iTit by Apple Makes Men Listen But Is It Real?

The iTit by Apple is one of the latest offerings thought up by Apple to increase their female market share.  But Is it for real?  Apple announced today that it has developed a breast implant that can store and play music. The iTit will cost from $499 to $699, depending on cup and speaker size. This is considered a major social breakthrough, because women are always complaining about men staring at their breasts and not listening to them.  How's that for science meets technology.  (It's not real in case you were wondering)

The Healthy Fruit Snacks and Ring Pops Got Some Great Reviews

We had an assortment of excellent offerings for the night.  In addition to our healthy fruit snacks and ring pops, we offered fruit roll ups and the ever popular animal crackers.  In the other bowl we offered the regular assortment of party KitKat bars, Almond Joy bars and other assorted chocolate favorites.

We planned for 150 trick or treaters.  In two short hours we blew through our entire stash of candy.   Some of the kids were excited with the ring pops.  Some loved the animal crackers.  Most loved the healthy fruit snacks as well (I was surprised).

One young girl accidentally put our fake tarantula in her candy stash and ran away.  One young child asked if we could move the spiders out of the way so she could make her way to the candy.  A couple young kids took big handfuls of candy

How do you tell a two year old to put it back?

We ended up shutting off our lights.  We just plain ran out of candy.  And the neighborhood was still crawling with kids.

Even after we shut off our lights, we had a couple kids ring the bell.  I told them we ran out and they appeared quite sad.  Then Mrs Happy pops in from behind with a small handful of candy Nerds she found in our cupboard.

She said if anyone else came, we'd have to give them some some of the wedding chocolates we still had from several weeks prior.

All in all a great trick or treat.  The healthy fruit snacks and ring pops came in a close tie, followed closely by the animal crackers and fruit roll ups.  The chocolates of course had no problem disappearing as well.

In fact, Mrs Happy recognized a ghost or two who may have come back for seconds.

I guess next year we'll have to get a bigger bowl.

Funny Homemade Halloween Costumes Happy Style

Funny homemade Halloween costumes then

Funny homemade Halloween Costumes now




Have a safe and happy Halloween from Happy and his family.  All costumes were homemade by the Mama Happy's own sweat and love long before there was Walmart (except disco Happy).  You dun good ma.

What Are The Side Effects Of Statins As They Relate To The Seasonal Flu Or Swine Flu (H1N1 Flu)?

The side effects of statins are well documented.  But did you know one possible unexpected benefit of statin usage was mortality protection from the flu?  As Dr Wes describes, an interesting study about to be  reported by the Infectious Disease Society of America suggests just that.  The retrospective analysis compared hospitalized patients with seasonal flu in 2007-2008 and statin therapy compared to those without statin therapy.  What they found was intriguing. Beside being used to treat systemic vascular disease, the side effects of statins may one day be used to treat the flu.

That's an interesting hypothesis and I'm excited to see how this plays out.  But I suspect the relationship will not be a direct one.  If older patients with underlying chronic disease are more likely to be admitted into the hospital, specifically coronary artery disease, it would make sense to me that those patients on statin therapy represent a more stable level and healthier status of their chronic disease.  It would make sense to me that they would there for have a  lower mortality, not necessarily due to statins, but rather due to more stable chronic disease, whether that effect was due to statins or to daily exercise or to healthy diet or to controlled diabetes or to whatever gives you more healthy coronary artery disease.

One thing I do know is that anyone who recently started a statin therapy and then came down with the flu may be left in a quandary.  Do they continue to take the statin because it may have a mortality benefit?  Or should they stop it when they start getting muscle aches and pains.

I for one would have a problem prescribing a medication who's most deadly side effect mimics one of the cardinal symptoms of flu, diffuse muscle aches.

As a primary care physician or a cardiologist or endocrinologist, I'm not even sure what I would tell a patient who develops muscle aches after starting a statin for the flu.  It could make this therapy option dead in the water if no clinician was willing to risk getting sued for dead flu patients who die of rhabdomyolysis because of failure to diagnosis.  Thus is the legal system we practice in.

How To Increase Emergency Department Throughput

I spoke with an old medical school friend of mine the other day.  They're having issues with emergency department throughput. He's an emergency room doctor who works in a hospital in which hospitalists cap their service at 15 patients a day.  He asked me whether I thought that was reasonable.  In his community, there are no primary care physicians who come to the hospital anymore.  They are also a large referral center for multiple Native American reservations.  When the hospitalists cap their service, they often have to divert patients to other facilities or have them parked in the ED for hours, sometimes a day or more which interrupts emergency department throughput.

Do I think hospitalist programs have hospitalist caps?   No, not at all.  I thinks instituting caps is a horrible policy.  Caps are a disruption to patient flow and can create animosity between doctors.  They can create emergency department throughput complications.  Many academic programs have instituted caps as a way of reducing work load for residents.  I think that's a shame.  In real estate the mantra is location, location, location.  For medical training it's volume, volume, volume.
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It's bad patient care to have them parked in the emergency room for hours when we all know that ED nurses and ED docs are not trained to manage floor activities well.  Their goal is volume.  Volume drives income, both for the hospital and for the emergency room physicians.  If you have patients occupying emergency rooms because the doctors won't accept them upstairs, there are no winners.  This is terrible for emergency department throughput.

Studies have shown that maximum hospitalist efficiency for hospitalists occur in the 15-17 patient per day range.  Depending on the complicated patient load, It could take me anywhere from 5-8 hours to see that many patients and feel good about the quality work I provide.

Do I do the hospital, the patient or my relationship with other physicians any good if I tell them no, I will not accept that patient sitting in your ED or wanting to be transferred directly from a small town because I feel I'm too busy?  No.  There are no winners in this capped model of care.

The solution lies within the ability of administration to realize that a great hospitalist care model that provides top quality service and runs at maximum efficiency will be one in which the patient load does not succeed 15-17 patients a day.  That's total encounters per day.  When administration realizes that the powerful benefits of hospitalist programs are achieved when these standards are maintained, they understand that future growth of the program through the hiring of more physicians is the only possible solution to preventing all the negative aspects of capped hospitalist programs.

Those administrations that choose not to pony up the cash to support such a model are the ones who wonder why all their hospitalists leave after a year and why they show no benefit in resource utilization or length of stay.  Just like everything else in this world, you get what you pay for.  If you want to run a hospitalist program on the cheap, you will never realize the back end savings of your front end investment.

