Nurses Treated Like Maids and Butlers

When nurses are treated like maids and butlers: 

Redneck woman with call light on, family was 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

How to earn the rockstar ER 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 epileptic 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.

For good humor, check out the  patient faking a seizure in the ER video.

Peeing in the Pool? Please Don't.

If you're peeing in the pool, please stop.  We don't need to swim in urine.  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, where a surgeon stops seeing their hospitalized patient:

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 (CPT 99253, 99254, 99255)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.  

How Do You Cut Wait Times In the ER?

How do you cut wait times in the ER and increase volume?

One health care consulting firm found by playing  the Lone Ranger theme hospital wide as a signal to initiate and expedite the hospital discharge process,  ER patient volume increased by over 15%.  How about that for innovation?  I suspect hospitalists were involved somewhere along the way.

I Want To Win $10 Million Dollars

Want to win $10 million dollars?  You're going to have to earn your millions.  Just answer the question:  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.

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.

Exhibit Hall At the SHM Meetings: Fear.

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

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.

CMS Shell Game

One physician laments the turning of hospitalists into a tool to sustain hospitals' profit margins as CMS  goes on a cost cutting frenzy. It's a CMS shell game.

I'm so frustrated with American health care 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 divvied 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.

Indian Health Care and Taxes

Wonder what effect taxes have on Indian health care? 

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.

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.

How Can I Be A Better Patient?

A reader asks How can I be a better patient?

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 canceled 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.

Italian Greyhounds Standing On a Tempur-Pedic Mattress

Here's a picture of Marty and Cooper, our Italian greyhounds standing on our new Tempur-Pedic matress.

Read On

There Are No Primary Care Doctors Accepting Medicare In Chattanooga

There are no primary care doctors accepting Medicare in Chattanooga, TN.  At least that's what a subspecialist at Happy's hospital told  me was his experience.

Does A Complication Make You A Bad Doctor?

Do complications 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 explained.

"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."

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.  

Hire a PA or NP or RN or High School Student?

Should I hire a PA or NP or RN?  That's a question a reader asks in this submitted story:

Happy, I came across a first the other day. I requested records from a subspecialist office in my town for a patient I was taking care of. In my 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 themselves. Time better spent doing higher paying CPT codes. 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"

Wow.  I'm impressed!  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 looks like 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".

Orgasm Facts You Didn't Know (With Bonus Video)

This funny and highly interesting TED video by Mary Roach about the orgasm (video below) telling you orgasm facts you didn't know.

 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

Bipartisan Commission To Fix The Entitlement Mess Needed?

Do we need an 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.

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

Nursing Home Consult, STAT!

Yes, there is such a thing as 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 for your time.

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.

It's called, going to the ER.

Hematology Gods Must Be Hungry: Three Critical Hematology Cases

The hematology Gods must be hungry.  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 

PT INR testing of 6.

Not on coumadin dosing.  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.

Major Complications of Cataract Surgery

Grandma Happy had her first major 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 bloodless 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 CPT® 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.

You can see much more in my free lectures on medical billing and coding.

Suburban Mom Bias

What effect does the suburban mom bias have on your medical care?  Sometimes it's hard to stay neutral.

How Do Patients Think?

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.

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

What effect will the new credit card rules have on poor people?

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.

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.

Can't Afford $4 Walmart Drugs

They guy can't afford his $4 Walmart drugs. 

He's on disability and 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.  

SHM Meeting Opinion

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

Read On

How To Listen To Breath Sounds

A reader asks the question regarding how to listen to breath sounds.

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 Beats Them All, On His Own.

Jerry of The Biggest Loser fame 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. By the way. He lost 180 pounds trimming down to 190 pounds from 370 pounds.  Amazing.  Simply amazing. Now. Now that's how you do non surgical weight loss.  What's your excuse?

Man Boobs? What's the Verdict?

What's your verdict on man boobs.  Would you ever date a man or find a man attractive who has man boobs?

Pet A Llama (Picture)

You too can pet a llama.
 

Meet Mr Llama, happy as a clam that I took his picture as he brings smiles to hundreds of kids.  How many people can say they pet a llama.   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.  Not your garden variety pet therapy dog.

Chronic Medical Condition Frustration With Diagnosis

A frustrated reader opens up her life looking for answers about what she thinks is an undiagnosed chronic medical condition.

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  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 (you can Google it).  (It's an advertising site, but the list is still nice)

I guess I'm #83

Going To Medical School While Drowning In Debt?

