Which Of These Fruits Are Not Like The Others

I'm thinking it's the Nerds candy.

Widend Pulse Pressure Record: 295/32 and Corrigan Pulse Experienced

I've never seen such a widened pulse pressure.  A widened pulse pressure is the difference between your systolic (top number) and your diastolic (bottom number) blood pressures.  A normal widened pulse pressure is 40mmHg, or the normal 120/80.

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What Should I Do With My 401K For June 2010 With S&P 500 At Critical Support Levels?

What should I do with my 401K?  That's what many people are asking.  Several weeks ago I wrote a post about the 200 day moving average (DMA) for the S&P 500, NASDAQ and Dow market basket indices and why they represent a critical support level for markets.  Once the 200 DMA is pierced above or below, that level becomes either a point of resistance or a point of support. Most trading these days is driven by  big money and sophisticated computer algorithms that set stop trading decisions at major market support levels.  The 200 DMA is one of those critical support levels.
 

The 200 DMA for the S&P was broken last month.   In fact,  that support level was sliced through like a butter knife in the now infamous flash crash that the mainstream media tried to pawn off as  sticky fingers of some  a novice trader.  Yeah, of course it was.  Do they think the general public is that stupid?   

Nobody has yet been able to explain the truth. As in hospitalist medicine, the easiest explanation is the most likely explanation.  Nobody wanted stocks that fateful day.  What was once valued at $50 became worthless for those fifteen minutes of carnage.

Twice now in the last month the S&P 500  has bounced off  its established critical  1040 support level  in an attempt to break back above the 200 DMA.  And both times it has failed miserably.  It has failed because the buyers of the market have left the building.  Unlike the Medicare National Bank, the real market sets the price of stocks.  And the market is saying it doesn't want to buy stocks these days.  

So where are we now?  Today, June 29th, 2010, the S&P sits at 1041.24.  This is a do or die week for the S&P with regards to holding its suppport and shooting higher  or rolling over like a dead dog.  The more times support holds, the stronger that support becomes.  But if it fails, look out below.  There are no buyers to prop it up.  We will be looking at a gap down to lower support levels, perhaps 10% or more.

Will the third time be a charm?  The S&P Point and Figure (P&F) charts say no.  Today, The S&P printed a double bottom breakdown.  That's not good, especially since there isn't a peep of good economic news coming our way.  Housing is collapsing.  Europeans are rioting in the streets. Jobs are scarce.  Banks aren't lending.  Prices are collapsing.  Nobody is spending money.  Everyone is scared.

I believe, this week, we are at a cross roads of incredible economic proportions.  I suspect is will be a week to remember.  What happens this week in world markets might very well set the stage for global economic collapse and social unrest that turns our lives upside down.  Or, we might fight our way out of this dangerous economic support zone to higher highs.  Only time will tell. How much faith in your government do you have?

I wish I could hope for the best, but all I see are failures of world governments to understand you can't get something for nothing. FREE=MORE has lead to the greatest sovereign debt crisis in generations. And the volatility is only going to get worse.  Markets hate risk.  Markets hate fear.  Right now they have both.

If you have been paying attention, major markets enter periods of relative calm or high volatility.  That volatility is measured by the volatility index for the S&P called the VIX.  A rising VIX indicates a market's expectation of a rising volatility of S&P prices  in the near future.  One can actually view a graph of the VIX to see how the undulating pattern of calm and  volatility plays out.   Higher volatility is a marker for fear.  And we know that markets hate fear.  Markets hate risk.  Right now, we have both.

A rising VIX is seen at market tops or bear market action while a low volatility is seen with a rising bull market. The current VIX bounced off its 200 DMA and has pierced through the 50 day moving average to settle the day, today June 29th, 2010, at 34.13.  A VIX above 33 indicates a high level of risk expectation in the market.  It indicates an expectation of increasing, not decreasing,  volatility in the days and weeks ahead.  It indicates a rising fear.

With nothing but bad economic news coming out and all major indices bouncing down and hard off their 200 DMA and  flirting dangerously close with their critical support levels (the third testing of their lows), and Bernanke and Co scared to death of a double dip recession or deflationary depression,  you would have to be a blind duck walking through a Chinese restaurant to try and ride this madness out.

Don't be an idiot.  If it walks like a duck, and acts like a duck, it's a duck.  What we have here folks is the largest bowl of  Sum Yung Duck soup the world has ever seen. On February 24th, 2010, I put my entire 401K into cash.  I have no faith in the current and future destructive political economic environment that is playing out directly in front of our eyes.  Our economies are failing not because of government inaction but because of their action and reaction.

