5' very often," Greenbaum writes. "That is the most expensive level of care on our office superbill, and I usually reserve it for patients with huge volumes of records, patients who take an inordinate amount of time, or patients who annoy me in some other extraordinary fashion.

The 75-year-old man with rheumatoid arthritis whom I’m describing, didn’t bring many records, but I spent a very memorable hour with him. I charged him level 5 for taking so much of my time, for bad-mouthing his previous doctors, and for incessant whining."

Assuming the patient is enrolled in Medicare, Greenbaum's indication of a "consult level 5" reflects code 99205. E/M University is run by Peter R. Jensen, MD, CPC a practicing physician and certified professional coder who practices in Connecticut and is Director of E/M Compliance for the Yale-New Haven Hospitalist Service. E/M University refers to code 99205 as such: "This is the big daddy. The 99205 represents the highest level of care for new patients seen in the office... The reimbursement for this level of care is approximately $197, which is pretty good. Usually the problems are of moderate to high severity." In 2011, code 99205 was $154.98 more than the most basic new patient office visit code 99201, according to the American College of Rheumatology's National Medicare Fee Schedule. Three sources of documentation are required for this code 99205—comprehensive history, comprehensive exam, and high complexity medical-decision making—or 60 minutes of time spent face-to-face, with proper documentation. Therein lies the loophole that allows Greenbaum, and doctors like him, to apply this code to those patients whose worst offense is to require a doctor's time or, as Greenbaum puts it, "patients who annoy me in some other extraordinary fashion." 

Other patients who have seen Greenbaum may have in turn been equally annoyed as HealthGrades.com's 10 patient surveys score the doctor well below the national average with a solid "not sure" in response to all of the following questions: "Do you trust your provider to make decisions / recommendations that are in your best interests? Does the provider help you understand your medical condition(s)? Does the provider listen to you and answer your questions? Do you feel the provider spends an appropriate amount of time with you?" And finally, "Would you recommend Dr. Greenbaum to family and friends?"

I am sure. Even though I've never been one of Dr. Greenbaum's patients, I also never will be.


Look for RA patient and health advocate HurtBlogger's post regarding Dr. Larry M. Greenbaum's article "Kiss My ..." later this week for which Greenbaum has been contacted. Visit www.thehurtblogger.com


  1. this doctor needs sensitivity training. By the time we convince ourselves we need to see a healthcare professional, we are usually in pain, stressed and already edgy. We definitely do not need this type of appointment and care.

  2. Great breakdown of exactly WHY Greenbaum should get his knuckles rapped, hard. Kiss my ***, indeed. He's a rheumatologist, fer crissakes. He sees people in pain every damn day. Does he mock every one of them behind their backs?

  3. Thanks Sarah, I'm glad you got on this right away & word is spreading. I got excited that you saw it and replied on FB. Even though that's my private page, there are now 48 comments. But, it will be a few days before I can get to this on the blog with pressure from urgent projects.

    There are so many levels where Greenbaum is wrong. Thanks for doing such a great job putting the spotlight on him as he was so busy pointing the finger at a patient that he can't even see what poor care he gave him.

    Hi, Casey, this is typical in rheumatology. And we see this kind of derisive talk about patients in our social media as well... more on the blog soon I hope.

  4. What a smart mouthed creep this doctor is. Perhaps CMS might look at his records to see if he's billing for providing care or to see if he was just annoyed by the patient. Medicare fraud is a crime and listening to a patient bad mouthing a doctor is not a billable service. I'm flummoxed by his nerve and insensitivity. When I went to Cosmetology school they told us aspiring hairstylists to never gossip about one client to another because they would be wondering what you said about them to others. This man takes it one further and posts it on the Internet for all to see. I'm disappointed with the publication for posting it as well.

  5. Great job, Sarah! Looking forward to seeing HurtBlogger's post too.
    Rock on!

  6. I realise the sort of utopian participatory medicine bubble I must live in when I come across articles such as the one you describe, Sarah. Thanks for your excellent commentary. I wonder how Rheumatology News will respond?

  7. Yikes. The doctor is the one who is complaining. He shouldn't be able to have a M.D. if this is how he cares for his patients. Unfortunately, this is all too familiar to me.

  8. This blog is very helpful and informative for this particular topic. I appreciate your effort that has been taken to write this blog for us.
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