Happy's hospitalist group is a testament to the massive success hospitalists can be to hospital systems across a multitude of markers, whether it's economic savings, patient satisfaction, nursing satisfaction, or physician satisfaction, when you do something well and you support great work, the return on investment is enormous.

If you have to cap a hospitalist program, you have to hire more docs.  It's as simple as that.

What Is Your Swine Flu Hospital Policy?

I learned recently that Happy's hospital was one of a growing number of hospitals nationwide banning children from entry during the pandemic H1N1 flu to protect their patients as part of their swine flu hospital policy.   But where is the science that says it works?  Hospitals nationwide are making up their policies as they go along.

I'm told that Happy's hospital set its rules based on the guidance of their infection control specialists.  But where is the evidence that it works?  Say granny comes in with pneumonia and the only daughter, a single mother in town with four children ranging in ages from 2-7 wants to come visit?  Are we going to have security guards tell her no?  Is Happy's hospital going to have a free 24 hour daycare available to the guests of patients?

What about all the doctors and nurses and cleaning people who have sick kids at home.  Are we going to ban them too because they might get the flu and infect our hospitalized patients?

I looked up the CDC recommendations and as far as I can tell, I couldn't find any recommendation to ban an entire population from hospital access.   Here is a small part of the CDC's recommendations

Elimination of potential exposures:  Eliminating the potential source of exposure ranks highest in the hierarchy of controls. Examples of interventions in this category include: taking steps to minimize outpatient visits for patients with mild influenza-like illness who do not have risk factors for complications, postponing elective visits by patients with suspected or confirmed influenza until they are no longer infectious, and denying entry to visitors who are sick.

 All people with H1N1 or symptoms of H1N1 should not go to the hospital.  That means whether you are 4 years old or 40 years old you should stay home.  Banning an entire population from seeing their loved ones in the hospital is, in my opinion, absurd.  You might as well ban everyone because most adults come in contact with children at some point in the day.

This policy sounds like a perfect Joint Commission/Medicare National Bank Quality Indicator.  Who needs evidence, right?

Why Are Dedicated Stethoscopes So Cheap?

When a patient comes in with an infection related diagnoses, efforts are often undertaken to keep that pathogen from spreading to other patient rooms.  In British hospitals they've banned ties and long sleeves.  At Happy's hospital we place a dedicated stethoscope  in the patient's room which is then shared by all health care workers caring for the patient.  And that stethoscope shall remain forever in that patient's room.

At Happy's hospital, the dedicated stethoscopes look like they were made in a Chinese  toy factory.  I know that the most important part of auscultation happens between the tips of the stethoscope, not the scope itself..  But there have to be some expectations that what you use has some real functionality. 

I've heard that some hospitals have real honest to God expensive fully functional dedicated stethoscopes that are chained down in the room.  I can only imagine what the patient is thinking when they see a big metal chain whip them in the back of the head for the seventh time in two days.

Oops.  Sorry 'bout that.

I suppose if you're going to go high tech, you don't want the poor primary care docs  stealing them for their clinic because they can't afford to buy their own.

Happy Hospitalist Has Been Referenced By Wikipedia

It's a big day for Happy Hospitalist.  It has officially been referenced by Wikipedia.  How about that?   Wikipedia reference #22. Like I always say, you get what you pay for.

Cooper, Our Italian Greyhound, Sings and Cries For The Puppy Park

He sure loves his play time.  Video taken with Mrs Happy's new 3Gs iPHone.  Not bad at all.

How Do You Get Hospital Efficiency Implemented At Your Institution?

A reader talks about their experience with hospital efficiency and cost

The CEO at my hospital spoke before a group of mostly non-physician hospital workers recently. I was the only doc in attendance. He complained that "doctors are not cost conscious and do not practice cost efficient medicine". The next day, the head of radiology spoke at our monthly hospitalist meeting, touting a new CT angiogram for the heart. Someone asked'"How much does it cost?" He said. "I DONT KNOW". I once asked pharmacy to list the cost of drugs we order so we could pick the best value. He said,"I CAN"T TELL YOU. WE DON'T WANT COST TO INFLUENCE YOUR ORDERING THE BEST TREATMENT FOR THE PATIENT". What is up with this? How come the cost of everything we order isn't available in the computer. I have worked at several hospitals and I always get the run around when I bring this up. What is your experience?

If I ask my pharmacist to give me a cost comparison between two drugs, I can get an answer about what they bill the patient, and what the actual cost to Happy's hospital is.  Having a pharmacist round with you every morning is probably one of the most cost effective ways to implement hospital efficiency into systems processes.  This is part of the hospitalist efficiency model. In the first year that Happy's hospitalist group went live, we saved a bunch of money having a pharmacist round with us every morning.

And you wonder why hospitalists are in great demand,  and why  hospital subsidies average about 100K a year nationwide.  If hospitals were wise, they would  actively seek out close relationships with hospitalists for ALL care issues.  The savings and hospital efficiencies could run into the millions upon millions of dollars a year.  Not a day goes by where I'm not wondering how I could do something cheaper and more efficiently.

If one hospital could save half a bunch of money a year by having a pharmacist round for 15-20 minutes every morning with your hospitalist, imagine how much money could be saved if you had someone from IT or radiology or lab or micro or clerical or nursing visit with the hospitalist group face to face on a regular basis with ideas about increasing hospital efficiency.

Mrs Happy Got The New iPhone

The 3Gs. I am so jealous. Only 10 months to go before I upgrade my 3G. Which smart phone do you have and what do you mostly use it for?

Should Physician Acceptance of Medicare and Medicaid Services Be Mandated?

Medicare and Medicaid services are often a losing economic proposition for physicians.  But should physicians be mandated to accept Medicare and Medicaid services anyway?  Physician assistant Michael Halasy over at Are You A Doctor? offers his panel of solutions to the current health care finance crises in a recent post, one of which involves mandating Medicare and Medicaid services.  What do you think?  I could write an entire book about this if I sat and thought about it.

I agree  with some.  Others not so much.  Perhaps the federal mandate for Medicare and Medicaid should only apply to independently practicing nurse practitioners, since they are the ones expected to provide access to those unable to find it.

Offering a VAT tax in lieu of federal income taxes is a great idea.  Having one in addition to federal income tax is a horrible idea.  All it does is fund more money into a losing proposition and encourages the expansion of unmanaged health care costs.

What do you think?