Despite 30 years of compound growth in front of me, I am not stupid enough to be that duck in a Chinese restaurant..  My risk tolerance is at an all time low.  I may be over reacting.  Or I may not.  Only  the future holds the key to the past. I will only know in retrospect if I did the right thing.   In medicine, sometimes the best thing to do is nothing.  Now might not be one of those times.  

Keep your family close to your heart.  I think a lot of folks are going to get slaughtered.

(This is not economic advice, only my perception of the current technical, political, and social market action on a macro and micro level. I've been studying this stuff on and off for 20 years and I know enough to make me dangerous but not enough to make me an expert by any means. It's your money.  It's your decision. What ever you do, remember don't be stupid.   The government will need someone to bail them out too so you will probably be on your own.)

Verizon iPhone January 2011 Debut? Take The Poll. What Will You Do?

Could a Verizon iPhone January 2011 debut be on the way.  That's what Bloomberg is reporting. Now the question is, do you want the ability to surf the net while talking on the phone which the AT+T network allows but Verizon's doesn't.  Or do you want a much larger 3G network available to make calls and surf the web.

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What Do Patients Want? I Mean What Do Patients Really Want?

What do patients want?  The doctor patient relationship will always be full of baggage.  Patients bring their own motivations and expectations to the office.  So do doctors.  One would like to believe that both operate in a sterile environment.  That will never happen because humans are not robots.


What do patients want?  Some want to get better.  They go to the doctor seeking help for their aches and pains.  They seek help for their new cancer diagnosis or their unexplained weight loss. 

What do some patients want?  Some just want to be fed and served.  I once had a patient admit she would get drunk and come to the hospital because she wanted a free meal and she wanted someone to serve it to her.

What do other patients want?  Some want doctors to perpetuate their drug addiction.  If we want doctors to stop being treated as licensed heroin dealers, we are going to have to deregulate narcotics and allow those patients that need help to get easy access to pain saving medications. Regulating narcotics doesn't prevent addiction.  It turns the doctor patient relationship into a game of cat and mouse and creates criminals out of both parties.

What do many patients desire?  I think many patients are willing to go to Hell and back for the power of love.   I learned this fact first hand a few weeks ago when I cared for an elderly woman with metastatic lung cancer.  

When all her family was around, she wanted everything done. She didn't want to let them down.  But get her alone, and the truth came out.  She just wanted to be at peace.  She wanted all the pain and suffering to end.  She thrived for a comfort driven care program. With that said, I think it's vitally important to separate the patient from their family  when talking about end of life care issues.

If we really want to know what patients want, we need to separate them from their families and talk to them alone.  Just as we were taught as medical students to always have mothers and fathers of adolescent teens leave the room so the doctor and child could talk alone, without the fear of parenteral action.

I've come to the conclusion that it's no different for the elderly.  Being too old or too young can have a major impact on how patients respond around their family.  I learned a big lesson the other day.  If we really want to know what grandma or grandpa wants, we have to get their family out of the equation.  We have to talk with them alone and let them understand that their decision is final.   Not their son's decision or their daughter's decision.  It's their decision.

Several years ago I cared for a 95 year old woman in the emergency department.  Just before she started to decompensate, she told me she did not want to be on a ventilator.  As soon as she crashed, the son demanded everything be done. 

For the next three years her son haunted the medical community by demanding irrational and painful medical interventions.  

That lady died this month at the ripe young age  of 98.  She died in a nursing home, on a ventilator.  What American doctors needs is immunity from retribution from family members who demand care that patients would not want.  The current legal process just doesn't work.

What do patients want?  They want the right to die with dignity. That's what they want

Double Dip Recession Or Massive Depression About To Shock The World. Leading Economic Indicators Say So.

Are we heading for a double dip recession or a massive deflationary depression?  All the indicators are pointing towards this final stage of worldwide debt destruction .  Last week we learned, despite trillions upon trillions of dollars of stimulus by governments all across this world,  that growth continues to tank,  jobs remain scarce and the housing market is in its worst shape ever.  

New housing starts for May came in 33% less than April, and the lowest on ever on record at just 300,000.  Sales on existing homes dropped 2%, despite thousands of dollars in free government money.   Unemployment shows no signs of recovery with actual unemployment numbers closer to 20% from the true shadow statistics, despite the government's official estimates.

