Thank You For Sharing This Lovely Friday Afternoon With Me

Funny Stuff from Doctor Grumpy.

Your insurance coverage runs out at the end of this month? My calender shows that today, May 29, is a Friday (which is a lovely afternoon by the way) and the last workday of the month. So Monday will be June, and we won't be able to get the MRI from your current insurance then, since it will have run out.

What insurance will you have on Monday? I'm sorry, I'm not contracted with that plan. I can send your internist a letter asking him to order the MRI. Oh, he's not contracted with it either. I see.

That Wasn't In The Job Description

Redneck woman with call light on, family visiting: "My son said to call you to put my socks on -- he said that's what you're paid for."

Ouch.

HelpmehelpmehelpmehelpmehelpmeOHhelpme...

I get at least one a week. FREE=MORE. We have somehow become the gatekeepers for inhumanity. It's no different than water boarding. The pain is the different, but really the same.

How To Earn Happy's Rockstar ED Doctor Award

1. Page me to the back line to the ED
2. Get put on hold for 5 minutes
3. Come back and say "Sorry for the false alarm. I thought I was going to have a guy with pseudoseizures.  But I got them and their family to go home."

If you could drink beer in the ED, I would have bought a keg of the finest import for that  good doc that fateful night.  I have taken care of several inpatients with pseudoseizures during my last six years as a hospitalist.  They always have normal EEG brain wave monitoring despite very scary looking spells.  They also have a clinical seizure presentation that makes no sense.  In one situation, the patient would go into these hilariously funny "fits" that looked exactly like the African anteater dance.  

Of course, it looks frightening to the lay person.  But to the trained physician, it's painful to watch.  Not because the condition is dangerous.  But because often times, there is no good way to tell the family that their family member has just experienced a major psychiatric break from reality.  I once had a family refuse to accept that the seizures weren't organic.  They went so far as to travel hundreds of miles to "a seizure specialist" (as if Happy's neurologists came from a cracker jack box) to find out the cause of their daughter's unexplained dancing fits.

Several months later came a fully documented 5 page summary of the one week hospital stay in the video monitored EEG facility.  

Diagnosis: no epileptical activity witnessed.  As painful as it is, I now tell families that we have no evidence of a seizure disorder.  That their shaking in all likelihood represents a psychiatric disorder, such as conversion disorder.  The brain believes it's real, even though it isn't.  That it is safe to go home. That you don't have to do anything if they start having their spells again.  And the treatment is follow up with the psychiatrist who saw them in the hospital.   It's a difficult talk, but it's the only option.  The science doesn't lie.

So for you rockstar ED doc, I applaud you for preventing a wasteful $10K hospital stay for a condition that requires an outpatient psychiatric evaluation.

Do You Pee In The Pool?

Swimming season is upon us.  Mrs Happy's father has an above ground pool.  It turned green over the winter.  Then it sprung a leak last week.  But there is nothing to fear, it seems all is fixed.  A little glue and some chemicals and everything looks great.  Grandma/Grandpa Happy just got the pool at their Phoenix love shack resurfaced last month.  Perfect swimming for those hot Arizona nights.

The CDC wants to make sure you practice good pool hygiene to prevent recreational water illnesses.  I personally have never had one.  I have never taken care of a patient who contracted one.  But apparently, the number of outbreaks is on the rise.  4,500 sickened in 31 states during a two year span in 2005-2006.  So make sure you stay safe.

And even though urine is sterile, please don't pee in the pool, like 17% of your fellow Americans admit to doing.

Is it OK For A Surgeon To Stop Seeing Their Hospitalized Patient?

A hospitalist describes what's going on at their institution.

This week, we ( hospitalists) are being asked to take care of post op ortho patients who the ortho guy will NOT see at all till the discharge day in the hospital. Is this now the new standard of care?

This is one of the worst examples of patient abandonment I can imagine. Surgeons are paid a bundled fee to provide surgical care for a 90 day period.  I'm pretty sure CMS would like to hear about this surgeon's policy of not providing their agreed upon service contract with the federal government.  

 I would never, ever, not in a million years agree to see post operative patients if a surgeon was not also following daily.  I am not trained nor experienced enough, nor do I have any desire to evaluate and manage post operative surgical sites of care.  

Your orthopaedic surgeon is failing to provide the standard of care and IF anything bad ever happened surgically they are screwed.  Here's what you do.  You write a letter to whomever is responsible for implementing that policy.  If it is an administrator you tell them you will immediately cease to follow or admit primary orthopaedic problems without daily orthopaedic evaluation.  If the surgeon does not want to do it, they should hire, or the hospital should hire a PA or NP on the surgeon's behalf to do post surgical related care.  You have no training, and therefor no responsibility to provide that care for the surgeon.  This is an example of gross incompetency on the administrator level, if they implemented the policy.  If the surgeon is "ordering you", you simply refuse to admit their patients or consult on them if they aren't willing to provide 24 hour care for their surgical care.  

It's time, in the interest of patient care, that you stand up for the patient and yourself, and say no.  You will not provide this service as you are not trained to provide this service.

This whole situation is just pathetic.  

If you are a hospitalist or anyone out there with experiences in health care, email me at happyhospitalistATgmailDOTcom and I will get you writing privileges to my other blog at Hospitalist With A View.  These are the kinds of things I like to here about.

How Do You Cut Wait Times, Increase Patient Volumes, Get 90% On Your Patient Satisfaction Scores While Generating An Extra $25 Million?

Apparently by playing the lone ranger theme.  Enter a health care consulting firm.

As a result of improved throughput, patient volume grew from 132 to 151 patients per day. To handle the increase in the Emergency Department, more inpatient beds needed to be available during peak hours. Hospital staff from the inpatient units pitched in to help the Emergency Department. They implemented several processes including a process they named Code Consensus. During a Code Consensus, a signal or code is delivered throughout the facility to expedite patient discharge, housekeeping and bed availability.

Stickel added, “The current code is the theme to the Lone Ranger. The first time we played it, we opened up 20 -25 beds in the first 2 hours.” 

How about that for innovation? A 40:1 ROI. I suspect hospitalists were involved somewhere along the way.

So You Want To Win $10 Million Dollars?

How do you save $120 million dollars in health care costs over three years for a community of 10K?  That's what some people are willing to pay big bucks to find out in a grand health care experiment.  Read the blurb below from The Health Care Blog.  

This belief is founded in the idea that aligned incentives can be a powerful way to spur innovation and seek breakthrough ideas from the most unlikely sources. Many of the reform ideas being put forward may not include some of the best thinking, the collective experience, and the most meaningful ways to truly implement change. To address this issue, the X PRIZE Foundation, along with WellPoint Inc and WellPoint Foundation as sponsor, has introduced a $10MM prize for health care innovators to implement a new model of health. The focus of the prize is to increase health care value by 50% in a 10,000 person community over a three year period.

Here's my solution.  Keep it simple stupid.   A high stakes game of chance which can only be won with strong personal commitment and responsibility to ones own health.   Let's use the national average of about $8,000 per person per year in health care costs.  That's $24,000 per person in health care costs over a three year period.  Multiply that by 10,000 people and the baseline cost to care for the community in question would be $240,000,000.  So the goal is to reduce health care costs by $120,000,000 over three years for this community of 10K folks.

How do you do that?  Here's my theory.  You can do more to affect health care costs by getting 10,000 people to change their lifestyle habits than you can by getting a few hundred docs to change how they document and collect data and prescribe some pills.

So here's what you do.  You bribe the public.  People are inherently lazy, but they respond well to piles of money. 

1. Pick three healthy lifestyle parameters.  I would chose nonsmoking status, achieved age appropriate exercise tolerance testing, and  lack of central obesity as my criteria.  
2. In your community of 10K, anyone who meets all three criteria of excellence will be entered into drawing for 3 million dollars at the end of the three year experiment.  One million for meeting each criteria.  There will be 10 random winners at a cost of 30 million dollars.    If you meet two criteria at the end of the three year experiment, you have five chances to win 2 million dollars  for a cost of 10 million dollars to the program.  If you meet one criteria at the end of the three year gig, you have just one chance to win 1 million dollars.   Total cost of the bribery?  41 million dollars.   
3. But here's the kicker, if you are picked as a random winner, in  order to collect on your winnings, everyone in your immediate household must also achieve the same number (or more) of defined lifestyle parameters  as you did for you to collect your millions.  So you're in it together.  For the long haul.
4. I am willing to bet the farm that $41 million dollars in bribes and a little peer pressure could potentially cut health care expenditures by 2/3 or $160 million dollars from a $240 million dollar starting pot.

Now.  Where's my 10 million bucks.

I Learned My Lesson The Hard Way

The Hospitalist Refugee sums up her his experience at the SHM Chicago annual conference. Here's a part that made me laugh.  

Finally, as someone who drives a fair distance to serve a rural-esque population, it struck me at the "Exhibition Hall" how disingenuous recruiters are when trying to convince physicians in a hot market to give up major aspects of what make a location desirable in exchange for promises of cash. I almost wish they would be banned from the whole enterprise next year. I realize they represent a significant revenue stream for SHM, but can we at least separate the people who have clinical information for us from the snake oil vendors? We're not stupid. A hunting/fishing "paradise" that's less than an hour (55 minutes at 85mph) from a regional airport makes lofty compensation promises that always always come with strings attached.

I was too afraid to walk through the exhibitors this year.    Several years ago I gave up my email address to a recruiter.  I still get the occasional phone call but the spam mail never seems to end.  I learned my lesson the hard way.  I will never do that again.

The Shell Game Known As CMS

One physician laments the turning of hospitalists into a tool to sustain hospitals' profit margins as CMS (known as See A Mess) goes on a cost cutting frenzy.

I'm so frustrated with American healthcare that I'm seriously wondering how long I can tolerate this B.S. I just want to take care of sick people. I bring enough value to the table as a hospitalist as-is. I'm going to get very sick and tired of being recruited as a utility in efforts to preserve a hospital's unsustainable profit margin in an era of regulation designed to erode it.

I look forward to the challenge. For years health care inflation has outpaced every rational economic inflationary measure. It rose faster in the era when physicians collected what ever they charged. It has risen ever faster for almost two decades in the era of the SGR, RVU, RUC mess we currently practice in that was supposed to control it. It threatens to destroy the very safety of our government's AAA bond rating.

No matter how you try and divvy up the pot of gold, the fine capitalist minds that run American health care will find a way to maximize their return at the expense of the Medicare National Bank. I am as sure of this as I am that Obama is not responsibly for the recent rise in gas prices (although many like to believe Bush was during his administration).

It doesn't matter. Let me say it again. It doesn't matter. No matter what payment model we eventually come up with, nothing will keep entitled physicians, patients, drug companies, device manufacturers, hospitals and every other pig at the trough from sacrificing their own personal economic interest for the good of the Great National Ponzi Scheme. Human nature is all about maximizing the economic self interest. That's what we get for living in a performance driven world. Our society values money. That is the engine that fuels most lives. This is also the reason why socialist welfare ponzi schemes will always fail in a blaze of glory, when given enough time. And take down great societies in a mass of unsustainable debt from an orgy of FREE=MORE

Why? Because the human race is inherently selfish. And that selfishness will never sacrifice their own economic good for the good of society, no matter how good the speech writer in the TelePrompter is.

The only way to control costs is to stop paying for care. The other is to pay less. And we all know what happens when you pay less. You get less access. So we're stuck.

If you're going to pay less, you had better cost less to too. You had better bring the whole curve down to maintain your operating margins. I see hospitalist medicine as leading the pack in decreasing the costs of providing care. Bundled care is coming our way. I don't know when, but it's coming. Hospitalist medicine is in a perfect position to capitalize on that trend.

I envision a system one day where all patients who enter the hospital get first contact by a hospitalist who performs the medical triage based on their abilities as a physician . This process will be much better once the E&M system is abolished and these archaic payment models are disbanded in favor of bundled care models. No longer would it take me an hour to admit a patient. Without the regulations, I could do it in 15-20 minutes without any loss of quality. That's how you save money. Make me more efficient.

I'm like an HMO within a hospital.

If you want the government to pay for your care, you will have to choose between access and cost. Your government believes you can have both. I'm here to tell you, you can not. Nor should you have the right to. If you want someone else to pay for your entitled care, be prepared to live by their rules, which means restrictions of care that will come in many different ways, the least of which is a physician directed gatekeeper model.

It's coming. The question is when.

Many disease states can be managed by well trained internists. And cheaper too. For that matter, many conditions can be managed by RNs, NPs and PAs as well. The question is, how will it be divvyed up. I envision hospitalist physicians making the call. As payment models for hospitals decrease, finding a way to decrease the cost of care will be paramount to a hospital's survival. And hospitalists will be right there to take the lead in caring for those in need.

A form of physician directed rationing. At some point, hospitals will have to stop offering services or find a way to offer them cheaper. Hospitalist medicine is but one aspect of that formula to decrease costs without decreasing service.

And that is one way to survive in the age of overtly rationed health care which is coming to a city near you.

If You Raise Taxes On The Rich, You Just Might Sacrifice Some Indians

I got this great email regarding a program in India that helps get critical care to patients of traumatic accidents quicker. It seems that auto accidents and traffic is quickly rising to a top three cause of death for those in India. A non profit organization funded by money raised by Indian Americans is helping to make critical care access a reality by taking critical care to the accident and saving precious minutes which could mean the difference between living and dying.

SevaMobiles are planning to commence operations this winter. The project is funded by the Patiala Health Foundation whose funds have been raised by Indian-Americans across the United States through six benefit events in Ohio, California, North Carolina, New York and, most recently, Virginia. The organization is also actively looking for additional donors, corporate partners and grant giving organizations interested in improving health care for low-income citizens within India.

