The ‘Be Well’ DPC Sign Off and Its Double Meaning
Author: Landen Green, DO
Most know the meaning behind ‘Be Well’ in the DPC world.
- A patient complains about not having their non-urgent email responded to within the hour? … Be well.
- A patient wants to quit after being charged $4.57 instead of the $4 you quoted them?…. Be well.
- Someone abuses the ‘unlimited’ access and then terminates their membership, deciding your practice isn’t worth the money… Be well.
- Someone punches you in the face for not prescribing a 360 day supply of Percocet? … Be well.
Okay, so the last one will need a different approach, but you see the point. Signing off with a “be well” is seen by many as our secret society’s version of “F off.”
I argue that the meaning depends on the heart of the sender, and the original creator of the phrase agrees. To quote the creator, “It’s your choice, and only you know” the real meaning behind it. It “does NOT mean that when you say “Be Well” it is always a bad thing. Sometimes YOU REALLY MEAN it in a nice and genuine way.”
The latter I encourage. Finding yourself frustrated, annoyed, or angry with a patient and ready to throw a “be well” at them? Breathe, find a peace with letting go, be unrattled by those who cross boundaries. Pause, attempt to elegantly defuse, sincerely wish the best, for them to ‘be well’… and then move on. When done right, even the most outrageous situation can lead to a positive outcome.
Here is the inspiration for this article:
A completely random New Patient signed up. They paid the registration and membership fees and immediately scheduled their first 90 minute visit. Nothing strange about it. On their intake form, pertinent information was that they had a history of back surgery, were on a blood pressure medication, and their main focus for the visit would be their hip pain.
The New Member Visit day comes, they arrive 15 minutes late but apologize. We discuss their health in its entirety. Review the hip pain and plan for physical therapy, conservative approaches, and 4 week follow up. Discuss health maintenance and plan to order a mammogram, pap-smear, and FIT. Review their controlled hypertension and plan for a medication refill. Plan for routine annual labs. Review all the things – medications, family history, exercise, nutrition, sleep, cycle, etc. The visit goes pretty smoothly, ahead of schedule. As I am wrapping up, literally walking out of the door, the bomb drops.
Them: “Oh, can I also get a refill for my pain medication? I am almost out.”
Me: ”uhhhhhh, ummmmm, huh?”
After over 60 minutes of thoroughly reviewing their history, this comes up right at the end? Not a good sign, right?
This is the overview of the conversation from then on:
Me: Oh, you did not mention that before. What is the medication?
Them: Oxycodone 15 mg three times a day
Me: Where have you been getting this?
Them: Another doctor in town.
Me: No problem, what’s their name?
Them: I don’t remember.
Me: Where is their office?
Them: I don’t know, I think they moved.
Me: How long have you been getting this medication from them?
Them: Oh several years, been stable on it, doing well.
Me: Okay, so you have been getting it for several years but do not know the name of the doctor or the office location?
Them: I never met the doctor.
Me: Did you ever go to the office?
Them: No it was phone calls.
Me: Where are they now?
Them: I don’t know, I have not heard from them in a while.
Me: Oh, well, maybe they are in jail! This seems like a very odd thing.
Them: (laughing) Yeah, maybe so! They were a bit weird.
Me: Okay, so oxycodone 15 mg three times a day for several years. Anything else?
Them: Yeah and I don’t even take them that much. My mom lives with me and is in bed a lot, so I give them to her too.
Me: Okay, so your mom’s health is not so great?
Them: Yes, she pretty much stays in bed so I give her my pain medication when I feel like she needs it. I give her tramadol too.
Me: Do you get the tramadol from the same doctor?
Them: Yes
Me: Are you on anything else for pain?
Them: Yes, I also use fentanyl patches.
Me: Where do you get them?
Them: My cousin.
Me: Okay. Well unfortunately, these things are not something we can help with. As office policy, we do not continue chronic pain medications.
Them: (frustrated) Well I wish I would have known that before all this!
Me: I am sorry that was not clear. We offer Meet and Greets in hopes to prevent this sort of thing and it’s on our website that chronic pain medication isn’t something we manage.
Them: (increasingly frustrated) Well, what am I supposed to do now?!
Am I annoyed? That’d be an understatement. Frustrated? Abso-freaking-lutely.
Taking a deep breath and remembering all the things I learned from trolling DPC communities, naturally, “Be Well” popped into my head. But not from a place of anger, more from a place of relief. I thought “so glad I don’t have to deal with this.”
I let her know I would refund 100% what she paid, essentially giving her a free, comprehensive health evaluation with recommendations. I also let her know I would look into practices that could help her with her pain medications and that I would send those resources to her. Although we did nothing wrong, I apologized for any confusion or miscommunication and left her with a “Be Well.”
The next day, we got this text:
I let her know I would refund 100% what she paid, essentially giving her a free, comprehensive health evaluation with recommendations. I also let her know I would look into practices that could help her with her pain medications and that I would send those resources to her. Although we did nothing wrong, I apologized for any confusion and miscommunication and left her with a “Be Well.”
The next day, we got this text:
So, what does “be well” in DPC mean? It all depends on where it comes from. Similar to an “okay” or “sure” text message from a spouse or friend. It could be sincere, or could be a frustrating short response. This situation went from a potential disaster, a Facebook or Google bad mouthing, disgruntled patient harassment, who knows? But instead, it turned out with an overall positive outcome with zero headache.
“Be well” is the right response to several situations in DPC, small business, and life, but the meaning is up to you.
To read the complete origin story and learn about the email that started it all, check out Dr. Douglas Farrago’s book Slowing the Churn in Direct Primary Care.
I’d hate to be a pain management doctor except if a primary care doc recommends a referral for a recognized condition before the patient was addicted to high dose narcs. I did that with my patients when I could and the pain clinics always preferred seeing my patients partly because of the long referral letters I dictated and sent all the radiographic studies I had done and previous treatments I provided. Of course if I found a blown disc or something else surgically that could be addressed, I’d refer on to the appropriate surgical specialty as soon as possible. Those patients usually did a lot better and if still with residual pain, were on much lower doses of narcs to deal with it. Many were pain-free after getting over the surgery. Those patients are relatively rare though but since I had a geriatric practice I saw a fair number of them.
When people wanted to become “new patients” one of the first question my screeners would ask on the phone is, “What pain medications are you taking?” If on high dose narcotics and if they weren’t dying from metastatic cancer the reply was, “Doctor doesn’t prescribe those medications.” The phone would go “click”. That prevented many of the problems outlined in the above tome for me when I practiced. I had two older DISH syndrome patients (look it up) who had chronic pain and there was nothing surgical to be done. The rheumatology guys and surgeons had nothing for them. I maintained them on low dose narcs for years along with some Pain Clinic local injections. Many times 3 or 4 Vicodin helped them for years in spite of what they say about narc tolerance. For one I offered to increase to percocet but he declined it. I’d see a DISH patient out at Wal-mart and they’d always thank me for the care I gave them and the referrals I made for them. They seemed happier that they had a diagnosis and they weren’t “nuts” from the pain they were having. I wished every pain patient was that easy to deal with. Stuff like this is rare though.