When To Plan An Impromptu Trip To Walt Disney World

Mrs Happy and I up and left for  a partial week long jaunt down to Disney earlier this month.  If you are planning an impromptu trip to Walt Disney World and don't want to wait on any rides, you need to take your family the first part of October, on a Tuesday or Wednesday.  I

t was incredible.  We did all four parks in two days and road just about everything.  When we went two years ago, in June, the lines were one to two hours long.  By Thursday and Friday, the lines were returning, but nothing compared to the summer months.  Perhaps  the recession has something to do with it.  Here's my favorite picture of Happy and his family doing mouse ears on Splash Mountain, one of my favorite rides.  I'm doing scary mouse ears.   We even got some stranger in front to pull them out. What's your favorite Disney ride?

click image to enlarge

New Pictures Of Marty & Cooper In My Slideshow

I've got about 25 new pictures up of Marty and Cooper, our Italian greyhounds,  in the slide show in my side bar.  If you don't have  the stomach to handle seeing precious puppy angels snuggling with each other, I suggest you don't watch it.  Otherwise enjoy the beauty that they are.  The new pictures are at the front of the show in case you are one of the 1000 viewers who have watched our little angels in the past.

Take The Recommended Childhood Vaccinations Or Get Out Of My Practice

If you don't let your child have their recommended childhood vaccinations, I'm kicking them out of my practice.  That's what some docs are saying.

Here's my position.  The physician patient relationship is one of mutual consent.  A patient is free to walk away from the relationship at anytime for any reason at all.  So is the physician, minus the generally accepted 30 day grace period to allow the patient to find another doc.

Dismissing patients or their children because their guardians won't allow immunizations is a perfectly legitimate reason to sever a relationship.  If the guardian does not cooperate in good spirit with acceptable recommended medical therapies, breaking the patient -doctor bond is well within the rights of both parties. 

Doctors are under no obligation to provide an environment of acceptance and to provide a service to patients or their children that represent a community health hazard.  Let them go find a doctor Oprah recommends.  If you are worried about the safety of the children, call child protective services and let them handle it.  That's why they pay social workers the big bucks.

Will Pill Robots Someday Make Endoscopic and Vascular Procedures Obsolete?

Perhaps someday, the patient simply swallows a florescent tracer that lights up the polyp  and then swallows  a radio controlled pill robot (cool video) to get their colon or  stomach or small bowl biopsy done by a technologist in a primary care office in the middle of North Dakota.  For a fraction of the current cost of doing business.

Perhaps the same technology that makes health care unaffordable today may someday make it cheap enough  for the masses by allowing technologists by the thousands to play carpenter while doctors are out cogitating.   Perhaps one day the same technology could be used to inject vascular robotic stents or other plaque dissolving devices right from the internists office or surgical dissolving robots or cancer bots that target only cells for which they are programed to destroy.  I've seen what's coming and it is sweet.  Be prepared for a whole new generation of therapies that will revolutionize the way we practice medicine.

That's efficiency for you.  And that is one of the only ways to  survive in money driven medicine

via Better Health

Is This A Child Abuse Story Or Is This About Weight Lifting Records, Specifically Children Weight Lifting

A five year old Romanian weight lifter struts his stuff and the world accuses the parent of child abuse. Is this a child abuse story or is this about weight lifting records, specifically children weight lifting.  I suppose watching television is a much safer option than excelling at sports.

Read the comments

Sustainable Growth Rate For Seniors Bill Shocks America

(HNN).  Surprising legislation has emerged out of the Democratic  Congress that promises to protect America for generations to come.  Called the Sustainable Growth Rate (SGR) for Seniors Bill of 2009 it promises to solve the Medicare finance quandary we currently find ourselves battling.   Charles Rangel, D-N.Y committed political suicide with his bill in what will surely be a show down with  other politicians who show no interest in personal sacrifice for the common good.

When asked why he would do such a thing, Mr. Rangel responded, "Obama said it's time for banks to say thank you by loaning money to Americans who can't pay them back.   How can you question such dedication ?  We talked.  The time is now for me to take one for the team.  So I did.  I love that man."

Sustainable Growth Rate for Seniors Bill of 2009 promises to do for seniors what it did for primary care physicians everywhere:  Annihilate them.  The bill solves the finance problem  by requiring all  health care cost inflation above GDP growth to be paid for with a value added tax on seniors, disabled folks and the poor.   It holds these groups accountable for the cost of the care they receive.

Current Senate Finance Committee members indicated this could total $500 per beneficiary the first year, rising every year that costs aren't controlled.

"How am I supposed to afford my cigarettes and cable TV? ", a disgruntled senior, who wishes to remain anonymous , was heard saying.

The program represents a stark contrast to the complicated Sustainable Growth Rate formulas for relative value unit codes, current procedural terminology codes and international classification of disease codes that plagued  physicians for years.  Put simply,   any growth in spending over GDP for beneficiaries will be considered a value added  tax liability.

One Senator, who wished to remain anonymous because they were not given authority so speak on the matter , called it the Alternative Alternative Minimum Tax (AAMT), something vehemently opposed to by the AARP

Some Democrats expressed concern that little old granny wouldn't be able to pay for her value added tax  and her motor home at the same time.  Not to fear said the Democratic Caucus. Other proposals are in the works.

Nancy Pelosi, D-CA was heard saying, "This is great.  What's not to love about taxes?  Besides, I have in my possession my proposal for the Yearly Stimulus Plan for Seniors Bill of 2009 that gives all seniors, disabled and poor people a bonus check every year till the end of time to pay for the extra cost of their value added tax for their free government health care.  And I've proposed a tax on everyone making over $250,000 a year to pay for it.  It's called the Sustainable Growth Rate For Rich People Act of 2009 a plan to make sure rich people never make more than $250,000 a year ever again.   And I've set up another government agency to make it all happen."

Concerned Republicans were also found getting behind this bipartisan bill.  "If Sustainable Growth Rate  for Seniors does for seniors what Sustainable Growth Rate did for primary care, the answer to the finance question is simple.  Let's just let Sustainable Growth Rate for seniors wipe them all out.  No more old people.  No  more disabled people.  No more poor people.  If Sustainable Growth Rate for Seniors collapses, so will the Sustainable Growth Rate for Rich people.   And rich people will thrive again", Senator Mitch McConnel, R-K.Y was overheard saying.

And the government wheels keep on burning.

Are Health Care Expenses Being Driven By Hospitals?

I think health care expenses are being driven by hospitals.  Here's one reader's experience.

How does this sound?. I had a rash and the derm doc put me on some steroids. I filled it at MY HOSPITAL   pharmacy=   $60.  Checked with drugstoreDOTcom=  $17  bucks.. A friend of mine across town runs the pharmacy at another hospital. Checked with him. Their cost = $6.   Nice to know things like this.  Does your hospital do it this way?