So, can anyone guess what happens to the poor Indians dying on the streets when Obameconomics decides that the rich aren't paying their fair share? That's right, Good bye poor Indians grateful for the assistance, Hello entitled American's who demand others pay for their FREE=MORE.

I would much rather give money to those in need, based on my own criteria, than to donate it to a massive political front who decides who gets what based on the number of votes they can buy.

If you have money to donate, what would you do if your tax bill suddenly jumped 5-10% a year? Would you cut back on your charity donation? The answer, is of course, yes. Something bleeding hearts don't seem to understand. The next time you wish the rich to pay more, just remember, an Indian will be sacrificed.

The Hungry Addict Fell Off The Wagon

Go over there and give him some inspiration. Weight loss Healthy living is not an easy thing. It takes personal sacrifice for lifestyle modifications. But it can be done. And for many, if they don't, they will find themselves shut out from a government run bankrupt health care system that will start to say no to their health care needs.

With a personal drive and support system, anything is possible.

How Can I Be A Better Patient?

A reader asks the question:

Anonymous said...

Here's another question. How can I be a better patient? What habits or attitudes could I adopt that would allow my doctor to do a better job for me?

Thanks for stopping buy. In order to get the most out of your health care experience here is what I recommend.

• Have a list of your current medications with you when you go to see the doctor.
  
• Keep an updated list of your medical problems and surgeries as well.
• If your doctor wants to order anything, ask them what the risk of not doing it is. Discuss the risk and benefit of not doing it. Remember you always have the right to say no to a study or test. Often times tests are performed for low probability rule outs to cover one's butt. Sometimes they are done out of practice style without evidence based medicine to back it up. Sometimes they are done out of greed. If you are willing to accept the risk of low probability, then by all means, refuse a test. Watchful waiting is what makes comprehensive care physicians cost effective. Many problems will go away by doing nothing.
  
• Mutual respect. Yelling and demanding things from physicians is no more right than if they did it to you. If you don't 'respect your physician, find another physician. It does you no good to be in an adversarial relationship with your doc.
  
• Be proactive. Ask that your test results be faxed or mailed to you. That way you guarantee someone looks at it, you. And if it looks abnormal discuss it with your doctor. In the massive paper trail of medicine we live in, it is just too easy for things to slip by unnoticed.
• Care about yourself. Don't expect your doctor to make you healthy. Heal thyself with healthy lifestyles.
• Pay your bills. Your doctor provides a service. If they want to give it away, they will let you know.
• Come with a limited focus. Your doc does not have time for "Oh, by the way." Every time that happens, your 10 am appointment becomes 10:45, and nobody is happy. If you need to address multiple issues, make multiple appointments.
• Ask questions. I would much rather have a patient understand what I'm saying than one who doesn't care.
  
• Understand that medical care is filled with unknowns. That means schedules are often changed at the last minute and appointments may be cancelled or run very late.
  
• Just because the doctor doesn't agree with what you say or describe doesn't mean they aren't listening. If the doc doesn't understand what you are saying, more than likely, the explanation is that there isn't one. Certainly zebras exists, but the most likely explanation of the unexplained is that it will forever remain unexplained. Watchful waiting usually wins on average.
• Usually when a patient says the doctor isn't listening, it's because the patient isn't either. Generally, in my experience, patients who complain that they aren't being listened to don't want to hear what the doc has to say. Usually because it is something they don't want to hear. If you find yourself complaining that the doctor isn't listening, it's time to find someone else who you think will.
  

I'm sure you all can think of others.

I Finally Got My Page Rank Back

After changing my link and messing everything up, I changed it back. And my page rank has finally caught up.

In case anyone was wondering.

We Went To Buy A $299 Mattress And Ended Up With The Tempur-Pregnant Model

Or at least we hope.  

So we walked into the furniture store looking for a $299 sale mattress and walked out with the Rhapsody by Tempur-Pedic.  I'm excited. We've been getting daily ultrasounds (we're up to nine now) of Mrs Happy's ovarian follicle.  It seems just about ready to burst.

Perhaps a ruptured follicle and pregnancy would make the perfect owner story and get  us a spot on their website.  Perhaps they could rename it The Tempur-Pregnant model.  

Anyone out there got one of these things?    What's your experience?

There Are No Primary Care Docs Accepting Medicare In Chattanooga

At least that's what a subspecialist at Happy's hospital tells me was his experience.

Does A Complication Make You A Bad Doctor?

It's 3 am in the morning.  Into Happy's ED comes a 92 year old female, with son in hand claiming they will never "go back to that other hospital because that's where the bad doctor is."

It's 3 am.  I just had to know what he was talking about.  So I asked.  He said a doctor "poked a hole in my mom's lung while trying to put a central line in."

Mind you.  It's 3 am.  I took offense to that.  So I responded.

"Sir.  That does not make the doctor bad.  That is a complication of the procedure.  Every doctor, has at some point or another caused a lung to collapse from putting in a central line.  If they haven't, they haven't done enough of them.  Even I have 'poked a hole' in a lung."

At which point the man responds, "I assume you have that out of your system by now, right?"

Some people just don't understand.  Complications are part of medicine.  We spend 3-7 years of residency and fellowship learning to manage complication of disease, not the disease itself.    Anyone and a text book can manage protocol medicine.  It takes a physician to manage the complications.  There are no shortcuts in that regard.  

Perfection is the exception in medicine. 

Why Hire A PA or NP When You Could Hire An RN For 1/2 Price?

I came across a first the other day. I requested records from a subspecialist office in Happy's town for a patient I was taking care of. In Happy's town many PAs and NPs are used as data gatherers for the physicians. Their role involves nothing else. Templates in hand that guarantee a full level five consultation for every opinion asked. Their use in this capacity is entirely a function of the rules of the fee for service payment model we currently live in. It's easier to send a PA or NP to do all the data gathering and examination requirements necessary to collect a level five consultation visit than it is to spend an hour doing it yourself. Time better spent doing higher paying CPT codes.

I can tell you from experience, to do a complete history and physical, write admission orders and dictate will take about an hour. I can tell you over 1/2 of it is wasted time filled with inefficient documentation requirements necessary to get paid and not be accused of fraud.

So I was not shocked to see a subspecialist outpatient clinic note, in template form, filled with all the requirements necessary to obtain a level five out patient office visit. Filled with review of systems and physical exam components that most internists don't even perform on routine office visits.

But there it was, in all it's glory. A complete outpatient follow up exam. A level five on a stable follow up exam.

Who's documentation was performed by an RN.

Not a PA. Not an NP. But an RN. With well placed "Per Dr Subspecialist" scattered in every possible section of the complete level five clinic note in order to get paid for "work done". You see, under current rules, RN's can not bill Medicare and get paid. But you get around that, apparently, by having them do all the data gathering and document "per Dr Subspecialist"

I know this is all a documentation game. It looks like the data gathering role once delegated to the PAs and NPs is creeping into the RN world as well. It seems to me, as long as you clarify, "Per Dr Subspecialist" you could have a highschool student taking down the history and just document "per Dr Subspecialist" and all the requirements are met to get paid.

It's quite possible the role of data gatherer for PAs and NPs, currently being used in this capacity all over this great country of ours may go the way of the dinosaur, in favor of questionnaire specialists looking for a summer job to pay for their school outfits.

First it was MD doing the work. Then it was PAs and NPs. Now it's RNs. Soon, LPNs. Before long, high school students will be gathering the data.

With bundled care coming our way, we could have 1/2 as many physicians supervising hundreds of low paid high school students with questionnaires in hand. I imagine myself as a third year medical student presenting to the attending. I gather a ton of data. I have no idea what any of it means, but I look up in awe to the doctor who knows what it all means, instantly. Without even hesitating.

That's the future of our health care. Good bye NPs. Good bye PAs. Good bye RNs. Goodbye MDs.  Hello high school students.

Addendum:

Under current Medicare rules, the only components that can be used for billing purposes from a medical student note is the review of systems and the past medical family and social history.  HPI cannot.  Physical exam cannot.  Neither can medical decision making.  The only folks that can bill for HPI and physical exam are MD, PAs and NPs.  Unless of course you have an RN doing it with documentation stating "per Dr subspecialist".

Ten Things You Didn't Know About The Orgasm

This funny and highly interesting TED video about the orgasm (video below).   For example, did you know you can have an orgasm by brushing your teeth?  Did you know dead people can have an orgasm?  If you can't watch the whole thing, which you must, fast forward to about minute 11:20.  And you'll see something you've never seen, nor will you ever see again.  Enjoy

>
If you've never watched a TED video, you must get into the habit.

Thanks to a reader for pointing out this video.

Do We Need A Bipartisan Commission To Fix The Entitlement Mess?

There is an economic tsunami off the coast and it's ready to wipe us out.  So says Representative Frank Wolfe, R-Va.  He's right.  There is a tsunami.  The triple death threat is Medicare, Medicaid and Social Security.  These underfunded mandates threaten to destabilize the AAA bond rating that Uncle Sam carries on its debt.  In fact we learned that this may just happen to Britain.

Financial markets were rocked last week when Britain was warned by Standard & Poor's Ratings Service that debts it had incurred in trying to dig out of its economic crisis could result in the loss of its triple-A rating. The threat of a downgrade could signal similar problems for other big economies — particularly the United States, whose finances has been hit just as hard.

We know it's not a lack of information.   It's a lack of political will.  Nobody wants to commit political suicide and increase taxes or decrease benefits for any of these entitled programs.  Remember, the people see themselves entitled to them.  Nobody, but nobody will touch them.

One proposal out there involves creating a "bipartisan committee" to tackle the problem and create an all or none proposal.  The Grand Bargain.  Political cover for the wimps on the Hill.

The entitlement mentality was a political phenomenon used to buy votes.  It has worked like a charm for over 1/2 a century.  It is not about protecting the people.  It's about protecting politicians.  This is why economics and politics don't mix.  Politics will always win the sprint, while the laws of economics will always win the marathon.  

The only way to solve this political entitlement problem is to take the solution out of the hands of politicians and put it back into the laws of economics.  Only then will it fix itself.  

We are entitled to nothing in this world except freedom and office magazines

The Stat Nursing Home Consult

One reason I love to do hospitalist medicine is the security of knowing I don't have to travel from one hospital to another, traveling across town, spending uncompensated travel time taking care of patients who may or may not pay you.

The same can't be said for specialists and subspecialists who must travel from hospital to hospital taking care of whatever comes their way.

So I'm talking to a subspecialist the other day who got a text for a stat consult.

Get this...

At the nursing home.

We laughed. Talk about something that ain't gonna happen.

Ever.

Ranked #4

Last week I discussed search engine optimization (SEO).  I discussed how my ranking for the key word "hospitalist" had dropped from page one, to page eight after I had changed my domain name.  A great discussion ensued.  And one that was very enlightening.

I decided to change my url back to the original thehappyhospitalist.blogspot.com  to fix the mess I created.

And over the last 4-5 days I have checked everyday.  What was once page 8, became page 6, then page 2, then page one.  

Now I noticed I am the 4th link on page one for the key word "hospitalist", in front of SHMs (Society of Hospital Medicine) link.  Perhaps only temporary.  Who knows.  But I'm back to where I started.  After a really difficult week of complicated, I mean really complicated patients, it's nice to know that this problem has worked itself out.

It's amazing how google ranks the search links.  It's also no wonder why SEO is such an important business.  It could make or break your business.  Google is the yellow pages of the world. 

Now, if I  could only figure out how to get my page rank back I'd be set...

The Hematology Gods Must Be Hungry

One hell of a week.  It hasn't been this busy in six months.  Disease seems to come in spurts.  This week was a hematology extravaganza. I'll leave you with three board type scenarios.  Scenarios we internists must know to pass our board exams.  If you don't know your differential diagnosis, you are of no use to the patient.  So, here goes....

• A 65 year old with acute onset of pancytopenia and severe mucositis. 
  

WBC 0.2

Hgb 6.9

Plt 12K

Afebrile.  stable vital signs.

PE  petechia.  mucositis.

Let's hear the differential diagnosis.  

• 89 year old vomiting blood.  
  

PTT 130

PT 70 

INR 6.

Not on coumadin.  Not on anticoagulants.  No response to Vit K.  Partially corrects with FFP

What's your differential diagnosis.  

• 31 year old with fatigue.  
  

Hgb 3.2.  Profuse bleeding with surgical interventions.  Menorrhagia.  MCV 57.  normal PTT/PT/plt.  Her periods last 20-30 days a month.  Stable vitals.  

What's your differential diagnosis.

Complications of Cataract Surgery

Grandma Happy had her first complication from her cataract surgery. She looked in the mirror when she got home and said

"I never realized how many wrinkles I have."

I think she should sue the ophthalmologist for not fully explaining the risks of this procedure.

Cataract Surgery Cost Pays For Those Free Magazines

So how much does cataract surgery cost you ask?  Mrs Happy's Grandma stayed at our humble cottage last night.  She underwent cataract surgery and couldn't drive the 30 minutes home yesterday. My tomato plants I planted a month ago look great.  But none of the seeds I planted survived.  I must have planted them too deep and soaked them with too much water.

So we planted a bunch of new seeds.  Just barely below the ground and just a sprinkling of water. Today Mrs Happy took grandma back for her follow up visit.  Everything was great.  The room was filled with people much older than grandma.  All of them looked decrepit.  Probably used a walker or a wheelchair.  Perhaps a cane.   None of them looked like they could break a sweat.