Commodity and consumer prices are falling, indicating a wave of deflation has in fact started to gain traction.  Deflation is deadly to world economies.  Why buy something today when you can buy it tomorrow at a lower price.  This sets off a spiral of decreasing growth and decreasing jobs and decreasing spending.  

I suspect a  deflationary depression is starting to set hold, one the current generation has never experienced and one that scares the Hell out of Bernanke and Co.      So how can we be sure that a double dip recession or depression is on the horizon, if not already here?  Because the leading economic indicators suggest so.  

Paul Krugman and the other Keynesians are convinced governments can spend their way out of deflation.  The last two years of stimulus have done nothing but delay the inevitable asset collapse.  Despite trillions of dollars of stimulus and trillions of dollars to bail out bond holders of the biggest banks in the world, our growth prospects are nil, our unemployment shows no hope or change and our prices continue to drop.    Not until  the cleansing of public, private and sovereign debt have run their course can a new wave of investment lead the recovery forward.

The only hope and change we can look forward to is one based on truth, not smoke and mirrors.  Hang on to your wallet.  I think the world is about to be turned upside down.  Keep your ears and your eyes open about where we are heading.  Don't get stuck in the down draft.  Some folks have suggested, based on long term economic cycles, that the current market will not be done correcting until a DOW:GOLD ratio of 1:1 has been met.  10,000:1,300 says we have a long way to go.  Either the Dow is going to tank, or gold is going to skyrocket.  Or both.

Look for Obama and Co to start pushing for more stimulus dollars and try to prevent what they say can and must be prevented.  Look for them to try and push the US government closer to the brink of default than ever before.  Look for them to blame a lack of further stimulus and failure of government action as the cause of all our problems.

We are in the situation today because of government action, not despite it.  What ever happens, don't be stupid.  Keep your family close to your heart.  Nobody knows how bad it's going to get.

Congratulations To Happy's Hospital On Their National Awards

A round of applause goes out to everyone at Happy's hospital for receiving both the HealthGrades Distinguished Hospital Award for Clinical Excellence and the Patient Safety Excellence Award for 2010.

As one of just 74 hospitals nationwide to receive both awards, I am proud to be a part of this clinical excellence.  It also gives me a chance to announce my own award.

Happy's hospital has officially won my "How Not To Implement an EMR and other IT Support Award"  for the worst integrated IT support system in the universe.  

Congratulations.  That takes effort.

Although times are changing.  We now have our very own Chief Information Officer with grand plans to change all that.  Keeping my fingers crossed...  As Holmes on Homes says:  Make It Right.

Firedfighter or Firefighter? Don't Be Surprised As State and Local Governments Go Bankrupt.

I snapped this picture below at a local fundraiser for a small town firefighter department.  It was a street dance with a $5 entry fee and $5 barbecue pork sandwiches.  Inside their fire station hangs all their firefighter gear.  And all this gear belongs to volunteer firefighters.  That's how most of rural America battles their fires. With volunteers.  This might represent the future of fighting fires through all of America as firedfighters are forced to find other paying jobs.

If you have been paying any attention at all over the last year, you would know that state and local governments all over this country are in deep doo doo.  In addition to the federal spending that is out of control by Democrats and Republicans alike, state and local governments have been spending far beyond their means.  And the federal stimulus money, which cities and states have been using to fill budget deficits, which did nothing but mask the problem for two years.  Very soon,   most state and local governments in this country will have incredible revenue deficit cliffs to deal with. 

California alone  has one of the largest economies in the world and it is billions of dollars in debt, despite some of the highest tax rates in the country. California ranks 6th higherst in state and local tax burdens for its residents.  The California state budget is over 20 billion dollars in the hole.  The issue isn't about not enough taxes.  The issue will always be about too much spending.  Raising federal income or FICA taxes will not close budget gaps. The California situation says so.

                    Image from The Two Americas

California politicians, like all politicians are out of control spending other people's money and giving state and local government workers unionized contracts that are irrational by all economic measurements.  The numbers just don't add up.  When all this implodes, the result will not be pretty.  Short of default, which will send borrowing costs through the roof, unions will have to accept massive cuts in wages and benefits that are much higher than private sector economies are willing to pay.  The solution must include massive government spending cuts. But it ain't happened yet.  And even in my own town, such a proposal was met head on with 100% unionized resistance.  The only solution is to start firing government workers and expose them to the same economic principles that govern private sector workers.  That means a firefighter becomes a firedfighter, despite union objections.  Too bad they had to have it end this way.  The unions have created the problem.  It's time for them to accept the consequences of their irrational and entitled wage and benefit expectations.