We got labs drawn for our IVF fertility stuff at both a hospital and at a local lab.  The lab's cash price for phlebotomy fee was $4.  The hospital's cash fee?  Almost $40.

Forty bucks to draw blood. Not to run the blood, just to draw it. It's unbelievable what's going on out there.  And I had no way of knowing what that price was until the bill came due.  My words of advice.  If you can avoid hospitals for the cash elective stuff, run as far away as you can, especially if you are paying cash.

Would you pay $20 a pound for tomatoes if you knew the cost up front?  Until transparency in pricing is achieved, there will be no competition for the health care dollar. Health care expenses are driven by hospitals.

Do Halloween Yard Decorations Scare Your Dogs?

The other day Mrs Happy and I were walking our little puppy angels around the neighborhood when we came upon one of those inflatable skeletons  and other assorted Halloween yard decorations.   Much like this picture here.

Our dogs are creatures of habit. If something seems out of place, like Halloween yard decorations, they get nervous. Marty, our little white Italian greyhound with the grey helmet saw this skeleton in the neighbors yard and went berserk. He stood steadfast staring and barking at that skeleton for almost two minutes straight. The hairs on his back created a mohawk (what we call a backhawk) and he was completely engrossed with this strange Halloween yard decoration display.

A few blocks down the road and our little Cooper, the grey Iggy with the white boots found himself spooked by small metallic Halloween yard decorations in the shape of a wizard hat and a spooky looking cat. After being startled by their presence and running away, he proudly came back and attempted to relieve himself on them.  Perhaps as a sign of dominance.

I tell ya dogs do the funniest things.  Ours are no exception.  You can see their angel like presence in the slide show at the top of my middle sidebar.  They really are a beautiful part of our family and bring great joy to everyone they come in contact with. And they are each other's best buddies.

Lawnmower Accident Takes Child's Leg And Parents Sue Because Dad Ran Over Child

Dad ran over the child in a lawnmower accident  and the lawyers were seeking 11 million dollars.
What does that say about America?  And its lawyers?

Halloween Food Porn or Fun Halloween Food Ideas With Popcorn

That's a fun food idea and Halloween food porn for ya.

The Pillar Of Health Care Reform Can't Survive On Medicare Alone

You know things are bad when Obama's Mayo can't survive on Medicare.  That's just a travesty.  And your democratically controlled Congress wants to expand Medicare for all?

It's quite a quandary we have.  Medicare doesn't pay enough to sustain operating expenses of large hospital systems or small doctor's offices everywhere.  Yet it is so bankrupt it threatens to destroy the  fabric of our country's economic survival.

That's one hell of a dilemma we find ourselves in.  Good luck Washington.  At some point, the Medicare people in this country are going to be in for a rude awakening because either they won't be able to find a doctor, or they won't be able to get the pacemaker.  It's going to be one or the other.  Which  one would you rather have? Perhaps they'll just get pain pills.  Or  they'll have to wait until they turn 75 to get their free medications.

How Does A Hospitalist Clear A Nonelective Surgery

I love it when surgeons have enough confidence in their skills to do their own preoperative history and physical and feel confident in their ability to clear the patient for their operating suite.

Then there are the 3am requests to clear the healthy patient for a nonelective surgical problem.  To that I have a couple comments:

1. First of all hospitalists don't clear patients.  Anesthesiologists do.  We recommend further evaluation before surgery, which for non elective surgery is generally a non issue.  If the patient needs surgery, they need surgery.  My opinion doesn't count, even if it's bloodless surgery.
   
2. Physician Assistants hired by surgeons are the perfect group to provide 3 am pre-op H&Ps on healthy patients.   Asking Happy to do one under the stealth clearance request is just another example of wasteful Medicare spending.  You don't need to pay Happy $200 to say the patient needs non elective surgery to do a pre operative H&P that offers nothing of value to patient care.
   

Perhaps in the back scratching days of I'll call you if you call me, this practice would be acceptable.  Everyone gets paid and nobody gets hurt.  Except we can't afford that anymore.  At some point the Medicare National Bank is going take that $200 that I get for my preoperative thank you  sir can I have another and send the surgeon a bill to pay back a portion of their global fee.  Only then will we really know how important that $200 is to aspiring surgeons everywhere.  Or perhaps it will be a boom for PA medicine.  Who knows.  I do know that it's one of the worst ways Medicare can spend $200.  And that is spoken by someone right in the thick of the greatest bankrupting in the history of civilization.

With that said, if there are medical issues that need addressed pre or post operative, I will gladly earn my keep. I'm always here to help. 

A Cure For Diabetes Is Through Sweat And Tears

A testament to the power of personal choice and sacrifice as a cure for diabetes.  What a beautiful article about the success of lifestyle choices as we battle out of control health care costs.

When patients fail medication therapy in the treatment of type II diabetes we doctors add more medication.  When patients fail exercise therapy, we quickly accept it as failure and add medications.  It's all backwards.  A cure for diabetes requires some fresh thinking.  When patients fail medications, what we should do is order exercise, not more medication.   By exercising, we cure the disease.  With medications, we simply mask the physiology of the disease process. 

Medications are an excuse.  As Dr RW says, administering insulin is not physiological.  There is nothing more physiological than exercise.  When are we as a nation going to stop making excuses and start making progress?  These folks in the article mentioned above are a testament to the sacrifices required to cure type II diabetes.  80% of diabetes, heart disease, stroke and cancer can be prevented if patients took care of themselves.  Hopefully, any new legislation that is ultimately signed will make sure that those who don't care for themselves pay a greater share of social solidarity than those who do.   As they should.  For the common good.

Are You The One Searching for Dirty Halloween Costumes?

Here's an inside look  into the world of search engine optimization (SEO).  The online world runs on search engine optimization.  If you can get your product onto the first page of a Google key word search, you may just strike it rich.  If you don't, you may be headed for bankruptcy.

Take for example the key word search "dirty halloween costumes"  While certainly not on a grand scale, it's interesting to note that my blog landed on page one for that search string.I noticed this after a rather intriguing number of folks found my site with that key word string "dirty halloween costumes"

There I am, #3 on page one for a Google search for this search string. It's the direct result of this post about dirty Halloween costumes I made a few days ago.

On October 22nd, I started to notice an increase in traffic from no hits to near 30 hits a day from that search string alone.

It currently ranks #10 on my key word searches that find my site through internet search engines.