But a magazine on the rack caught Mrs Happy's eye.   Runner's World magazine.  You see, I have recently been excited at the prospects of Mrs Happy's new devotion to running.   This magazine had some excellent articles in it for the beginner.  She wanted to take the magazine home.  More on that in a little bit.

Mind you, this is an ophthalmologist office.  An office lined from door to exam room with old 100% insured Medicare patients draining the full service Medicare National Bank of all its bankrupt glory.  Imagine a puppy mill.  Now imagine a blind puppy mill.  It's pure economic gold.  Case after case. Back to back to back to back to back.  It's the procedural mentality.  Volume rules in a fixed cost environment.  An idle OR or procedural suite is money wasted.     I presume actual OR time lasts about 15 minutes.  Perhaps a few minutes more or less checking off the mini H&P or reading the primary docs H&P.   A few minutes to gown and glove and the race begins.  An army of nurses prepare the patient, dilate the eyes, fill out the paper work, the discharge work as the doctor roams from surgery to surgery at the speed of light.

It's a highly lucrative business, that cataract mill.   Not to mention the facility fees you get from owning your own specialty hospital. CPT codes 66982-66984, depending on which code is billed pays between 10-15 work RVUs.  These are cataract extraction/lens implant codes.  Here is how cataract surgery cost is determined as explaned through RVUs.  The current government rate is about $35 per RVU.  I'm sure there are other codes that can be added on as well.    This is a global 90 surgical period.  It doesn't really matter however.    The surgeon probably spent about 15 minutes operating perhaps another 5-10 dictating or talking with family.  Perhaps a good 10 minutes answering and looking at the eye post op day #1.  I would guess the total time spent was maximum, 45 minutes.  For which they were paid 10-15 work RVUs.  Not to mention practice expenses and malpractice.  That's $350-$500 for physician work effort (work RVU) only.  For 45 minutes of work.  And no phone calls.  No paper work.  No busy work.  No preauthorizations.  No family medical leave forms.  No disability forms.  No complicated drug evaluations.  No multiorgan failure.

Just to cut out a cataract.  And move on.  It doesn't get any better than that.  Remember volume rules in the current payment environment.  Pay for volume, get volume.  It doesn't matter what you do with any reform, as long as volume rules.

By the way, the cataract surgery cost  used to be much higher.

Now,  let me put that in perspective for you.  It's all relative.  For me to generate 10 RVU's of critical care time (in work RVUs) , I am paid 4.5 RVUs for the first 30-74 minutes of a dying critically ill patient (CPT 99291).  The next 30 minutes could get me another 2.25 RVUs (99292).  The next 30 minutes could get me 2.25 RVUs (99292).

In other words, to generate just under 10 RVUs, I would have to take care of a critically ill patient with multi organ failure for two hours and fifteen minutes.  And I still wouldn't generate enough RVUs to equate to a 45 minute cataract surgery cost.

How about hospital follow up visits?  The highest level hospital follow up visit pays 2.0 work VUs.  I would have to see five of them to generate 10 work RVUs.  This is the highest level of complexity for a hospital follow up visit.  Here is how you meet the requirements.  The AMA expects a 99233 to take 35 minutes.  On a good day, I can maybe get five 99233 done in 30 minutes each.  That's 2 1/2 hours of work to generate 10 RVUs.

Now, let me ask you, as a medical student, if you have the opportunity to slave away with complicated medical disease or do 10 or more cataract surgeries a day generating 3-5x the income, which would you rather do.

Now.  Can someone explain to me what about a cataract surgery cost, that takes 15 minutes in the OR to perform, is worth 3-5X more in RVUs than critical care work or high complexity hospital follow up care?  The RVU system is a sham and until that payment model is abolished for good, no meaningful reform will ever happen.

Now back to the original story at hand.  Mrs Happy found this running magazine in the office full of old blind Medicare patients who couldn't walk without a walker, let alone take up running.  So Mrs Happy asked the front desk if she could take the magazine home with her, thinking it may as well get some good use out of it.

Thinking the asking was only a formality, she was shocked to learn that not only is the waiting area "low on magazines" (which no one can read anyway), but they asked she bring it back next week.  Almost offended that someone would even ask.

How about that.  I find good humor in it all.  An office raking in the dough like a blind puppy mill filled with senior citizens who can't see, let alone run.  And yet they can't seem to find enough cash to stock their front office with magazines.  And when they do, they pick a magazine that will find no use amongst the blind and disabled and find annoyance that someone would ask to take it home.

Most people would have just taken it.  That's what makes Mrs Happy special.

Suburban Mom Bias

Sometimes it's hard to stay neutral.  

LINK UPDATE ALERT

If you have linked to my blog in the last 30 days or so using

http://www.happyhospitalistblog.com

That link is now dead. It leads to nowhere.

You can find me back at my original link at

http://www.thehappyhospitalist.blogspot.com

That's all.

How Do Patients Think?

Now a hospitalist for six years, I am constantly amazed at how people respond so differently to their illness. Some people want nothing done. Some people want unreasonable care.

I've had 95 year olds and families of 95 year olds demand everything despite medical futility.

And I've had generally healthy 85 year olds tell me they are grateful I am not ordering every test under the sun and just want to go home and what happens happens.

Has anyone figured out what determines how a patient responds to their illness?

Is it life experience? Education? Religion? Common sense? Personalities or personality disorders? I haven't quite figured it out.

Any Search Engine Optimization Experts Out There?

I had an advertiser email me the other day concerned about my drop in "PR". I don't claim to be an expert in Search Engine Optimization (SEO) at all. I didn't even know what PR was. I now know it stands for "page rank" You can check your page rank here. The higher the number the more important your page is. And every time someone links into your page or you link to any other page your page rank will increase or decrease based on the importance of the pages you link to.

For example. If http://www.ibm.com links to http://www.happyhospitalistblog.com my page rank would increase since IBM.com is considered a highly ranked page.

So the higher your page rank, the more important you are to advertisers because when they place their link on your page, their page rank increases as well, and increases the likelihood that their page arrives closer to the top on a Google search.

Isn't Google amazing.

To get on with the story. My page rank was a 5/5 ( on some scale) and it dropped to a 0/5 this month. The advertiser expressed some concern, and I don't blame them.

I believe the answer lies in my change of my URL from http://www.thehappyhospitalist.blogspot.com to a purchased domain (purchased through the blogger service ) that redirects all traffic from that link to http://www.happyhospitalistblog.com

I believe that caused my page rank to drop significantly. I also noticed that I used to be on page 1 for the key word "hospitalist" search. Now I am on page 8.

So , if there are any SEO experts out there, how do I fix it? I would like to keep my new domain name. The blogger service should be forwarding all my links to my new URL but it apparently has disrupted my page ranking.

Anyone?

Also, for anyone still reading this, if you want to help Happy out, and I am linked on your page in some way or another, if you could kindly change your link to my new URL at

http://www.happyhospitalistblog.com

It would be greatly appreciated.

New Credit Card Rules Will Kill The Poor Folk, Not Help Them

Congress just passed sweeping regulations to protect the consumer (poor folk) against those big bad banks that give us the American past time known as credit cards. Your wonderful government hails the program as protecting the consumer. I say it will kill the poor folk and cause much more harm than good.

The new restrictions will protect debt-ridden consumers from many of the surprise charges common in the industry, like over-the-limit fees and a charge to pay the bill by phone. People under 21 also will find it difficult to get a card.

As banks scramble to make up for the lost revenue, cardholders who pay off their balance in full each month could see annual fees become the norm and lucrative rewards programs canceled.

Here's how I see it. Your government has just made using a credit card worthless to me. I would never pay a fee for the right to pay on credit, when I can pay cash. I would simply stop using my credit card. People with money in the bank have other ways to gain credit than through a credit card. When I, a great credit candidate stop using credit cards because

1. I won't pay a fee
2. I have no benefit to using one without a rewards program

The credit card company loses money from the fees they charge merchants from my purchases.

When I stop using credit cards because of the benefits it gives me, the credit card companies will be left with a pool of high risk candidates who are at much higher risk of defaulting on their agreement to pay back their cards.

What that will do will

1. Cause the people who require credit cards to survive to experience even HIGHER interest rates as banks need to charge higher rates to make up for a declining pool of credit card candidates. With increased risk comes increased rates.
   
2. Find it even harder to get credit card companies to give them credit.

Obameconomics in all its glory, not only protected the consumer from predatory banks, it has created credit which is even more unaffordable and difficult to obtain for the poor folk.

Perhaps that is the magic of Obameconomics. Make credit harder to achieve for the poor, there by increasing reliance on government handouts and increasing the expansion of the democratic socialist movement.

Thereby increasing the taxes on those with good credit, making them harder to achieve their financial independence without credit cards, which they now can't obtain because all the banks have left the business.

Soon, even the rich will be waiting for their government handout as well. And all the credit will be gone. And growth will be dead.

I Can't Afford That $4 Walmart Prescription

A guy on disability says he didn't want his Medicare premiums being withdrawn from his disability check every month.  Said he had "better things to spend his money on." 

Of course now he says he "can't afford" the $4 Walmart script after the unpaid $20,000 hospital stay. 

Not to mention the two pack per day smoking habit that prevents him from picking up his $4 script.  

$4 bucks.

That's all I asked of him.  And he thought I was Satan.  

What Was Your Opinion Of the SHM Meeting?

I don't know how many hospitalists read this site, but if you went to the SHM meeting, I'd love to hear your opinion.  A few left theirs here.

I'd also love to hear your thoughts in general about anything you wish to discuss over at Hospitalist With A View.    It's open to anyone and you are free to write about anything you want as long as it isn't illegal.  That's my only criteria.  Just contact me at happyhospitalistATgmailDOTcom and I will get you privileges to blog.

Me personally.  I pet a llama.  Ate some sea bass and an Indian buffet.  Listened to toilets being flushed at all hours of the night.  Words of wisdom, I would never stay at the Hyatt again.  For $200 a night, you're wasting your money.  Five years ago, I found the Sheraton a much better experience.

I accidentally walked in an autism walk.  Ran inside Soldier Stadium.  Took an architecture tour of the Chicago river.  (Did you know it's now called the Willis tower, not the Sears tower?)  .  Almost got attacked by a shoe shiner.  Didn't talk to a single exhibitor but still managed to tick a few off. I got spammed to high Heaven last year when I left my email address with these attack dogs.  I am still bombarded to this day with spam mail promising $350,000 a year + production in beautiful country side estates on beautiful rivers and lakes 20 miles from the nearest interstate.  Please, for the love of God, I'm not some little old lady  sending blank checks to Nigeria.  Give it a rest.

Oh yeah, and I went to a few lectures.  My favorite quote (paraphrased) from the whole conference came from the NP/PA in hospitalist medicine lecture.

"We don't send out PAs/NPs without supervision.  We don't do it with physicians either.  It's called residency."

Job security, I suppose.

Obamallama

Read the comments.   That is just good humor.

Waiting To Exhale

A reader asks the question.

Anonymous said...

Yeah, I've got a question. Why is it that doctors, when they listen to my lungs, seem to only listen to the inhalation phase, when the wheezing I sometimes hear is often audible (to me) on exhalation only? Shouldn't they listen to me exhale if they want to hear that?

Great question.  Now here is your answer.  Your doc is too busy to wait for you to exhale.  I suggest next time you make a loud sucking sound as you inhale so your doc can't hear anything.  It will keep his/her attention long enough to listen to you exhale.  And also to wonder what the hell that sound was on inhalation.  I guarantee he/she asks you to take another breath.

The art of diversion.  

The Biggest Loser Makes No Excuses

Jerry spent two weeks on the show before he was kicked off. He proceeded to beat every one of the at home challengers by losing nearly 50% of his body weight

On his own

At 64 years old.

An inspiration for everyone who always seems to have an excuse. (video below)


By the way. Here is his before picture at 370 pounds, before trimming down to a slim 190 and change.

Now. What's your excuse?



picture via NBC's Biggest Loser
Amazing. Simply amazing.

Do You Want A Better Sex Life?

Lose Weight

What's The Verdict On Man Boobs?

Would you ever date a man or find a man attractive who has this problem?

I Made A New Friend At SHM

Meet Mr Llama, happy as a clam that I took his picture as he brings smiles to hundreds of kids. Life is about the llama at the petting zoo. Many people forget what's important in life. Too many people spend so much time worrying about life, they forget to pet the llama.

A Frustrated Reader Is Looking For Answers

A frustrated reader opens up her life looking for answers.

I have had a chronic medical condition for almost a year now.  My symptoms include fatigue, abdominal pain, headaches, nausea (mostly pain related), and reoccurring flu.  I have had various blood tests, urine, stool, etc.  Only two have turned up positive: an endoscopy showed inflammation (the medication they gave helped with that, but the cause is still unknown) and an x-ray showed malabsorption in my small intestine (negative for Celiac and gluten sensitivity).

Whatever this is has cost my job, my insurance, and a year of my life.  My home and my sanity are soon to follow.  I am now on the county's (in Houston) insurance plan, which takes months to get a first visit, while taking hours to kick me out of the ER and clinics with no help.  I don't know what to do next and my condition is getting worse.  Please help.

Sincerely,

Let me just say, for the record, I'm not your doctor and anything I write here or any responses by readers is to be considered for entertainment purposes only and not as medical advice as no doctor physician relationship has been established.

Here's my list of studies I would consider, if not already done for someone with this chronic/progress type presentation.