In the greatest recession in over 50 years in which almost 10 million jobs have disappeared, state and local governments have laid off maybe several thousands.  And in Washington DC the numbers keep growing and growing and growing.  Just the thought of 5 or 10 state or local government workers losing their jobs makes headline news. 

That's going to have to change by  slashing government pension benefits, health care benefits and wages alike.  And by cutting jobs.  Workers will have to get fired.  No job is safe. 

That means firefighters may become firedfighters.  And we might have volunteer firedfighters in major metropolitan cities all across this country.  If that's what it takes to fight fires in our cities, that's what it's going to take.  Rural America gets by.  Perhaps it's time our cities do as well.

Baby Bunny Trying To Buy The iPhone (Cute Video)

Mrs Happy took this video of a baby bunny caught in the city landscape.  It turns out this baby bunny kept slamming into the AT&T store.  I can only assume it was trying to buy the new iPhone 4.  

How To Exercise When You Are Old. Swimming Baby!

Mrs Happy and I took in a summer membership at the local full service gym.  They have a nice big pool.  It was perfect pool weather.  We were doing some soaking in the pool when some elderly lady came up to us and told us the pool was being used for an exercise class for the next hour. 

But this was no ordinary exercise class.  It was  filled with a bunch of old people and a couple of pregnant women dancing to  hip hop music.   Back and forth.  Back and forth they went.  For an hour they jumped and danced their way from one end of the pool to the other. 

I realized this was the perfect place for a single old man to pick up a woman.   I'd say the ratio of men to women was at least 10:1.  One old guy was showing off with this arm weights the whole time. Heck, if you're on the hunt for a woman at 80, at least you'd know your woman didn't lay on the couch all day watching Oprah and waiting to die.

If you are old and you want to exercise, fork over $100 a month of your social security check and head to the gym for a little swimming.  You can pay for it by canceling your 999 channels of HD cable or satelite TV.

Just don't use your handicap parking permit to  park your convertible in the front row.

Italian Greyhound Splashing In A Puddle (Video)

Italian greyhounds don't like water all that much. By Marty, our little white Iggy has taken a liking to splashing in puddles or pools or the lake when he gets hot from running around.  Here's a video of him splashing around in a puddle that caught Mrs Happy and I by surprise after several days of very heavy thunderstorms.  He was going nuts.  I missed the first half of his spaz out moment.

But this is still classic Marty action.

Heres another video of our Italian greyhounds playing in the water.  And one of our Italian greyhounds swimming in a baby pool.

Click here for all my Marty and Cooper posts.  If you want to see all their videos, click on the video tab in my menu bar.  If you want to see over 200 pictures in a beautiful slide show, click on their slide show in my middle side bar. 

Too Old or Too Young. Which Would You Rather Be?

I snapped this picture at a local outdoor market the other day. It's a nice image of transitions of age. On the left you have a young lady pushing her baby. On the right you have an older woman pushing her elderly mother.

Too old or too young. Which would you rather be?

Why Should Investors Have To Sue BP To Get Their Money Back, While "Little People" Just Have Go Pick Up Their Check At The Command Center?

People who live along the Gulf Coast and invest their capital to make a living on the waters of the Gulf accept a risk of losing all their money and livelihood  from economic disasters, such as the BP oil spill.

Investors who invest in companies and make their livelihood by investing their capital in companies such as BP  risk losing all their money and livelihood from economic disasters, such as the BP oil spill. 

Obama demands BP to set up a compensation fund to pay the "little man" who accepted the risk of living on the gulf where hundreds, if not thousands of oil rigs pepper the Gulf and provide a vital economic infrastructure.

But the billions of dollars investors have lost, people who's livelihood depends on a viable BP must sue to get their money back.

Why is that?  Why should one risk be valued less than the other?  Why should residents along the Gulf get free money simply by claiming poverty from the spill, but investors must sue in court to reclaim their loses?

Thus is the nature of crony capitalism, where politicians get to decide who is valued more than others.  Hint, the people of the Gulf have no more a claim to compensation than do the investors who lost billions.  Yet they get their money by bypassing the courts because the government pressured them to do so.

Politicians decide when it is politically correct to pay off the "little man" with votes and screw the investor.  I wrote a satirical post about BPs 100 billion dollar compensation fund for investors.  Not a chance in hell that will happen.  Because that's not what is supposed to happen.  Risk involves loss, unless you are the "little man" living on the coast.  Then you get a free ride from the court system.