Here are my top 10 key word searches for the last 30 days

1) happy hospitalist (1808 hits)

2) the happy hospitalist

3) hospitalist

4) how to make methamphetamine

5) happy hospitalist blog

6) a happy hospitalist

7) how to make meth

8) prilosec and plavix

9) average RVU per hospitalist

10)dirty Halloween costumes (52 hits)

In the last 30 days 3,844 different key word or word string searches landed people on my site resulting in 7,871 unique hits from search engine traffic, less than a third of my overall traffic.

I'll have to see how many people are searching for dirty Halloween costumes in the next week.  It's an inside look into the massive behind the scenes business of search engine optimization (SEO) that Google has generated out of thin air. A thriving business that I'm sure generates thousands of jobs all over the world, perhaps hundreds of thousands.

It's why Google is the king of the internet.  And why they can make or break a business model just like that.

Doctors and Texting

I find one of the most difficult aspects of my day is not dealing with patients who live in the age of immediate gratification and entitlement but rather doctors who don't.  The patients are easy to deal with.  I tell them the hospital runs on a mysterious just in time schedule where they could be called up for action or delayed to the sidelines at anytime for a million different reason.

But doctors?  I don't get them.  They are another story entirely. Unfortunately, somewhere along their training, many doctors developed an entitled sense of "Do Not Disturb" from other doctors.  It seems like half my day is sometimes waiting on hold trying just to contact other doctors hidden behind their 12 minute automated answering service.

No I don't speak Spanish or Chinese or Portuguese.  No I don't need medical records. I definitely don't need to make an appointment or to refill a medication.  I just want to talk to you doc.  That's all.  I just want to discuss the patient we have been taking care of together for the last four days.

Why must it be so hard?  Why do some doctors or some offices refuse to let other doctors have their cell phone number?  When I call a doctor regarding patient management issues, I'm calling because I need to discuss patient care issues. Not because I want to annoy you.

Fortunately, since I have discovered smart phones and texting in the hospital, I have discovered the beauty of real time hassle free communication.  Many doctors don't want to be interrupted to answer a cell phone.  And I get that.  There are times where I can't be interrupted either.  But obstructing access to your colleagues is not the answer either.  We are all doing our best to provide efficient care on a real time basis.

Some doctors have entered the age of technology gracefully.  They have embraced texting and its ability to strengthen the teamwork between physicians taking care of hospitalized patients.  There are some physicians I love to work with because of that openness to communication.

I was shocked recently when I received a text from a surgeon whom I had discussed a consultation request by phone earlier in the day.  It was a fantastic surprise as I was not aware of any surgeon who knew how to text, nor any that owned a text capable phone.  In fact, I don't think I've ever seen a surgeon log into a computer to look up their own labs.  So finding one that knows how to text is a major step forward in surgical residency training.  Perhaps one day  a month of residency training in  "How to do a lap with your eyes closed" will be replaced with "How to text your colleagues and look really cool at the same time."

I wish there was a list.  A list of all doctors who knew what texting was and how to do it.  Life would be so much easier if I could text them to call me at their convenience, or to let them know that certain issues needed addressed.  Or that I was discharging the patient and needed their follow up recommendations before they left.  We lose so much time to inefficiency in the hospital.  And a major part of that problem is the lack of communication between physicians regarding the plans of the day.

And now I learn that nurses are not allowed to text patient specific or even room specific issues on the texting system.  What HIPAA has done is immediately destroy possibly one of the greatest efficiency weapons in the history of hospital based medicine.  For all the hours spent waiting on hold for a physician's office to call you back, imagine how many lives could be saved and how many man hours eliminated waiting on hold or waiting for the doctor to call you back, if only hospitals allowed nurses to text patient care issues as well.

Someday, things will change.  Hopefully as the exponential expansion of computer technology continues, new ways for real time communication will revolutionize the way doctors and nurses communicate in hospitals.  And that can only be a positive thing for the patient experience.

How Does The Price Of Football Tickets Compare To Health Insurance?

How does the price of football tickets compare to health insurance?  A patient told me that a football ticket in 1940 only cost them ten cents. Using the inflation calculator, one learns that the same ticket could be purchased for $1.54 in 2009  if the price of tickets rose with the buying power of the dollar over time.

The last time I checked the price of football tickets are $50 or more.  That represents a compound annual rate of almost 9.5 per year for 69 years.

And you thought health care was expensive.  Where is the government takeover on football tickets?  Where is the outrage?  Who can survive without football tickets?  Why is the price of football tickets so high?

There's An App For That For Nurses Too

Dr Wes alerts us to an iPhone app (there's an app for that) about heart stuff that gets him all excited. I'm just not feelin' it. Let me tell you what would light a fire in my loins.  An app that offered the following:

STOP RIGHT THERE.  Do not call the doctor about Mr Smith's critical lab value.  When objectively reviewed in the context of the patient's current and past medical history, it is not necessary to stop what you are doing to interrupt both your work flow and the hospitalist's beauty sleep.  You have been granted full immunity by Happy's hospital  lawyers to table this issue until daily rounds.

Now if I could only get this integrated into the nursing work flow, that's an iPhone application that  I could get behind.

Money Driven Medicine Cashes In

An excellent post from DBs Medical Rants about the conflicts of today's money driven medicine.  What should be patient driven decision making, is in fact everything but.  The reality is as long as someone other than the patient pays their health care bills the doctor will always respond to outside forces that pay their bills.  The quandary doctors are placed in here is how do they pay their bills when the right medicine for patients often doesn't?  This is money driven medicine.

Is it better to abandon patients who's insurance doesn't pay the bills, leaving them with no access at all?  Or is it better to offer them substandard care, whether it be shorter visits than are necessary to cogitate or to perform unnecessary testing to pay for the over head of the office or to refer patients unnecessarily to others to open up the clinic to more volume  generated relative value units. This is money driven medicine.

The answers aren't  simple. But the fact of the matter is many offices, especially primary care offices, cannot survive on the mafiaesque like price fixing of third party payers, government and private.  In fact, just a few months ago a major primary care clinic with over 5000 patients in Happy's town ,most of them Medicaid and Medicare, was closed abruptly due to a failing business model that relied on substandard government payment rates to pay their overhead.  It's hard to find a new home for government patients when the only federally subsidized primary care clinic has a 3-4 month waiting list for new patients.  This is money driven medicine.

The government's idea of fair it seems to me is bankruptcy.  This is the model of the public option that Democrats are trying to offer this country as the competition to provide industry.  It's easy to compete when you set rates that don't pay the bills.  And just print more money when you run out. Unfortunately, the government option will become nothing more than hospital insurance as doctors every where will opt out of a money losing proposition.Ultimately you get what you pay for.  And paying poorly gets you poor access to care.  This is money driven medicine.