1)  ANA to screen for autoimmune disease

2)  Iron studies to screen for iron deficiency

3)  Cosyntropin stimulation test to screen for adrenal insufficiency which most commonly is an idiopathic condition (nobody knows the cause).  This is the top of my differential diagnosis for anyone with nonspecific complaints such as fatigue, abdominal pain and nausea.

4)  B12 level to screen for deficiency.

5)  Inflammatory markers (CRP and sed rate (ESR)).  When these are low, I am comforted as a physician for the patient.

6)  Heavy metal poisoning.  Arsenic, lead.  This can be done in urine or serum.  Is someone trying to kill you?  Do you drink well water?

7)  Porphyria.  This is more specific testing for chronic unexplained abdominal pain.  It has a laboratory panel.

8)   Carcinoid syndrome/tumor can do funny stuff.  Screen for metabolites

9)  Hepatitis screening for Hepatitis B and C.  These can sometimes do funny stuff clinically.

10)  Thyroid studies

11)  CPK levels to look for muscle damage.

12)  Of course the basic panels: CBC and electrolytes/renal function.

13)  Carbon monoxide poisoning.  I think this is mandatory that you check  both your blood and for your home for possible toxicity.

14)  Whipples disease caused by a bacteria.  I doubt, but possible?

15)  LDH (lactate dehydrogenase)  to screen for lymphoma.

16)  Serum Protein Electrophoresis to screen for monoclonal gammopathies ( such as multiple myleoma)

17)  Urinalysis looking for red cells or more importantly the spilling of protein.

18)  CT scan of chest/abdomen/pelvis screening for tumors/ enlarged lymph nodes.

21)  Consider MRI pituitary gland to check for pituitary adenoma if screening hormones are abnormal.

19)  Bone marrow biopsy if any of the blood counts are abnormal.

20)  Endometriosis?  Perhaps a laporoscopic surgical evaluation of the abdomen is in order.

I'd be curious on what the endoscopic biopsy showed.  Eosinophils?  Gastritis?

Plus I've never heard of an xray that can show malabsorption.  I don't have any idea what this test is.

Do the readers have any other suggestions in the differential diagnosis of this type of persistent undiagnosed condition?

Lots of Twittering Going On

100 Best Twitter Feeds for Nurses.  (It's an advertising site, but the list is still nice)

I guess I'm #83

Can You Go To Medical School When You Are Drowning In Debt?

A reader posed this question.

Hi. My name is XXXX, and I know that this is a bit of an awkward request, but I wanted to see if I could get the advice of someone who has been where I want to go. I completely understand if you're too busy to respond, but I thought it was worth a try to seek your advice.


Long story short, I spent my entire college career trying to figure out what I wanted to do, and I finally settled on web design/development. It wasn't until a few years after I graduated that I finally decided that I wanted to become a doctor, but four years of college and a few poor financial decisions have put my wife and me in a considerable amount of debt, over $20,000 of which is high interest credit card debt. On top of that, we're paying $640/month in car payments and $1427/month on our mortgage. We also have a 9-month-old daughter who apparently enjoys to eat on a regular basis.


Which brings us to today. I want more than ever to go to medical school, but at the age of 31 and with the level of debt my family is currently dealing with, I'm trying to determine the feasibility of doing so. At the moment, I'm working a full time job as a Flash/Photoshop trainer and a part time job as a freelance web developer, but I'm concerned that if I'm able to start medical school I won't be able to afford our monthly bills. Is this a valid concern, or is it possible to get enough financial aid to cover these kind of monthly payments?


I'm currently working on a plan to ramp up my freelance design work in order to try and pay off this debt a little quicker, but if I'm able to go to med school, I don't want to put it off TOO much longer.


So, I realize that this is kind of a generic, blanket question, but as an objective outside observer, what advice would you give to someone in my shoes?


Thanks so much for your time,

Here's my advice.

1)  First get into medical school.  It's not an easy thing to do.  You have to have excellent college grades (on average at least a 3.5 GPA).  You have to have all the prerequisites completed.  And you have to do very well on the MCATs.  It's not as simple as saying you want to go to medical school.  It takes years of consistent hard work and determination as well as high intellect to pass through the hurdles put forth in front of you.  Now, if you can pass these hurdles, my next recommendation is

2)  Don't worry about the credit card debt.  At $20,000, even at 30% interest, your minimum monthly payment is 500 a month.  You can pay for that by doing #3

3)  To pay your minimum monthly payments on your credit card debt, sell your new cars to get rid of your car payments.  and buy cheap transportation.  Perhaps invest in a $1000 vehicle that has four tires and an engine.  When I was in medical school I drove a 15 year old car that had no air, no heat, rust in the floor boards, no power anything.  I drove it until it died, the week of my residency, at which point I leased a Ford Focus for $200 a month.  If you want to do medical school on your financial status, you will have to sacrifice.

4) If you are renting, find a cheaper apartment.  If you are buying, find a cheaper house.  Your goal, if you wish to go through medical school soon on your current debt is to sacrifice every way you can.  That means your wife and daughter will sacrifice as well.  No vacations.  No luxury.  If your wife is working, great.  If she can't afford to work because of child care, fine as well.  Either way it's possible to make it through medical school on skin and bones with a wife and child.  I had lots of med school colleagues grow their family during school.  It is possible.

5)  Loans.  You can take out lots and lots of loans.  13 years ago the living expenses I got in loans was about $1,000 a month for me alone, single no wife and no children.  Fast forward to today And I'm sure it's quite a bit more, also depending on which part of the country you live in.  You very well may be able to avoid some of the above sacrifices if you can secure enough loans to cover your current expenses.

6)  At the current payment rates of outpatient primary medical fields, you would have to think long and hard if you plan to do them at your age.  You will be almost 40 years old with no retirement savings and close to $300,000 in debt.  You will never come out ahead in the primary medical fields of family medicine, internal medicine and pediatrics at current payment rates.  If you choose to go into a subspecialty, you have the ability to thrive, and at your age, I would suggest you have no alternative if finances are any consideration on your radar.

What do you readers think?  Can he go to medical school in his current situation?

Octomortarians

I learn so much at SHM. Find the definition here.

Medicare: The New Era Of Saying No?

Have we finally reached a point where special interests do not decide that Medicare will pay for everything under the sun? Have we finally reached a point where economics play some part in the equation? In the last week, Medicare has said no not once, but twice.

First they will not pay for the new warfarin genetic testing. Say bye, bye to the test. If Medicare doesn't pay for it, no one will. And that means nobody will order it. Nobody will pay for it. And nobody will get it.

“CMS believes that the available evidence does not demonstrate that pharmacogenomic testing to predict warfarin responsiveness improves health outcomes in Medicare beneficiaries,” the agency said in its proposed decision.

Good for them. There should be clear evidence of benefit, that is cheaper than currently available therapies before anything is approved and paid for. Just because we have a test does not mean it should be run, nor paid for.

Next up is the virtual colonscopy, a turf war between the radiologists and the colonoscopists.

“Overall, when considering potential benefits and potential harms, there is insufficient evidence to conclude that the use of CT colonography improves health outcomes in Medicare beneficiaries,” Medicare said.

Once again, good for them. Just because you have a test does not mean it should be paid for. This is the the current reality. A slow but steady wave of saying no will start to creep into the delivery of your health care by government forces. These are small baby steps that will amount to no significant change in the overall expenditures of the Medicare National Bank.

But look out. Once the bank is insolvent, which is less than a decade a way, you will be seeing lots of nos in everything from no dialysis for anyone over 80 years old to no ICU for those over 80 to no payment for COPD exacerbations in those testing positive for cotinine to no treatment of any kind for lifestyle related diabetics who aren't wellness program members.

The age of rationing is just beginning. Be prepared to take care of yourself before you find yourself shut out from care for which you are deemed unworthy of.

And The Appropriate Response Would Be To

You tell me

How Much Money Does It Take To Run A Solo General Practice Office?

HalfMD runs through some numbers.  Many factors need to be considered.  Costs that need patient contacts to generate revenue to pay for everything from your legal fees and accounting fees to your rent and lawn service.

You now know why primary care is a dying field. Who wants to see 30 patients in a day, only to be the lowest paid doctor?

It's all relative.  But the numbers are not pretty.

What Did You Eat Today?

A bunch of doctors with job security.

What is The End Goal of Quality In Health Care?

I listened to the President of the Joint Commission, Dr Mark Chassin. If you want my opinion, you'll have to go the the SHM blog site to read it.

If you are interested in keeping up on what others are saying as well, here is the link to the SHM Conference Blog itself.

The Hospital Gown. The Next Hospital Amenity

Some things haven't changed in 100 years. Like the hospital gown. Cheap, flimsy, ugly, but highly functional. Some people are trying to change that.

"Nobody is happy with it," says Blanton Godfrey, dean of the College of Textiles of North Carolina State University. "It is amazing -- we have created a product nobody likes."

Just for the record, I'm happy with what we have now. Cheap, flimsy, ugly and highly functional. The hospital is not a fashion show. If you are worried about how you look, you are not sick enough to be in the hospital. Perhaps we need personalized hair stylists. Maybe a massage therapist. Perhaps your own personal chef. Oops. I forget. Patients are all about the amenities. Maybe we do need some fashion gowns.

Thanks to HalfMD for directing me to this article.

Welcome To Chicago

I'm currently at the Society of Hospital Medicine's sold out 2009 yearly conference. Happy's group dragged along six members to bask in the glory of all is hospitalism. I am trying to Twitter my experiences but find that the 3G network on my iPhone is nearly non existent three stories down in the basement of the Hyatt Regency Chicago.

We decided to take the train into downtown. $2.00 per person. It beats the $50 cab ride. Wouldn't you know it. Our train was stopped a couple blocks from our station. Apparently some sort of "medical emergency". Our train conductor was the kind of guy that loves his job. Apologizing over and over again for the delay.

We saw the "medical emergency" leaving the train deck in a motorized wheel chair. I suspected the emergency was that the chair ran out of juice. But he looked fine.

We got out and huffed and puffed five blocks to the hotel and then took a six mile walk/jog along the pier. Apparently there was some guy who stabbed his family yesterday. As we were walking the roads of downtown, we almost walked down a stairwell to the street below. Mrs Happy saw the guy first, apparently pleasuring himself (possibly). I must not have been paying attention. We decided to find another way down to the roads below. She also thought the guy looked like a man who stabbed his family.

Welcome to Chicago

Should Families Be Able To Look At The Patient Chart While Hospitalized?

A reader discuses a personal scenario.

Dear Happy, never actually had this happen but I had a patient's daughter (who is a nurse) ask to see her mother's chart (her mom said it was OK). Can she do this? Or can any patient do this? I didn't feel comfortable and said she would need a written release and should probably wait until the patient is discharged, as the chart is an original, etc. I think there was no malicious intent but who ever knows? Of course this was late at night and I wasn't in house, but I don't want to deny a legal right if indeed that is their right at that time. Thanks.

I occasionally get asked by nursing staff if it is OK for family to look at the chart.   I always say it's OK with me.  I have no idea what the legalities of it are.  I leave that up to someone else to decide.  I figure, if someone is calling me to ask me, I must have some say in the matter.  Or maybe we are all just ignorant to the process.   With that said,  I have never thought of the legal angle where a family member could alter the original chart.

What are your experiences?  Do you let families look at the chart or tell them to wait until the chart has been officialized in medical records.

Grand Rounds

The beset of the medical blogosphere for the week, presented by Florence Nightingale

Out of Pocket Expenditures Over Time

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A reader asked for the graph relating out of pocket expenses as a function of time.  Here it is.  Go here for some other great graphs of health care inflation since the Medicare National Bank was opened up.  Notice the direct correlation (cause and effect?) with rapidly rising costs and decreased out of pocket expenses. The only problem I see with this graph is that we are not really paying less for our care out of pocket. Every $10,000 your employer spends in premiums for you is $10,000 less you take home in salary.  You are paying for it one way or another.

The only way I see fixing the problem is to take the third party out of the equation, whether it's Medicare/Medicaid or your employer and make the 300 million Americans price with their wallets. The government spends $100 for a surgical screw. Your private insurance spends $2,000 for an MRI>  I can assure you, the public would not stand for it. Place the word medical on anything technology and the cost sky rockets. Why? Because the Medicare National Bank pays for everything under the sun.

Take away the MNB and make the public accurately price goods and services for what they are worth. That's how you fix over and under supply.

Take that $10,000 your employer is spending for you and spend it yourself, with contracts of care determined between you and doctors, you and pharmacies, you and hospitals  in a market based bundling system of care.  What's holding this country back isn't too little insurance, it's too much insurance.

When the patient, hospital and physician has skin in the game, it's WIN-WIN for everyone.

Facebook Users Get Lower Grades

Um.  I guess the whole world will get lower grades.  

I'm thinking back to the time I was in school.  We only had television and sports to distract us.  .  Oh, and Atari.  

Somebody Is Going To Start Saying No, One Of These Days

Panda Bear gets it.  

Don’t get yer’ shorts in a bunch.  I’m just throwing it out there.  But the wails and gnashing of teeth when medical care is finally overtly rationed as it must be under any system where it is given away for free will rend the very stones…and not just from the patients either.  Money drives medicine and the steady flow of government money cannot possibly continue.  Somebody is going to start saying “No” one of these days.

As an American, I'm telling you right now, you need to find a way to make yourself healthy.  Stop eating McDonald's.  Stop smoking.  Exercise as much as you can.  Get that blood flowing and the good chemicals traveling through your blood vessels.  Lose the central fat weighing you down.  No more excuses.  And whatever you do,   get rid of the diabetes.  As we move further toward the centralized government's delivery of health care, we move closer to economic failure.  Ye who owns the money owns the power.  And ye will decide who lives and who dies, unless you have the cash to make your own decisions.