A reader posed this question about going to medical school while drowning in debt.

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.  However, 2010 hospitalist salary rates are rapidly increasing.  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.

Saying No In Medicare? Have We Entered A New Era?

Have we entered a new era of saying no in Medicare?

 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 

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 colonoscopy, a turf war between the radiologists and the colonoscopists.

 CT colonography

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.

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

How much money does it take to run a solo general primary care office practice?  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.

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

Hospital Gown Technology: It's Not Your Grandma's Hospital Gown We're Talkin' About

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," 

Just for the record, I'm happy with what we have now. Cheap, flimsy, ugly and highly functional hospital gowns.  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 (perhaps even experts in hair restoration for women (and men!). Maybe a pet therapy dog.   Maybe a massage therapist. Perhaps your own personal chef. Oops. I forget. Patients are all about the hospital amenities. Maybe we do need some fashion styled hospital gowns.

Welcome To Chicago SHM (At the Hyatt Regency)

Welcome to Chicago. I'm currently at the Society of Hospital Medicine's  (SHM) 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 an electric  motorized scooter 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 SHM.

Can I (Patient) Look At My Medical Hospital Chart? Can My Family Look?

A reader nurse asks me whether a patient or their family can look at their hospital medical chart while they are hospitalized by 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.

Out of Pocket Health Care Expenses Graph, Over Time (Percent Since 1960) and Other Interesting Graphs.

A reader asked for the graph showing out of pocket expenses over of time. 
 

Go there for some other great graphs of health care inflation as well 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 including my hospitalist salary in 2010.  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 and Grades In School? Are They Lower?

Some research suggests a link between Facebook and grades. 

Read On

Saying No In Health Care.

Saying No.  Panda Bear gets it.

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.  

Surgeons Operate To Impress Women and Hit On Chicks

Why do surgeons operate?  Surgeons operate to impress women hit on chicks. At least that's what a surgeon says is one of their surgical principles.

Raising Campaign Money To Look Like Funds For Medical Research (Arlen Specter)

How do you 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?

I think that's disgraceful.  

Reasons To Get Divorced (10 Crazy Reasons). This One Involves a Penis

Want a bunch of crazy reasons to get divorced?  Here's one crazy reason.

A man was divorced by his wife after his penis extension snapped off during sex.

See the other nine crazy reasons to get divorced. 

"I'm Thinking About Cutting Off My Balls." You're Not Alone, As Surprising As That Is

If one day you wake up and find yourself with the thought:

I'm thinking about cutting off my balls.

Just remember, you're not alone.  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

Dog Food That Looks Like People Food.

Is that dog food really people food? Some people can't tell the difference between pate and dog food. 

 dog food

How about a dysphagia diet?

Strangest Baseball Game Ever: KKK vs Hebrew All-Stars

This has to be the strangest baseball game ever:  The KKK vs The Hebrew All-Stars.  You don't see that every day .  The KKK won.

Personal Responsibility In Health Care

Personal responsibility in health care?

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.

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?

 potentially unfair

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

Daniel Hauser and Rejecting Chemotherapy For Minor Child? Court Intervention Ensues.

Here's a story about a father who rejected chemotherapy for his minor child, Daniel Hauser, resulting in a court intervention and forced therapy. 

Daniel Hauser, a minor,  has Hodgkin's lymphoma.  Hodgkin's lymphoma is a highly curable cancer.  This 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.

 he is a medicine man

What do you think, catholic hospital 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 therapy dog.    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?

Called For Jury Duty? What To Do Fail (Humor)

Here's a Fail moment on what to do if called  for jury duty.  This guy counts the wrinkles on his dog's balls.

Have you ever been called for jury duty?   Addendum: Wouldn't you know it, I got a jury summons today. First ever.


see more funny videos, and check out our Yo Dawg lols!

What is Emergency Medicine Like?

What is emergency medicine like?  Here's a day in the life of American emergency medicine and 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

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

Price of Stamps vs Inflation (CPI) vs Gasoline Price (Graph). It's Not Pretty.

Heres' a graph showing the price of stamps vs CPI inflation vs the price of gasoline. It's not pretty.

It sure seems like price gouging to me. This graph represents  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.

Geithner's Stress Test (Saturday Night Live Video Humor)

How did the banks do on their stress test? Geithner answer's the question in this Saturday Night Live video spoof.