What most smart offices are doing is eliminating the lowest paying payers one by one as a matter of necessity.   For many offices, that means limiting exposure to or entirely removing all Medicaid or Medicare patients from their panels.   One by one as third parties slash their payment rates, offices either end their association with or risk suffering under the heavy weight of overhead and loss of lifestyle.  This ultimately leaves access only to those able to fund their own health care needs.  There is a reason why most doctors limit exposure to Medicaid and Medicare.  It's because they must first pay their bills.  This is money driven medicine.

Third parties have systematically destroyed the relationships doctors have with patients by changing the dynamics from what's best for the patient to what's best for their overhead.   There is only one way to handle    money driven medicine. That is to accept it as necessary in our capitalistic society that is responsible for all the great advances of the last 200 years.  This is money driven medicine.

There is only one way for our society to survive in money driven medicine.  And that is to drive efficiency.   Realize however that doctors, whether they know it or not,  are business people first and doctors second.  A bankrupt doctor is no good to patients without a clinic to operate in.  So are hospitals.  So are insurance companies.  So are medical device companies.  So are drug companies.  So are nursing homes.  So is every participant on the receiving end of third party money.  They are all businesses first. and foremost.  Accepting each as a money driven enterprise is necessary to move forward with solutions to the finance quandary.  We must accept money driven medicine.

If we can not drive efficiency, we are doomed for failure.  I say often I could see double, triple or more the number of patients  daily if I wasn't forced to spend 70% of my day documenting worthless information necessary only to get paid and not be accused of fraud.

For those who believe that large hospital/physician organizations are the solution, just remember, even doctors that are salaried must prove their worth to those that pay their bills and that means insurance companies and government programs  that devalue their work also devalue their salary and  make conditions of employment a volume driven entity.  Show me a hospital that pays its doctors based only on patient satisfaction  instead of volume of RVUs generated and I'll show you a hospital that goes bankrupt.  This is money driven medicine.

Money driven medicine is a good thing.  But it doesn't work when efficiency is driven out of the market by unrelenting rules and regulations that make it impossible. If we cannot drive efficiency the only alternative is to drive away access.  Which will be the defining endpoint of bloated regulation driven substandard government health care options.  In that case we will have the worst of all worlds.

Poor Pricing Competition and Yet Health Care Survives

The lack of pricing competition is striking.  I checked on the price of a generic antibiotic for a  patient.  I called Walmart and learned that you could get a two week course of  the medication for about $10 in cash. The patient requested a different pharmacy because they didn't believe in what Walmart stood for.  So I called the patient's pharmacy to learn the antibiotic, the same one, same pill, same dose, charged $100.  And that was perfectly OK.

I was quite intrigued on two levels.

1. How can one pharmacy survive charging over 10x more for the same medication.  Imagine going to a grocery store to pay $20 a pound for tomatoes when the shop down the street charges $2.  The only way the expensive store survives with such a pricing model is when third parties accept it and pass on the costs to other premium paying customers.  This is a flagrant example of what's wrong with third party medicine
2. The lack of objection to allowing their insurance company to pay $100 for what could be obtained for $10.  This represents an irrational separation of personal responsibility in the economics of health care.  I guarantee if the patient was responsible for the cost, they would not pay full price or allow their insurance company to fork over $100 for something that could have cost $10.

I might add that Walmart is the company they are today because Americans love getting cheap Chinese warehouse goods, no matter what they stand for.  If you are going to blame Walmart for what they stand for, you might as well blame all the American's who continue to drive their expansion by shopping with their wallet.

Obama Thinks Banks Should Lend More Money As A Way of Saying Thank You To The Taxpayer

This cracks me up.  Obama thinks banks should start to loan more money to small business as a way of saying thank you to the taxpayers who stood by them during their crises.

 taxpayers 

It's amazing too me how the Presidenst of the free world could think like this.  I'm sorry to report to you Mr President, but the world does not operate on fairy tales and roses.  It operates on the economic self interests of millions of Americans each doing their own selfish things for their own economic good of their family unit.

I suppose you also believe that Americans should gladly forfeit double their income tax as a thank you to the government for giving them multiple stimulus checks, free cars, free homes and years of unemployement checks? 

Banks don't owe anyone anything.  They report to their shareholders and their boards of directors, the same as they did before the government came to save the day.  And if they cannot compete with other banks they go bankrupt.

Or in this case, they get free government money for acting badly.   The only thing the taxpayers got out of this whole deal was a giant bill.  Here's an idea.  Why don't you slash the tax rates of all tax paying Americans who stood by while government regulations manufactured the greatest recession we have seen in generations.

"These are the very taxpayers who stood by America's government in a crisis, and now it's time for our government  to stand by taxpayers  and slash the tax rates they need to open their wallets, grow their personal wealth and create new jobs," Obama said.

One can only dream...

Should Pregnant Women Stop Drinking and Smoking?

Happy:  Hope you don't get H1N1

Pregnant Nurse:  It's nothing a little alcohol won't take care of.

Of course this was in jest.  Pregnant women should quit drinking and smoking. But I do know a nurse who drinks while she's pregnant and thinks nothing of it.  I don't know about you but if you aren't going to give alcohol to a toddler of  yours, why would you give it to your unborn child?  And that goes for smoking pregnant women too.  Your child has no one to depend on but you.  Why would you assault them with developmental toxins before you even gave them a chance to thrive?  Of course pregnant women should stop drinking and smoking.

Are you that selfish?

If you're poor, get your Chantix for free.  UPDATE:  Chantix lawsuits, here we come.  

Are Colored Cosmetic Contact Lenses Dangerous To Your Health?

That depends on if you can afford to get them.  Colored cosmetic contact lenses are all the rage for Halloween by adding an exciting dimension to the costume wearer.   But did you know it's illegal to market them as over the counter?

 FDA- regulated medical devices,

I didn't realize that. It's amazing that you can pay someone without a medical license to  get eyeball tattoos or to put a piercing in your tongue for cosmetic reasons but you can't buy a harmless colored cosmetic contact lens without a prescription.  I can understand some protection of the cornea is achieved by proper fitting but the same could be said about cosmetic tongue piercing.   And I don't see the FDA swarming over tatoo artists.

Why can you get colored cosmetic contact lenses in Canada without a prescription?  Do they make cosmetic lenses better and safer in Canada.  If safety was an issue, are we to assume the Canadians don't care about safe products or practices?  Is that why their care is cheaper?  Or did the people realize that paying Canadian doctors $100 won't make the lenses any safer or sterile for casual use.  Perhaps the Canadians realize that this type of legislation only adds unnecessary cost to an unnecessary process. 