Ye will have to say no to something, eventually.  And you sad smoker or indulger in the Big Mac are going to pay the price with your life.  We are over 10 trillion dollars in the hole as it stands now with only 50 million Medicare beneficiaries.  Imagine how many trillions more if we try and apply government care to 300 million people.

If you don't make yourself better, the government will eventually put you out of your misery.  

Surgical Principle Number Eight

We do it to impress the chicks.

How To Raise Campaign Money To Look Like Funds For Medical Research

Just ask Arlen Specter.  And you want these people making financial decisions about your health?

In two national TV appearances Sunday, Sen. Arlen Specter plugged specterforthecure.com — a website he said he launched to “put more pressure on Congress” to increase funding for medical research. 

What Specter didn’t say: The website is owned by his reelection committee, and contributions made there go straight to Specter’s 2010 reelection campaign. 

I think that's disgraceful.  

Why Do Couples Get Divorced?

Here's one crazy reason.

A man was divorced by his wife after his penis extension snapped off during sex. Doctors in Voronezh, southern Russia, had fitted the special prosthetic when Grigory Toporov, 47, told them he didn't measure up to his wife's expectations in the bedroom.

See the other nine crazy reasons here.

Have You Ever Thought About Cutting Off Your Balls?

Apparently there are men out there who do.  And like all good scientists do, they study it.  And they report it.  From the Journal of Sexual Medicine, the inquisitive mind learns that many men have extreme castration ideations.  I personally have never met such a man.  But these researchers have apparently been able to find enough of them to publish a study.  

What they found was 731 individuals who responded to a survey posted on http://www.eunuch.org.  They called those who responded "wannabes".  Then they compared the responses of these "wannabes" with 92 men who were voluntarily castrated.  Again, I've never met such a man, but apparently there are at least 92 of them out there.

The results?  20% of the wannabes were at "great risk" of genital mutilation.  19% have attempted self castration, but only 10% have sought medical assistance. 

I'm not going to debate the math but we are told at the end that physicians need to be aware of males who have strong desires for emasculation.  I've got to admit, I'm not even sure how I would bring it up in conversation.  Perhaps I should just come right out and say it.

"Have you ever felt like cutting off your balls?"

Now I just need to figure out whether to ask this during the HPI or during the physical exam.

via Marginal Revolution

Can People Distinguish Pate From Dog Food?

You'd be surprised 

Although 72% of subjects ranked the dog food as the worst of the five samples in terms of taste (Newell and MacFarlane multiple comparison, P<0.05),

How about a dysphagia diet?

Strangest Baseball Game Ever

You don't see that every day. Thanks to a reader for this strange story.

Nations That Eat The Fastest Have The Highest GDP But Also The Most Obesity

graph via Marginal Revolution

Interesting associations.  Cause and effect or perhaps just correlation.  Maybe we can thank McDonald's.  

How To Bring Personal Responsibility Back Into Health Care And Save Lots Of Money At The Same Time

The LA Times Health Blog is reporting on exactly what this country needs.  I say it should be instituted for Medicare and Medicaid as well.  Over at the NYT, it looks like our federal government may just  codify healthy behaviors with tax credits to employers.  What a fantastic idea.  What is this magic button?  Skin in the game.  Why?  Because people respond to money.   In this example,  United Health Care can save you  a lot of money.

Two years ago, United Healthcare introduced an option for employers called Vital Measures. Employees of firms that contract for this option select a high-deductible medical plan and can get a voluntary screening to see if they meet benchmarks for such things as body mass index, cholesterol, and blood pressure. For each benchmark met, employees receive $500 off their deductibles, according to company spokeswoman Cheryl Randolph. Meet all four, and the deductible for a healthy single employee can be lowered to $500, down from $2,500, and for a family of four to a deductible of $1,000, down from $5,000.

Wow.  A family of four deductible being reduced from $5,000 to $1,000 doing nothing more than practicing healthy lifestyles?  That's exactly what this country needs.

Would you consider this discrimination to charge families who meet healthy lifestyle goals less than families that don't?  I say it's no different than employers (who pay for the premiums) paying smokers less than their non smoking employees, and yet I get trashed for suggesting such a ghastly thing.  If you cost your employer less because you practice healthy lifestyles, you should expect to see some benefit.  And a lower deductible is an excellent benefit and market solution to having skin in the game.  If you don't want to exercise feel free to pay $5,000 a year in deductibles.  The ball is in your court.  It's nobodies decision but your own whether you want to reduce your contribution to $1,000 a year. And make it affordable for you and your family.

What do the critics say?

Critics say that holding people financially responsible for their health behavior is potentially unfair and that employers have no business prying into their employees’ private lives.

You'd have to be a moron to believe that.  If the employer is paying for their health care, they have every right to pry.  If you don't like it, don't accept the insurance.

Codifying benefits for healthy habits  takes FREE=MORE and turns it into FREE=LESS

Can A Family Reject Chemotherapy For Their Child Despite Doctor Recommendations?

Daniel Hauser, a minor,  has Hodgkin's lymphoma.  Hodgkin's lymphoma is a highly curable cancer.  The family does not want him to have standard western medical therapies, which include chemotherapy and radiation.  Instead they have chosen natural remedies, such as herbs and vitamins, against the recommendations of his doctors.

Their county attorney in Minnesota has accused the parents of child neglect and endangerment and is asking the judge to order the boy into treatment.  The parent's defense?  Treatment would violate their religious beliefs.

Daniel, one of eight children, has asserted that treatment would violate his religious beliefs. The teenager filed an affidavit saying that he is a medicine man and church elder in the Nemenhah, an American Indian religious organization that his parents joined 18 years ago (though they don't claim to be Indians).

What do you think, religion or otherwise?  Does a court have a right to order treatment of a disease for a minor against the wishes of their guardian parents?  There are lots of things that parents do that endanger their children.  They smoke in front of them.  They don't make them wear seat belts.  They feed them McDonalds.  They let them light firecrackers.  They let them watch R rated movies.  They let them stay up late at night.  They fight in front of them.

Perhaps the belief that the Hodgkin's lymphoma represents a life threatening endangerment makes the county attorney feel obliged to get involved in this case.  However,  if you're going to force a family to give chemotherapy to a child, you also must force them to stop feeding them McDonald's.  Or to force their obese children to exercise on a strict government regimen as both conditions are killing their children as well. Or to make them go to bed on time.  Or not to fight in front of them.

One can also reverse the situation and discuss elderly family members who are unable to make their own medical decisions, but rather rely on the decisions of their guardians.  My existence as a hospitalist is one where every day family members are making wrong informed decisions.  They demand that we do things to their grandma and grandpa that you wouldn't do to a pet.    Placing futile feeding tubes in patients with end of life disease burden.  Forcing intensive therapy cares on end stage disease processes with the hope of squeezing one last week of survival. Sticking tubes, catheters, knives and cameras in every orifice with the hopes of extending for another week or another month the painful existence many elderly live.

Should we not also call the county attorney every time we are forced to provide care which we as physicians deem inappropriate or abusive?  

What do you think?  Should parents be forced into making their child get chemo+ radiation?

What Should You Do If You Are Called For Jury Duty?

This guy counts the wrinkles on his dog's balls.

see more pwn and owned pictures

Have you ever been called for jury duty? 

Addendum: Wouldn't you know it, I got a jury summons today. First ever.

A Day In The Life Of American Emergency Medicine

Financial collapse viewed through the eyes of the ED.  The ED is FREE=MORE at its finest. Rules designed to enforce a feeding frenzy of expensive all you can eat health care.  None of which contains an ounce of skin in the game.  The only skin being spent is your tax money.

You can talk socialized medicine all you want - in my opinion we already have socialized medicine -EMTALA and Medi-Cal which has lead to rampant abuse of the ER. Socialized medicine will only make that worse unless something is done to fix the underlying problems, people need to be told NO sometimes.

Get ready to be told no.  There is no other way to pay for it.

Is The United States Postal Service Price Gouging Stamps?

It sure seems like they are.  Here is a graph representing the price of a first class stamp from 1919 to present day.  Starting yesterday, the price of a first class stamp will rise to 44 cents a piece.  That's an increase of 21X since 1919 when the stamp was 2 cents.  Dr Perry asks if there should be federal hearings to investigate price gouging by the postal monopoly.

On a side note, I went to buy some first class stamps the other day and discovered forever stamps. Here's a picture of the stamp, the only stamp being made as a forever stamp:

 Apparently, you can buy the forever stamp at any time and you can use it forever to mail a first class  parcel.  In other words, I could buy a forever stamp for 44 cents and in 20 years when it costs a 20 trillion dollars to mail a letter, I could still use my forever stamp purchased in 2009.  For 44 cents.

I had never heard of this stamp.  When I asked the postal guy what it was he said,  "If I have to explain forever stamps one more time, my head is going to explode."

What a nice postal man you are Mr Postal Man.  Thank you for kindly doing your job without having your head explode.  I appreciate your time explaining to me how to buy a forever stamp and what it means, and I really appreciate you not letting your head explode.

How Did The Banks Do on Geithner's Stress Test?

Geithner answer's the question. (video below)

via Calculated Risk

Can You Bill A Discharge Code (99238 or 99239) The Day Before The Patient Actually Leaves The Hospital?

I received this question from a reader.

Dear happy, how do you code when for a patient that was "discharged" by your partner but then has to stay an extra day (for placement or whatever). Do I bill for discharge, or does my partner have to resubmit his billing card and remove his discharge day code? This would not be easy because the cards are usually tuned in and the original hospitalist will probably never be aware that the patient was not discharged on the intended day.

If the hospitalist the day before discharged the patient but the patient didn't go until the following day because of placement issues, you can let the discharge code stand as billed by your partner, as long as you don't bill anything on the following day, the day the patient actually left the hospital.

You can bill a discharge code on a day different than when the patient actually leaves.  See A Mess had a major rule change last year that allows you to bill a discharge code, even if the patient doesn't leave on that calendar day.  I discussed it here on my blog last year.

I invoke the rule on a regular basis when, say I do all the discharge work, dictate and contact the patient's out patient primary physician on a Sunday with plans to leave to the nursing home on a Monday (there is some sort of unified no nursing home transfer rule on Sundays rule that all nursing homes in this country have apparently made).

You can see much more here in my coding lectures or earn CME at E&M University.

Because I did all the work for discharge, I bill the discharge code, either 99238 or 99239 on the Sunday, and leave a little note for my partnter that the patient is leaving on Monday, but that nobody has to see them.  Obviously, you can't bill a discharge code on the Sunday and a follow up code on the Monday.  But you can bill a discharge code on Sunday and bill nothing on Monday when the patient actually leaves the hospital.  You simply don't bill a Monday code and the patient leaves to the nursing home on the Monday.

That way, the new hospitalist coming on service doesn't have to sit there and read the whole chart, trying to learn the patient who is leaving in an hour.

Now, obviously, if the patient doesn't leave on the Monday, the new hospitalist bills a follow up code and the Sunday hospitalist's billing code gets changed to an inpatient code. (99231-99233)
You can learn more about coding here in my coding lectures or earn CME at E&M University

What Can You Expect Under Obamacare?

At some point, diabetes (weight related) may  be considered an Obamisease by the centralized rationing committee known as Obamacare.  What is an Obamisease?  It is whatever Obama says it is.  As with all socialized medical systems, the FREE=MORE mentality will not survive unless overt rationing denies care based on the political whims of the Obamessiah.   At some point, any targeted Obamisease, by proclamation of the Obamessiah himself, will get denied as fiscally unaffordable by the Obamabank, which is filled with Obamabucks, backed by the full faith and power of the Obamahouse.  Now, as long as Obamamessiah keeps printing Obamabucks, we can afford all the Obamacare that FREE=MORE can offer. 

Until one day the Chinese come knocking on the Obamahouse's front door, wondering why their Obamabucks are worthless.  To which Obama responds "Come in, let me get my teleprompter."

Does Massage After Exercise Improve Your Muscle Health?

Good question. Some theorize that massage after exercise improves blood flow and actually removes lactic acid from the muscles. According to researchers, most physical therapists believe this to be the case as well. Even the Canadian Sports Message Therapist Website lists the removal of lactic acid as a benefit of massage, despite no evidence to support it.

So what's the verdict?

Kinesiology MSc candidate Vicky Wiltshire and Dr. Tschakovsky set out to discover if this untested hypothesis was true, and their results show that massage actually impairs blood flow to the muscle after exercise, and that it therefore also impairs the removal of lactic acid from muscle after exercise.

Take home point: Even though massage feels good, especially after exercise, it may be doing more harm than good. Leave the massage for later, after your muscles have freed themselves from the lactic acid build up.

via Blog Around the Clock

How To Prevent Blood Clot Formation After Hip and Knee Surgery

It looks like the future is bright. It may be as easy as taking a once a day pill.  Perhaps no more frequent protime/INRs lab draws  required for warfarin or needle sticks with Lovenox.  It seems too good to be true.   Rivaroxaban, appears close to approval here in the USA for the prevention of post surgical blood clots.  Let's hope it doesn't go down in a blaze of glory in a post marketing experience as the direct thrombin inhibitor ximelagatran did in 2006 with its fatal liver toxicity.  If approved, it could perhaps revolutionize blood clot prevention in other medical and surgical patients as well.  No more Lovenox shots.  No more headaches on dishcharge trying to arrange shots and warfarin and protimes.  Just take the pill and be done with it.  Perhaps it would eventually expand to treatment  indications as well.  Atrial fibrillation?   Heart failure?  Peripheral vascular disease?  Maybe even the treatment of blood clots in DVT and PE.  One can only hope.