And you wonder why health care  is so expensive in this country.  Because you can't get a Halloween costume without a prescription.  And you want more government rules to direct your care?

How's That Hope And Change Working For You Now Buddy?

How's that Hope and Change workin'?   Hopin for some more change come 2012?

Identical Twins Research Shows Dramatic Effects Of Lifestyle

The same as it is for everyone else. Identical twins are the perfect research candidates to show the effects of lifestyle on health.  Here's a fascinating look at  identical twins research showing external changes that occur when one twin chooses health and the other doesn't.

If this is the damage going on outside the body, just imagine what the difference is inside when one chooses to ignore the effects lifestyle plays on their inner workings.  It's also why we can prevent 80% of diabetes heart disease, stroke and cancer by choosing to live our lives in ways that are known prevent disease and disability.  I wonder what free Chantix would have done.

A picture is worth a 1000 words.  Go check them out.

UPDATE:  Chantix lawsuits, here we come.  

Our IVF Swine Flu (H1N1) Experience Was Frustrating

I think Mrs Happy has

• Fever
• Chills
• Cough
• Body aches
• Malaise
• Headache

Sounds like H1N1 swine flu to me.  And it happened right at the start of an IVF cycle.  So we aborted the process.  We talked about it and felt we weren't prepared to take care of little pigs.

 Get well fast piggy.

By the way, did you know Tamiflu costs $90 for a 75mg bid x 5 day course?  On the lighter side, check out this funny swine flu pic.

Did You Hear the One About The Insurance Company Denying Health Insurance To An Obese 4 Month Old?

That's pretty messed up.

Unexpected Things You Can Wash In A Dishwasher

Things you can put in a dishwasher:

Baseball caps 

I don't think I've ever washed a baseball cap.

Will Health Insurance Companies Lose Exemption From Federal Antitrust Laws?

If Senate democrats have any say in the matter, the answer is yes. I would say that this one act alone would do wonders for the ability of businesses and patients and doctors to compete for the best price on both sides of the equation. What we have now is mafiaeque economic terrorism codified by federal exemptions to antitrust laws.

I can guarantee to you that if true market forces were allowed to run rampant, private insurance would demolish government run plans in every possible metric you could measure.

There is a reason we don't run our country like North Korea. Because it doesn't work.

Gatekeeper Medical Care: Would You Do It Save Money?

Do you know what gatekeeper medical care is supposed to be?  Do you know what can internists do?  A lot of folks think of internists and family medicine doctors as nothing more than primary care.  Some folks view primary care as simple care.  Care that is limited to prevention.  Care that requires simple one step thought processes.  Care that is nothing more than a gateway to more complicated subspecialty care.  These are the folks who believe that those with vastly inferior training in both time and scope can replace family medicine docs and internists as the first point of contact.

Unfortunately, those that believe this are also the ones who believe that family medicine docs and internists are incapable of practicing what primary care really is.  It's not about prevention and referring.  For that, you can find yourself a real good office nurse and some EMR software help and you have your  system set up to catch every PQRI bonus the government can offer.

No.  Primary care is about being the primary doctor.  That's hard for many people to understand.  Even with all the advancements in technology these days, a simple fact remains: most conditions can be managed competently by family medicine and internal medicine doctors without any need for referral.  The reasons they aren't in today's payment model has more to do with economic and legal ramifications than they do educational ones.

You see, what internists and family medicine doctors can do is not to act as the primary referring service.  It's to be the sole provider of care for most people.

I recently took care of a 69 year old alcoholic with acute decompensated alcoholic hepatitis, ascites and acute renal failure with underlying chronic heart failure and uncontrolled diabetes.  She was as orange as orange could be.  From start to finish I medically evaluated her, developed a differential diagnosis treated her appropriately and discharged her with no need for secondary referral to a subspecialist.  I withheld discussions about liver transplant options.  In fact, I wouldn't even consider her a candidate, despite her 50% mortality in the next 30 days.  The system rations livers, as it should and she was not a candidate.

Someday, the system is going to ration a heck of a lot more to make up for the drunken sailors we have become today.   There is no other way.  Unfortunately, nobody wants to be told no.  When gatekeeper medical care was  big in the 1990's, health care inflation took a predictable drop south. But the people would not have it.  They could not be told no.

As a result, we find ourselves heading head fast into a situation where the government can't afford what it's offering and big business can't afford what it's offering and individuals can't afford what they are being offered.

So I ask you this, if you had the opportunity to sign up for gatekeeper style medicine where your internist or your family medicine doctor was the gatekeeper and they got paid well to provide their service to you and in return you got 20%, 30% perhaps 50% reductions in your premiums

Would you do it?

If every American is required to purchase their insurance or every business is required to offer it, I can assure you that gatekeeper medicine will be coming back to a mall near you.  The only question is, will you sign up out of necessity or will you continue to pay out of control premiums for the freedom to make your own decisions?  Rationing is going to happen one way or another.  Gatekeeper medical care is one  competent rationing tool that can prevent unnecessary utilization of resources.

What's Behind The Sweat Lodge Deaths In Sedona Arizona?

Two people died and multiple folks were injured after under going a spiritual experience at a sweat lodge in Sedona sponsored by self help spiritual guru James Ray

Brown and James 

I find it intriguing that a nurse hired by Ray was performing CPR when one ambulance arrived.

 a nurse hired 

Just as Dr Conrad was charged with homicide in Michael Jackson's passing, I think it's only right that this nurse gets the book thrown at them for accepting money to look the other way while innocent bystanders were placed into an a very clear life threatening situation.

His/her experience as a nurse  put them in a situation of responsibility far above the average bystander and not calling police to shut down this obviously dangerous operation was a gross negligence on their part.  If Dr Conrad is going to be charged with homicide for performing unorthodox medicine and placing the public in great harm, this nurse should as well for being a hired accomplice and looking the other way as innocent people needlessly died at the hands of greedy nurses.

They should be charged with homicide and have their license revoked indefinitely.   Perhaps the money he/she was swimming in was too much to turn down and the nurse let his/her ethics pass them by.  The nurse should have shut down the sweat lodge before it ever heated up.  The fact that this nurse didn't makes him or her an accomplice to homicide and they should get the book thrown at 'em.