So how does it do in cost.  At least in Canada, pretty close to Lovenox for post surgical prevention.

Sensitivity analyses showed that rivaroxaban remained more effective and less expensive than enoxaparin in more than 98% of the simulations. When 35 days’ rivaroxaban were compared with 10-14 days enoxaparin, rivaroxaban cost an extra C$90.34 per patient. However, when the improved efficacy with rivaroxaban compared with the 10-14 day enoxaparin regimen was adjusted for QoL, rivaroxaban produced a gain in quality adjusted life years (QALYs) of 0.0027. This translates to an incremental cost per QALY of C$33,323, which is below the commonly-referenced threshold of C$50,000/QALY.

There goes all our consults for anticoagulation management.  Being asked to follow do skut work in  stable post operative surgical patients with no active medical problems and no anticoagulation managment is the equivalent of health care fraud. These patients need post operative surgical care and nursing care, not hospitalists.

Where is the 787 Billion Dollar Stimulus Package Being Spent?

The government has a site, recovery.gov  But, 

Which doesn't have any details about contracts or grants yet—and won't until October 2009 or, more likely, sometime next year, long after the thrill of living is gone and a huge chunk of the $787 billion stimulus package has already been frittered away on "shovel-ready" projects such as the John Murtha-Johnstown Cambria County Airport (pop. 20 passengers a day).

So a private company decided that wasn't good enough and created their own website to track the spending.  Recovery.org

Track the spending, right down to your city.  Now.  Not next year.   Now ask yourselves, why it takes a year for the government to do something it took this company just days to do.  

Thanks to a reader for pointing this site out.

How Much Can You Expect To Earn As An On Call Doctor At A Hospital?

Hospitalist Leadership explains.

Not surprisingly, primary care  averaged about $300 a day.  Folks, that's $12.50 an hour to be available.  Neurosurgeons?  $2000 a day, or $83 an hour just to be on stand by.  I know my wife earned about $2 an hour to be on call as a nurse (an amount I find repulsive and insulting.)

There is nothing about a neurosurgeon's training and expertise that makes them worth 7X more than a primary care physician, including hospitalists, other than the fact that the hospital facility fees generated by a neurosurgeon are probably far greater than 7X  their on call premium. This is not about what the doctors should make.  It's about what the doctors can make for the hospital.   And surgical specialties are valued by hospitals because that is where profit margins are derived from.  

Most internal medicine related admissions will lose money for a hospital, or barely break even.  Procedural and surgical related admissions drive the profit margins of hospitals.  The goal is to get sick grandmas with pneumonia discharged  so that another total knee or bypass surgery candidate can fill their bed. 

This is why you never see free standing internal medicine hospitals.  But you do see heart hospitals, orthopaedic hospitals, general surgery and spine centers opening up by the hundreds all over this country.  They are basking in the facility fee profits generated from procedural interventions.  And it's all codified by the Medicare National Bank.

You pay for what you value.  I can assure you, if the Medicare National Bank paid handsome profit margins on internal medicine admissions similar to their procedural and surgical colleagues, the family medicine and neurosurgery call fee schedules would not be separated by a 7x figure.  

It's about capturing facility fees, not paying the doctors what they are worth.  The hospital gains nothing by paying doctors to be on call, except a guarantee that their beds fill with insurance paying patients.  The only way hospitals make money is to fill beds.  

The NYTs just had a great article on this.  I suggest you read it.  When hospitals do a great job of cutting readmissions, by spending hundreds of thousands of dollars on post hospitalization care programs, they not only spend money to provide the service, but they lose the money on readmissions.  And nobody, including the Medicare National Bank, is willing to pay them fairly for their efforts.  So what do they do ?  They stop offering the services that can keep patients out of the hospital.

Oh, what a mess we live in.  Incentives and motivations in all the wrong places but oh so predictable when you invoke the laws of economics.

How To Prevent Diabetes and Stay Out of the Hospital

So you want to know how to prevent, delay or reverse diabetes. Naturally? With no pills? With no toxic side effects? And feel like a million bucks at the same time? And at the same time stay out of the hospital?

• Physical Activity
• Low-calorie diet
• Don't Smoke
• No more than 2 alcohol drinks a day
• reduce your BMI and waste circumference to the normal range

Do all five and  you reduce the risk by 89% over those with all of these habits.    Diabetes is THE largest disease population I see in the hospital.  This is not a coincidence.   Diabetes is not a local disease of the pancreas and blood sugar management.  It is a systemic disease  of the blood vessels.  And I tell patients all the time to stop thinking of their disease as one of blood sugar and start thinking of it as a blood vessel disease.  Every part of our body that has blood vessels (all of it)  is affected by the diabetic invasion.  Just go from head to toe.

• Brain (stroke, dementia)
• Eyes (blindness)
• Neck (arterial occlusion)
• Heart (MI, arrhythmia, CHF)
• Lungs (increased infections)
• Abdomen (gastroparesis, arterial occlusions)
• Kidneys (failure, dialysis)
• Legs (PAD, amputations)
• Neurological (painful neuropathy)
• Skin (recurrent infections)
• Joints (arthritis)
• Sex (forget about it)

The number one killer in this country should be diabetes.  But diabetes itself doesn't kill.  It's all the side effects of the disease.  In fact, one could argue that diabetes is a physicians best friend.  It is in fact diabetes that keeps most doctors in business.  It certainly keeps hospitals in business.  One could in fact argue that a healthy population is detrimental to our economy.  An economy in which 15% of GDP is generated by health care spending.  Healthy people don't go to hospitals.  Diabetics do.  You could in fact make an argument that McDonald's is responsible for creating 15% of our GDP.  And without them, millions of health care related jobs would be gone.

However, we are rapidly approaching an era where the cost of care is prohibitive for most.  Without drastic change, there will be no money to care for anyone.  We must  cut disease related to lifestyle.  We should be spending our money on creating health, with the goal of achieving these above lifestyle related end points in 90% of our population.  Anything else is a lost economic cause, as we have seen for the last 40 years.

Prescribing Pain Killers Could Land You In Jail

Big Brother Is Watching.

One red flag the government uses, for example, is to look for physicians who simply prescribe a raw number of pills that investigators say is too high, a practice pain advocates say has made doctors afraid of engaging in the high-dose opiate therapy course of chronic pain treatment that’s been so effective. Other red flags include doctors who spend what investigators say is too little time with patients to make an accurate diagnosis, a problem pain advocates say has become increasingly common not because more doctors are selling scripts to addicts and drug dealers, but because the few doctors who do still treat chronic pain are overwhelmed with patients whose former doctors have been arrested, stripped of their licenses, or run out of business by investigations.

I have a patient that routinely comes into the hospital on very high doses of oxycontin. I'm talking over 600 mg twice a day. I can't imagine the risk the outpatient doc places themselves at for refilling it every month.

via The Daily Dish

Job Offer: Physecretary

Over in the comments section.  

Today I saw a job for a primary care physician requiring that the doctor be able to type at a speed of at least 30 words per minute.

This is just good humor.  Maybe typing 101 will be part of the next generation medical school cirriculum.  I shouldn't knock it though.  A good physecretary is hard to find these days.Perhaps we will soon see job offers for Physeaning, where mop experience will be required.

The Zobama Express

The First 100 Days Under the Bus (video below)

Via the Daily Dish

Leaving Your Patient Dressed And Prepped In The OR, And Then Not Showing Up

Will lead to a suspension.

The part I found intriguing was earning $7.2 million dollars for doing 500 surgeries.  

That's $14,400 per surgery in cash.  I would have to see a daily census of  about 160 people a day, 365 days a year  to generate that kind of income from cognitive medicine. If I worked 18 hours a day, 365 days a year I would have to see about 9 patients an hour, or 1 patient every 6 minutes and 45 seconds.  And everyone one of them would have to be considered a 99233, a high level, highly complicated hospital follow up patient and CPT code that the AMA says should take 35 minutes to complete.  

And I never not show up.  

Of course, I'm sure these surgeons don't accept insurance and can charge what ever they want to desperate patients looking for answers.  In which case I say, they are worth every penny their patients make them out to be.

via Inside Surgery

What EDs Look LIke

Picture here.

The New Form Of Anti Gay Torture: Gluing Shut Your Anus

What a crappy way to die.   And you thought you had a bad day.  This makes the rest of humanity look bad.

Found at KevinMD.  Read more at Movin' Meat   via   The Atlantic

Tort Bar Madness

What are the odds you got asbestosis and silicosis?  

I can only imagine this is the kind of fraud going on with the trillions of dollars being given away on our tax paying backs.

Free=More Through The Eyes Of

Grunt Doc

Yes doc.  Free=More will eventually collapse in a blaze of glory.  It will happen to every socialized medical system in this world if limits are not placed on consumption of resources.   There is no way we can, as a nation offer unlimited access to all care all the time and pay for it.   Medicare, a program for 50 million is already over 10 trillion dollars in the hole in unfunded mandates.  

The only way to change that is to tax the Hell out of Americans or change the mandates.  And that means rationing.  When you tax something, anything, you will always get less of it.  Eventually less work means less taxes and the weight of socialism implodes on the entitled masses, as the free loaders wonder in disdain why the rich refuse to support them, instead choosing to join them.

Medicare Joke of the Day

Don't sleep with him

A Baptist High School Plans To Suspend A Student For Going To Prom

I'm not talking about boozing it up or getting jiggy with  it.  I'm talking about simply going to prom.  A baptist school is planning on suspending a student less than three weeks from his high school graduation for going to a public prom with his girlfriend.

"In life, we constantly make decisions whether we are going to please self or please God. (Frost) chose one path, and the school committee chose the other," England said.

What a terrible life message that sends.  He can't even hold hands or kiss or listen to rock music.  I suppose he can't watch Dancing With the Stars either.  This school is living in a fantasy world devoid of reality.  It's this exact attitude they force on the kids that causes kids to rebel.

Health Care Debate

The Republican response.  Politics as usual.

Mapping The Seven Deadly Sins

Cool.

Extreme Nursing Home Exercise

 You don't see that everyday

The Juice To Squeeze Ratio

The Hospitalist Leader explains why doing CPT codes that pay more do not always generate the most revenue when looked at on a time based axis.   He calls it the juice to squeeze ratio and says hospital follow up codes are the best.

I can extrapolate this concept very easily across other CPT codes.  For example procedural/intervention codes have a large juice to squeeze ratio when compared with their cognitive evaluation and management (E&M) cognitive  relatives .  This concept explains why medical students are driven into specialties that pay more juice with less squeeze.  It's all relative.  And the juice to squeeze ratio among E&M vs interventional codes is clearly in favor of the latter.  

And if you can set up a practice that is highly efficient at moving people through the procedural mill the juice to squeeze ratio can make you filthy rich beyond all belief. It's like having a power juicer at your finger tips.

One can also extrapolate the juice to squeeze ratio between the difficulty rating  of like surgeries as well.  In straightforward uncomplicated lap procedures the juice is far greater than in the sam lap procedures that require cutting through matted scar tissue, followed by a week of post operative complications.  The less complicated the procedure, the higher the juice.  Less time per patient leaves you more time for other fee for service encounters.  This explains why many physicians are leaving ED call where more complicated and sicker patients present with their advanced disease state.  Why take ED call with perforated bowels and a prolonged hospital course when you can do elective bowel resections scheduled around your vacation time?

The juice to squeeze ratio also explains why some procedures are done at the physician owned speciality hospitals (good paying private insurance and sometimes Medicare) while the rotten juice of the uninsured and Medicaid and HMO populations are absorbed by your community hospitals.  Send the rotten juice to someone else.  Just don't make me taste it.

Another similar analogy is  the outpatient FP/IM/Peds/PA/NP  practice model where quick and simple encounters drive the juice or the complicated time consuming encounters requiring a higher level of education are sent out to others to keep the juice flowing freely in the office.  There is no time to doctor complicated patients who's juice is rotten for no other reason than they take too much time to manage on the juice to squeeze axis.  Time that is better spent seeing juicier patients.

The juice to squeeze ratio is a perfect analogy to our current health care delivery.  Everyone is trying to squeeze the most juice out of the least squeeze.  And this results in the movement of medical students into the high juice specialties and the movement of patients with rotten insurance juice to community hospitals leaving nobody but emergency room docs and hospitalists to care for those with the rotten juice.   Everyone else has left the building to bath in the freshly squeezed offerings of the day.

Economic Forces Of Destruction

Dr Jay Parkinson hits a home run with this comment from an orthopaedic surgeon.  It sums up the destructive forces codified in the delivery of our health care courtesy of the Medicare National Bank.  

 

In one of the only examples of its kind, a true randomized placebo trial was published on this in NEJM and there was found to be no difference in outcome for knee scope in pts with joint space narrowing, yet the procedure continues to be done at a very high rate.  Why?  Because it pays $800-$1000.  And it takes 1/2 hour.  In fact there are studies showing that people who get scoped, go on to get a knee replacement sooner.   I don’t know if any committee is the solution.  Since patients don’t pay their own money, they are not incentivized to ask the right questions or be skeptical enough.  And the CMS fixed pie system makes the PMD/ specialist war almost inevitable.  Sad.

• FREE=MORE
• Juice to squeeze ratio
• RUC/RVU broken economics
• Destruction of primary care

$1000 for 30 minutes of work?  I would have to see over 10 patients of high complexity hospital follow up in 30 minutes, or 3 minutes per patient, to generate that kind of income on a procedure that has no benefit.  And I can assure you these procedures are being done at physician owned specialty hospitals which will also collect 10x's that amount or more in facility fees. 

I remember reading that article in the recent past.  Why anyone is paying for this procedure now is beyond me.  If a patient showed up to have their knee scoped, and they were paying cash, I would presume they would like to know that the data suggests it is unnecessary and potentially harmful.  But a surgeon tells them it may help them and because they or their employers or their government has paid their $10,000 in premiums for the year, they decide to proceed with no questions asked, entitled to the services about to be rendered.  

Imagine for a moment if the Medicare National Bank decided tomorrow they will no longer pay for knee scopes due to the lack of benefit shown by good randomized data.  I can assure you as confident as I am that the RUC is corrupt, that that the delivery of this service would essentially cease.  No patient would pay for a service that shows no benefit.  And no surgeon would perform it without getting paid.

End of story.  Instead, we have a legalized pillage of the Medicare National Bank.

The Battle Of All Fonts

Strangly Amusing

Watch Font Fight on CollegeHumor

via The Daily Dish

Pistol Packing Pharmacists

Fighting back against Oxygontin/Oxycodone robbers looking to cash in on the street market value of $8000/bottle.


What do you think? Do you keep a gun handy in your doctors office? Or carry a concealed weapon while seeing patients?

Cardianal Health's Moisture WIcking Scrubs

One "perk" of writing a blog is getting requests to try out new products. The latest was an  opportunity to try out a new moisture wicking scrub from Cardinal Health. Here is the original email.

My name is XXX and I am contacting you on behalf of my client, Cardinal Health, regarding their new line of high-performance, durable surgical scrubs, Endura™ performance apparel, which was unveiled yesterday at AORN.

 

Based on the postings on your blog, I thought you might be interested in learning more about Cardinal Health’s new, more durable surgical scrub and possibly taking a look at the new product and providing feedback.  

 Endura represents the first innovation in surgical scrubs since the 1960s, and is made from an advanced synthetic material that is high-durable while being breathable and flexible to keep surgeons and nurses dry and comfortable, even after hours in the O.R. To help regulate body temperature, Endura’s Active Moisture Management™ technology wicks excess moisture from the surface of the skin, transporting it to the surface of the fabric where it evaporates quickly, allowing the body to cool naturally. This new material is also abrasion and tear-resistant, making it highly durable. In fact after 90 washes, Endura is 30 percent stronger than the top-selling traditional scrub.

We wanted to give you the opportunity to be one of the first people to have a pair of Endura scrubs. All we ask is for your feedback, be it private (to me, via e-mail, which will be shared with my client but not made public) or publicly via your blog.

Let me know if you’re interested in the scrubs so I can get your size and shipping address and provide you with whatever else you need.  Thanks for taking the time to read this – greatly appreciated!

 

So here's my opinion.  From a comfort level these things were incredible.  I have about 10 pair of normal scrubs (polyester/cotton mix).  When I'm busy running around, or putting central lines under bright lights, I have been known to break a sweat or two.  These test scrubs, a mix of 88% polyester and 12% spandex were very comfortable.   No feeling of stiffness.  It was just a smooth, almost form fitting feel. And I never broke a sweat.  And very comfortable when taking a snooze on those night shifts. 

However, a few things about them I did not like.  The extra pieces of color fabric woven in made me feel like MC Hammer at a fashion show.  It felt funny. And the openings to the shirt and pant pockets were too small.  It was difficult to place my normal sized reference materials without trying to stretch the opening. 1/2 an inch more and they would have been fine.  

It looks like top and bottom run about $30-$35 each.  I have no idea how that compares to a normal priced scrub.

Fourth Hand Smoke

You've heard of first, second and third hand smoke.

How about 4th hand smoke?

Academic Fraud

Grade Inflation.  Perhaps everyone isn't getting smarter, they just think they are.

We Should Be Turning Our Health Care Over to Walmart

The only thing holding back cheap innovation is the government gravy train known as the Medicare National Bank.

At Walmart you pay $10 for three months of pills, with free shipping to your home.  And there isn't a government hand anywhere to be found.  This is private industry driving affordable health care.  If you want Obameconomics to be in the driver's seat, be prepared to  get less for more.  For example, he turned 7 billion dollars for Chrysler into zero dollars for the tax payers.  That's enough money wasted to provide a full year prescription with home delivery for 175 million Americans.

Feeding Your Baby McDonald's?

This is essentially state funded and sponsored terror child abuse.

But their mother denies they are suffering as a result.

'Babies are always hungry,' she said. 'Sometimes it's easier to give them food that's already prepared.

'Anyway, they don't always have junk food - sometimes I cook a microwave meal for them. My babies are healthy.'

She receives total benefits of £227 a week - £140 tax credit, £42 child benefit and £45 family allowance - which she spends on her ten-a-day cigarette habit and food.

And the nanny state thrives fighting Darwin every step of the way.

via Calorie Lab

The McDonald's Diet

This guy lost fifteen pounds in thirty days eating McDonald's

Just not the bad foods.

Duh.

Fighting Back Against Obameconomics

Just read the letter.  

via Cafe Hayek

This government is acting like the mafia.  If you don't do what the Obamessiah says, you must not be patriotic.  He just gave away 7 billion dollars in tax payer money to Chrysler, and now he says we must cut 17 billion from a  3 trillion dollar plus budget.  This is more comedy than I can handle.  How about cutting 2 trillion dollars from the budget and taking back the 12 trillion dollars backed by nothing you've given away in the last year.

And the Tax Payer is Screwed Again

Chrysler gobbled up 7 billion dollars of tax payer money.

And won't have to repay a dime.  Exactly what did we get for our money?

Oldest Dog Turns 21 Years Old

And guess what.

• Diet
• Exercise
• Not smoking

Are to blame.

Her home is kept at a constant 72 degrees. She eats boiled chicken with whole-wheat pasta, and a specially selected soft treat designed for her ancient teeth. And she spends her days relaxing at home, only taking walks in the summer. "She used to run three miles with me every day,"

You go girl.

Health Care's Simple Economics

From an economist. He eloquently sums up Free=More for me.

One of the cherished beliefs of many Americans today is that health care can be improved only through a collective effort. As a television talking head expressed it recently, "We all have to pull together to improve health care in this country."

Nonsense.

Each of us has it within our power to improve our own health care.

Read the whole thing. It's enlightening.

from Cafe Hayek

Should Pregnant Women Even Consider Drinking Alcohol?

I find this interesting. The British version of our comparative effectiveness research known as NICE has concluded that there is no evidence of harm if women drank no more than one or two drinks a week.

What if you were a bartender and a pregnant lady sat down for a drink. Would you serve her and her baby? How about out in public, would you say anything if you saw a pregnant lady taking shots of vodka?

Would you drink yourself if you were pregnant?

A Horse Is A Horse Of Course Of Course

If you eat like a horse, now you can walk like one too. This is just cool

via Boing Boing

Diseased Furniture Gone Wild

This is wild stuff. 3D printing brings you elephantiasis on an IKEA lamp

via Boing Boing

Is That Journal Real? Or Is It An Advertorial?

Here is an interesting story about blurrying the lines of science and advertisement. Known as advertorials, apparently big pharma is now sponsoring fake journals that have all the feel of real unbiased science.

Pharmaceutical giant Merck paid science publishing juggernaut Elsevier to publish a fake peer-reviewed scientific journal, Australasian Journal of Bone and Joint Medicine

Elsevier is a very respectable publishing giant. I run across their stuff all the time. I get a lot of journals in the mail. My weekly pile of mail sits on my kitchen counter top for weeks upon weeks filled with "throw away journals." I get such a large volume of medically related "research", I simply don't have time to read it all. And then you have these doctors that probably get paid thousands of dollars a year, perhaps hundreds of thousands or more to be on the boards of these fake journals adding a sense of respectability, where none should exist.

It's just like the physicians that collect thousands upon thousands of dollars a year in speaking engagements from pharma to convince other doctors that their antibiotic or their blood pressure medicine is better than the the drugs we've had for the last 10 years. When I see physicians bragging about earning "cha ching" for lecturing on drug X, and I have, it makes me ill thinking that they sell their patients or their patient's insurance drugs which are 10X more expensive and add little to no additional benefit. They become nothing more than puppets in my eyes.

How Much Sugar Is In Your Food?

Visualize it with sugar cubes.

via Boing Boing

Hospital Food From Around The World

Once again proving that you can make a web page about anything.

Including Hospital Food From Around the World.

Here's a free night shift snack I had the other day. A ham salad sandwich.

Not my favorite, but it's all that was there. What do you eat on your night shift?



via Boing Boing

Your Blog As A Weapon?

Our government wants to make it illegal for you to hurt someone's feelings. Via Boing Boing

Law prof Eugene Volokh blogs about a U.S. House of Representatives bill proposed by Rep. Linda T. Sanchez and 14 others that could make it a federal felony to use your blog, social media like MySpace and Facebook, or any other web media "To Cause Substantial Emotional Distress Through "Severe, Repeated, and Hostile" Speech." Oh lordy, there goes 4chan.

Did I just read that right? I suppose we just need to ban opinions. Someone is always going to be distressed when they don't agree with what you write. Get over it. Move on. Turn off your computer and quit being so sensitive.

Doing An Ultrasound With Your Smart Phone

The day is coming when nobody will get filthy rich off radiology facility fees. And docs like me stick a probe on the patient and a computer reads me a result. Real time data at my finger tips.

America's First Face Transplant Shows Face

Amazing

Find Out If You Have Pig Flu

Here

via Boing Boing

I Was Exposed To Influenza A Last Night

The H1N1 strain is an Influenza A.

Let's hope I don't turn into a pig.

More Coding Questions: Date of Service Clarifications

A reader posed this question:

Help. My hospitalist I support for coding and documentation have gone astray. They think they should bill 99221-99223 (admission code) with the date of the admission, not the date they have first face to face encounter. Can you please help? Thank you.

Your hospitalist had best listen to your advice.  What the hospital lists as the admitting date makes no difference for the doctor evaluating the patient.   The doctor can only bill on the day the service was provided.  That means if the patient was admitted at 10:00 PM May 4th with telephone orders but did not get their face to face encounter and H&P until 8:00 AM on May 5th, the doctor can only bill an H&P on May 5th.  The orders on May 4th are a freebie.  There is no billable code for telephone orders.  

The only time it gets tricky is when you are billing observation codes.  If the hospital lists a calendar day admit and discharge that are on different calendar days (such as admit May 5th and discharge May 6th), then the only codes the hospitalist can use are the observation admit codes 99218-99220 (if they saw the patient on May 5th or May 6th) and the observation discharge code 99217 for May 6th (if they saw the patient on May 6th).  Now, if the patient is admitted observation  status on May 5th but nobody sees them until the discharge day, May 6th and the doctor does their H&P on May 6th and discharges the patient right away, they can only bill either the 99218-99220 admit code OR the 99217 discharge code for May 6th, but not both, since Medicare will only accept one E&M code on a calendar day in this situation. Since they didn't see the patient on May 5th, they bill nothing for May 5th.

Now, if the patient presented to the hospital and is admitted by the hospital clock after midnight on May 6th and stays at least eight hours as an observation status and goes home the same calendar day (May 6th), then the doctor bills only ONE code, the observation/discharge same day codes 99234-99236.  But remember, the patient must be in the hospital observation status at least eight hours.  So if you phone in orders at 1 am, round on them last if you want the hospital and yourself to get paid when you discharge them at 9 am.    You can ONLY bill 99234-99236 observation/discharge same day codes when the patient is physically admitted and discharged on the same calendar day, not by the doctor's clock, but by the hospital's clock.

A patient admitted by phone orders at 10 pm on May 4th but not seen by the doctor until 9 am on May 5th cannot bill the 99234-99236 even though the doctor saw and discharged on the same day (May 5th) because the patient's admission to the hospital crossed the midnight hour.  In this case, the doctor must choose to bill either the H&P (99218-99220) or the observation discharge 99217 on May 5th, but not both. 

I hope that helps

The $13 an Hour Premium

Someone suggested I get off my high horse by suggesting that if nurses and other health care professionals were earning full wages for on the job training that residents should earn full doctor wages as well for their on the job residency training. The suggestion was also made regarding the physician "salary and perks" after the residency experience should more than make up for the decreased earnings during residency.

So I decided to see how the income comparisons played out between the BSN degree and the family medicine degree.

BSN degree.

1) Age of graduation 22
2) Student loan debt. Let's say $50,000
3) Starting Wage $20/hour 40 hours a week $41,600 a year
4) 3% yearly raise, 2% inflation
5) 10%/year contribution to 401K plus hospital match of 5%/year
6) Assume 8% return on retirement investment before retirement at 67,

This would generate 3.9 million dollars at retirement age (not inflation adjusted).

How about a family medicine MD?

1) Student loan debt. Let's say $50,000 for undergraduate, $150,000 for medical school for a total of $200,000
2) Starting wage, $10 an hour X 80 hours/week for three years with the same above parameters. Retirement savings generated in three years of residency $25,000
3) Now let's assume starting wage of family medicine MD of $150,000/year starting at age 29. With 10% contribution to retirement. Nobody there to match it. Same expected returns with retirement at 67 years old.

This would generate 5.6 million dollars (not inflation adjusted) at age 67 years old.

3.9 million vs 5.6 million in retirement savings.


What About The Lifetime Income Potential?

A BSN starting at age 22 and retiring at age 67 starting at $41,600/year with a 3% average annual raise will earn 3.8 million dollars in their lifetime (not inflation adjusted).