On a side note,  we have 60 folks sitting around paying $10,000 a piece to sit in a tent and sweat in 120 degree heat.  I thought nobody could afford their health insurance in this country?  I'll tell you what.  You can come into my basement.  I'll turn my thermostat way up and you can sweat all you want.  I'll only charge you $5,000 and I'll even chip in for some pizza and a diet soda.

Obama Eyes Breathing Tax For the Rich and Tax Credit For Smokers

(HNN) President Obama will introduce legislation next week that will pay off the ballooning federal deficit by 2017.    Called the Hot Air Initiative, the proposal is an effort to  raise trillions of dollars to pay for his social utopia. The proposal is simple.    A breathing tax will tax the wealthy for every breath they take.  "Carbon dioxide is a major greenhouse gas and it must be stopped",  according to Obama.

Many thought Obama's Carbon Tax would be directed at pollution spewing corporations as a way to hold them accountable to the environment.  But insiders, who agreed to speak on condition of anonymity, say that Obama scrapped those plans when lobbyists of big business and tobacco  agreed to contribute hundreds of millions of dollars to his 2012 reelection campaign.  

Instead, Obama is poised to introduce a breathing tax on the richest 5% of Americans.  Holding true to his own word, this tax will not affect anyone making less than $250,000 a year.  For all Americans above that threshold, they will be taxed based solely on their income.

As a progressive Carbon Tax Initiative, the more you make, the more you will be taxed.  As Obama said,  " Anyone making $500,000 a year must be full of hot air.  And those making more than a million?  Don't get me started.  I can't even imagine how much carbon dioxide they're spewing into the environment.  It's time to let the poor breath clean air once again."

On a surprise note, Obama and company said they will also introduce sister legislation that will drastically affect the lives of smokers everywhere.  As a smoker and a rich man, Obama plans to introduce the Obamarama amendment that would  entitle all smokers an exemption from any Carbon Tax Initiative, regardless of income.  After promising not to raise taxes on anyone making less than $250,000 a year, Obama felt the time to act was now to win  back the hearts of smokers that he lied to.

The medical rationale is simple.    According to Obama's physician advisers, smokers are incapable of exhaling all their carbon dioxide with every breath.  As such, they should not be penalized with a Carbon Tax.  In fact, they should be rewarded for breathing out less greenhouse gases.  Obama was overheard saying, "The more carbon dioxide we can prevent in exhalation, the better off our air will be.  Let's do it.  Let's give them free cash."

Anonymous sources have also indicated Obama's plans for a second sister amendment  that gives all first time smokers an $8,000 environmental carbon  tax credit as a way of saying thank you for saving the environment.  They will also receive $4,000 in smokes for every smoking cessation aide they bring to a Walmart disposal center.  Why Walmart you ask?  "We owe the Chinese a lot of money," Obama was heard saying.  

Exercise and Healthy Eating And Not Smoking Deserves A Premium

 Premium pricing on exercise and healthy eating and not smoking is hopefully coming our way.  I read an interesting article in my local newspaper courtesy of the Washington Post.  It represents a strong incentive in the right direction.  According to the Washington Post

Many employers are already offering lower premiums to workers who complete personal health assessments and others offer limited benefit packages to smokers.  Under the rules being proposed in Congress, wellness incentives are a giant loophole to Obama's goal of having a payment model devoid of any personal health characteristics and health status.

Accordingly, wellness incentives would allow insurers and employers to make coverage less affordable for people who chose not to participate in healthy lifestyles, such as exercise and healthy eating and not smoking.  Under current rules, incentives based on health factors can be no larger than 20% of the premium paid by the employer and employee combined.

New rules being proposed raise that to 30% with the power given to the government to increase that to 50%.  That means for a couple with $10,000 in premiums, $5,000 of that could be on the line.

And insurance companies would be able to make pricing arrangements based on participation in wellness programs to make exercise and healthy living and not smoking a top priority.

One company had a brilliant strategy.  They raised the deductible from $400 to $4000 for a family plan and gave their employees the opportunity to earn all that extra deductible back for healthy living and reaching healthy living parameters.

There is nothing more powerful for a family than to know that they have $4,000 a year in potential savings to their bottom line by doing something they should be doing anyway.  If they don't want to participate, they are certainly free to spend their own hard earned dollars reaching their $4,000 deductible and thank their employer for offering anything at all.  The result is just a 1% yearly increase in per employee health care costs for this company.

You see folks, it's not about insurance.  It's about exercise and healthy eating and not smoking.  Most of the sickest patients I take care of are on Medicaid and they get everything for free.  It's about exercise and healthy living.  When you get everything for free, you have no incentive to do anything for yourself.  Medicaid is the ultimate in social utopia for irresponsible patients.

It looks like there just might be some muscle in Congress left to force Americans to pay for the right not to participate in healthy living.  If you don't want to be told what to do, feel free to pay more for that right.

The choice is yours.  It's time to stop making others pay for your freedom and start taking responsibility for your actions.

Do You Ever Get A Christmas Card From Patients?

Sometimes I find myself deep in battles that aren't worth fighting.  Patients who are angry, belligerent, and agitated who have the capacity to make sound medical judgments,  but are struggling with being nice.  Sometimes I run into patients with chronic disease who demand therapies which are unreasonable and irrational in an inpatient hospital setting.

Take for example some type one insulin pump diabetics admitted to the hospital  who request  to get every  30 minute  injections of fast acting insulin to replicate the insulin pump  for the next 12-24 hours when their pump is not functioning appropriately.  I calmly explain  that every 30 minute accu checks are not a rational solution to the issue at hand.   I also explain that we simply do not have the nursing staff to provide something that is not necessary nor medically indicated.  And those services can only be provided at higher levels of care, which are not medically necessary.

I also explain my doubts as to the medical rational for giving every 30 minute bolus injections of an insulin that is injected every three minutes by pump. Why not give it every hour?  Perhaps every 10 minutes?  Maybe every 2 hours?  Or every 4 hours? I explain that the kinetics  of every 30 minute administration in the next 12 hours of hospitalization are not equivalent to an insulin pump.

I offer to give  a bolus injection of 1/2 the daily basal requirements as a long acting insulin and to provide meal based accu checks as warranted with carb counting and sliding scale requirements as necessary.

Sometimes, anger and agitation is all I get in return.  I'm left with telling them it's my way or else risk going into ketoacidosis.  As a physician, some ground work must be laid into not being bullied into ordering  unreasonable and potentially dangerous therapy.

Sometimes, they demand my name.  I give it to them.  It's Happy Hospitalist, MD.  In these situations, getting a  Christmas card is probably out of the question.   I guess you can't please everyone every time.