A family medicine doctor who begins their three year residency at 26 will earn $128,000 by the end of residency. Assume they start their practice at age 29 at $150,000 with a 3% average annual raise (which is unlikely) and retire at age 67, they will earn another $10,400,000 for a total of $10,528,000 lifetime potential income (not inflation adjusted).

3.8 million vs 10.5 million

So what's the take home pay like?


Subtract BSN contribution to retirement (10% of income with 3% rise every year). Or $385,000 lifetime. The rest comes from matching + growth. Subtract that from total income. You get 3.4 million dollars in total take home income.

The family medicine contribution to retirement (10% of income with 3% rise every year). Or $1,050,000. The rest comes from growth. Subtract that from total income. You get $9,470,000 in total take home income

As for the student loans. Let's assume 4% interest paid over 30 years. For the BSN the total paid from $50K in loans is $85K. Subtract that from total lifetime income and you get 3.315 million dollars in total take home income.

For the family medicine MD, let's also assume 4% for the 200K in loans paid over 30 years. That's $350,000 in total loan monies paid. Subtract that from lifetime income and you get $9,120,000 in total take home income.

Now let's deduct taxes. Let's assume federal (13% after deductions) +6% state +8% FICA, or 27% total income tax burden for the BSN. For the BSN that leaves a lifetime tax burden of $918,000. Subtract that from your totals and you get take home pay of 2.4 million dollars.

For the family medicine MD, lets assume federal (20% after deductions) + 7% state +6% FICA, or 33% total income tax burden. For the family medicine MD that leaves a tax burden of $3,125,000. Subtract that from your totals and you get take home pay of 6 million dollars.

2.4 million vs 6 million dollars in lifetime take home pay (not inflation adjusted).

Inflation adjusted, the lifetime earnings after school loans and taxes and retirement contributions for a BSN is about 1 million dollars.

Inflation adjusted, the lifetime earnings after school loans and taxes and retirement contributions for a family medicine MD is about 2.8 million dollars.

$1 million vs $2.8 million dollars in lifetime inflation adjusted take home pay between a BSN and a family medicine MD.

For a difference of $1.8 million dollars over a lifetime. Over a forty-five year work history, that works out to $40,000 a year extra in take home pay, after taxes, after retirement contributions and after loan repayments. That's $770 a week, or one $110 a day, or $13 an hour extra in after tax, after retirement and after loan income for a family medicine MD making $150K a year and a BSN making $40K a year.

The reality of the economics is simply that the perception of the "perks" are simply not true. You see the $150,000 figure and you think how much more it is than the $40K figure. And you make the conclusion that it's OK to pay residents slave labor wages because they will eventually experience "the perks".

In reality, the perks are not there. With 50,60, 70 hour work weeks routine, the extra $13 an hour in "perk money" is swallowed up by longer work days, weekends, nights of call. The rest goes to taxes, retirement catch up from opportunity lost, and paying off the loans.

The BSN retires with 3.9 million dollars in the bank (1.5 million inflation adjusted). The family medicine doc retires with 5.6 million dollars in the bank (2.6 million inflation adjusteted).

With a return of 5% after retirement, in inflation adjusted numbers, the BSN takes home $75K a year in retirement. The family medicine doc takes home $130K a year in retirement.

Thus is the power of compounding and the progressive tax structure.

$45,000 a year extra in expendable income, for a family medicine MD compared with a BSN, while not small change, does not constitute a significant "perk"as implied by the comments. This is not taking off on jets on a whim to far away places. This is not private school for all the kids. This is not eating out every night at fancy restaurants. A decent home with taxes would take at least 70% of that extra chunk of expendable income.

You see, for all the extra time put. Opportunity lost. For all the extra years of training. Of grueling residencies. The financial perks are simply not there to do a family medicine residency or other primary care tracks.

It's not unreasonable to pay residents more for their training since they do not realize the gain long term, at least in a primary care tract. It's not unreasonable to pay them full wages for doing what other health care professional do as well, train on the job, since their return on investment is not far off from those with no MD training at all.

They Will Never Forget

As a referral center for many patients from all over Happy's state, I have the opportunity to speak with whomever is covering small town emergency rooms. Emergency rooms that are often staffed with moonlighting residents, NPs, PAs or GASP, the occasional nonresident medical doctor.

Often, and I mean often, patients show up with a diagnosis that is not as advertised. Sometimes I find myself asking what kind of evaluation was performed. Sometimes, it's just the reality of small town care. Such as the limitation in resources. Lack of xray technology to fully evaluate some conditions.

Sometimes it's just sloppiness in the differential diagnosis. Sometimes it's a lack of education in the differential diagnosis. And sometimes it's just a mystery what they were thinking. If I have the opportunity to admit a patient who's transfer diagnosis is vastly different from my admitting diagnosis, I will often call the transferring facility and discuss the care with the transferring MD or other provider.

Sometimes, I have to walk a fine line when discussing the case with other board certified physicians who have been practicing for years and have clearly made an error in judgement. I once had a patient who was transferred to my hospitalist service "to be evaluated by cardiology" for new onset atrial fibrillation. The EKG that was sent with the patient was clearly not atrial fibrillation, but rather sinus arrhythmia with PACs. It wasn't even close.

That was a rather uncomfortable situation. How do you tell the doctor that the transfer was unnecessary. I called them and told them that I didn't think the patient was in atrial fibrillation and asked them if there was any other reason the patient needed to be transferred. Needless to say, this old timer was not happy. So convinced that the patient was in atrial fibrillation, they demanded that a cardiologist look at the EKG, as if I was some how incapable of reading basic EKGs.

So I consulted the cardiologists, who promptly signed off with a diagnosis of asymptomatic premature atrial contractions. I try and tread carefully with these situations, knowing very well that the small towns have a variety of hospital options for which to send their patients. I always try and leave the doors of communication open with respect, something I can't say for many physicians I come in contact with.

With that said, I also find that PAs, NPs and moonlighting residents are far more likely to be open to the idea that they are just plain wrong. I have no problem admitting ignorance when a medical problem presents itself that is clearly out of my scope of training and practice. I often find   it easier to discuss unusual care plans or misdiagnosis with providers who are not attending physicians. They are more open to the idea that they were wrong.  Whether it's transferring unstable respiratory patients without intubating them.  Or sending a patient, for whatever reason, without an IV in place.  Or giving lasix to a hypotensive septic patient.  Or administering  medications that are potentially harmful to the current disease state.  

I am also  interested, when discussing the course of events in patient care, to learn what is going through their thought process. I want to know why they were thinking what they were, so I can better educate them or help them understand why their differential diagnosis process failed them. Often, I find PAs and NPs taking care of critically ill patients at critical access hospitals at 2 am while their supervising physician is dead asleep 15 miles away, with no interest in coming in to evaluate a patient that clearly needs a higher level of medical understanding. It's shameful that PAs and NPs are often used in a way that they were not intended.  

When I find incidents of patient care that I feel are substandard, I call them to communicate my concerns. I ask them to guide me through their presentation so as to not jump to conclusions. And when I find breakdowns in judgement, I try and help them understand that an alternative course of action may have been better. I often find them open to discussion and willing to learn from their "mistakes". Which will happen when you are learning on the job. It is the residency experience in real life. Mistake after mistake corrected by more knowledgeable attendings that make sure you never make the same mistake again. Only in real life, there is nobody around to watch your actions.  My hope is that I can help them to never forget.

Drunkest Nursing Home Patient Ever

Drunk Nursing Home Patient.

Alcohol level of .210

If I'm ever in a nursing home, that's where I want to go.

see my other records

Nursing School Is Easy

So I'm talking to a nurse the other day.

Nurse:  "Nursing school is easy."  A lot of it is just common sense"

Me:  "You paid all that money to learn common sense?"

Nurse:  "Yep"

Me:  "Medical school was a bitch."

Nurse:  "You know what they say about a BSN, don't you?"

Me:  "No"

Nurse:  "It's a lot of B.S.  It doesn't even train you well for the real world. Real world nursing is so much harder.  You get better training in associates degrees with more clinicals."

Me: "Interesting.  So you pay a lot of money to learn BS.  And then get full pay for 6-12 weeks of on the job training while you're practicing on patients?"

Nurse:  "That pretty much sums it up."

Me:  "So it's kind of like a residency, only you're getting a real paycheck to learn what your school should have taught you."

Nurse: "Yep"

Me:  "Shouldn't nurses in on the job training be paid a fraction of what they normally get?"

Nurse:  "Of course not.  It's part of the job."

Me: "What, the training?"

Nurse:  "Yes"

Me: "Then why aren't medical residents paid full doctor salary for their three to seven year residencies/fellowships if all other healthcare professionals expect to earn full wage  to learn on the job?"

Nurse:  *silence*  "Good question."

America's Got Talent

(Video below) Extreme Beer Games. Thanks to a reader for this nice find.

How Much For A Screw?

So I'm taking care of a patient of mine.  A patient with a primary orthopaedic injury.  I run into the surgeon post op and ask him how things went.  He says it was a bad fracture.  He flips up a hard film (you never see these anymore) of the post surgical site.  Filled with plates and screws.   My eyes saw seven or eight screws.  

I asked,  "Titanium?"

"No", he said.  "Steel".

"How much do each of those screws cost?", I wondered.

"About a hundred dollars a screw", he said.

And I find myself thinking, while everyone is talking about paying doctors too much or too little, the whole country is getting screwed with $100 screws.  There is nothing about a steel screw that makes it worth $100.  

I find that utterly repulsive.

We Are Not Free For The Taking

So I'm talking to a surgeon the other day.  Talking about an experience he had a while back.  About a young healthy woman who was stricken with an acute surgical condition.

This young healthy uninsured woman had an uncomplicated surgery, overnight stay, and discharge from the hospital with the routine surgical outpatient office follow up office visit.

It was at this point, over a week after the initial unfortunate event,  when the office staff asked the patient, who has already received the services of the surgeon, a surgeon that saved her life, how she planned on paying for it.

At this point the patient became irate and demanded to speak with the surgeon.  At which point she complained that the office stay were acting like pit bulls, demanding payment for something that "wasn't my fault".

At this point the surgeon stated they were more than willing to work with the patient and set up a payment plan.  $25 a month.  $50 a  month.  $100 a month.  He would work with her to pay off the services he provided.  

And her response? 

Get this.

Are you ready???

"It's not my fault I needed surgery.  I can't afford $50 a month.  I would have to get rid of my cell phone or my cable TV."

So entitled is her mentality because her illness is not her fault, she feels no obligation to pay others for the service they provided.  Even though it saved her life.  

There you have it folks.  This is what we as physicians are up against every single day.  An entitled mentality that sees our education, experience and abilities as  some sort of legalized shoplifting as a freedom for their taking.   

This is why doctors are leaving emergency room call and setting up their own free standing cash or insurance up front offices.  We are not free for the taking. No matter how much the government convinces you otherwise.

Hilarious Swine Flu Humor

Find it here

**Warning. Dirty language alert.**

Survival Instincts of Wimps

Maybe this is why some men don't listen well.

via Blog Around the Clock

When Patients Are Sexually Harassing

I have heard that nurses are frequently the victims of inappropriate actions of completely competent male patients saying inappropriate sexual innuendo towards female nurses. Things like

"You can come lay next to me when you're done with your meds."

or

"When you're done with your paperwork, why don't you come give me a bath"

I have also heard of physicians using their perceived sense of power to make inappropriate sexual advances toward other work place professionals who may feel a sense of powerlessness as "subordinates".

Both types of actions disgust me. For the physicians engaging in such activity, you represent your profession poorly. I'm not here to judge your worthiness as a human. Only to say that I have no desire to work with you as colleagues. How you act toward others is a direct reflection on how you act toward me and my patients and I want no part of it, unless I have no choice in the matter. At which point I will put up with it out of necessity.

As for patients, I want to know how you as a nurse respond to inappropriate sexual advances from patients. What is the appropriate course of action?

The Health Czar Can't Calculate

Three hundred million people will always price health care better than any central authority can. We are in the mess we are today because Medicare, and their central planning mentality are a tent full of clowns each believing they know how best to value a service that no one but you, Joe Public knows how to value. This great piece not only says that a central pricing authority will get it wrong, they say it isn't even theoretically possible to try.

I agree. Thanks to a reader for pointing me to this great read.

In practice, a health czar would have to evaluate the quality, revenue, and cost of complex production processes, and billions of healthcare goods, services, hospitals, pharmacies, nursing homes, surgery centers, diagnostic centers, laboratories, outpatient clinics, home health agencies, hospices, long-term-acute-care hospitals, ambulances, patients, physicians, nurses, therapists, and clinicians, all across geography and across time. The health czar must therefore consider an almost infinite number of permutations in order to correctly allocate trillions of dollars.

Macrocytosis, My Highest MCV Ever

As far as macrocytosis goes, this is my highest MCV(mean corpuscular volume) ever

114

Differential diagnosis anyone? I tell my residents and students I work with that the differential diagnosis is pretty limited. Most commonly

• alcohol abuse
  
• liver disease (usually related to alcohol)
• hypothyroidism (although I've never seen an MCV that high from thyroid)
• B12/folate deficiency
• primary bone marrow failure, usually myelodysplastic syndrome.
• drug related (certain types of chemo etc...)
  

I had a patient once who presented with nonspecific complaints and had an MCV of 110 and nothing else. They denied alcohol use or even abuse. I confronted them with my suspicions about alcohol abuse based on this abnormal lab and they broke down in tears about their long standing closet drinking.

see my other records

The Hospital Is Full

I haven't been this busy in many many months.
I wonder if anyone has ever looked at hospital census as a leading economic indicator

End of recession perhaps?