Something to think about.  It's happening right in front of your eyes with health care. 

Do Physicians Game The System? Absolutely Yes. They Have To If They Want To Get Paid

 Fellow internist Dr Centor over at his excellent blog DB's Medical Rants discusses the idea that physicians maybe "gaming the system".  In response to a comment he explains his thoughts.

This great comment appeared yesterday:

GAMING THE SYSTEM – I want to seek an opinion as an extension of this post – What percentage of doctors try to game the system and to what extent? What is their motivation to do so? Is their any literature to predict who will game the system and who wouldn’t? Do only specialists do so and hospitalists/internists don’t or it’s just that specialists have more opportunity to do so?

Dr Centor responded:

Two types of gaming occur – intentional and unintentional.  I personally believe that most gaming is unintentional.  Physicians exhibit irrational decision making just as often as anyone else.....Go read the rest

Every time I am forced to document unimportant data for the purposes of achieving a level one or level two or level three hospital follow up visit, I am forced to game the system.  Sometimes all  I have to write is:

"Patient is stable.  No changes planned" 

Instead I write:

S) No CP, No SOB
O) 120/80 80 98.6
     RSR
     CTAB
     S/NT/ND/BS +
     No C/C/E
Hgb 12, PT INR testing 1.1  ECG tracing reviewed-Normal ECG
A) POD #1 TKA
    DMII stable no changes planned
    HTN Stable, no changes planned
    COPD Stable, no changes planned
    CAD Stable, no changes planned
    A/C mgmnt
P) Continue warfarin, same dose.  No other changes planned.

The first note doesn't qualify for anything, not even a level one follow up CPT® 99231.  The second note qualifies for a high level hospital follow up CPT® 99233.

LINK TO E/M POCKET REFERENCE CARD POST EM Pocket Reference Cards Using Marshfield Clinic Point Audit One Hospital: (Admit/Consult) One Side, Follow-Up On Other Side $10.00 One Clinic: (New/Consult) One Side, Established On Other Side $10.00 Two Hospital Cards $16.00 Two Clinic Cards $16.00 One Hospital Card + One Clinic Card $16.00 Two Hospital Cards + Two Clinic Cards $29.00 Click image for high def view

Now, is this documentation gaming the system?  You bet it is. Is it fraud? Absolutely not.  Was it medically necessary care?  You bet it was because Medicare medical necessity says so.     Do I have to game the system?  In the context of getting paid and not be accused of fraud, you bet I do.  If I want to get paid, I have to operate under the ridiculous rules I have been forced to play by. I will document till  the cows come home if that means it is required to get paid. 

Evaluation and Management (E&M) coding requirements are one giant game.  According to the Medicare National Bank, If I didn't document it, it didn't happen.   So I document everything.  And I play by their rules, just to get paid.  Nobody else cares about anything I've written.   The patient isn't on my side.  The government isn't on my side. Nobody is on my side but me when it comes to documentation requirements necessary to get paid.

I never read another physician's history and physical examination.  I only care about their plan.  But Medicare doesn't pay for only a plan.  It pays for documenting the HPI, ROS, PE, and adding up  3 points here and 4 points there.  That's why doctor's document what they do.  It's a game.  A game to get paid.  And anyone who collects money from Medicare or any insurance for that matter is playing the game.  If they don't play the game, they risk civil or criminal fraud charges by Obama's fraud police.

There is no fraud in this coding game.  Only rules to play by.   Those rules have turned medicine into a game.   Rules that are unreasonable and irrational.  All this documentation takes time.  And my time is money.  With Obama talking about all the fraud and waste in Medicare, this is the fraud he's talking about.  Physicians who fail to document the work they have performed get accused of fraud.  And nobody is going to defend them.  Not you, the patient.  Definitely not Medicare.  The physician will be left out to hang. These are the physicians who are not playing the coding and documentation game. 

Physician, if you don't want Obama throwing you in jail, it's time to play the game.   There would be no change in outcomes if I wrote the first note vs the second note.  The only difference is I wouldn't get paid in the first one.  I would get paid the highest rate in the second.  And it's all justified by the work I've done.  The only difference is the game I must play to get paid.

And that is the essence of the E&M game every doctor who doesn't want to be accused of fraud must play the game.  That means every hospitalist who bills E&M must play the game to get paid and not be accused of fraud.  We have been placed in a position which me MUST play the game.  If we don't, we becomes a part of Obama's rampage against waste and fraud.

So in answer to your question and thoughts, Dr Centor, I believe the gaming is, to a great degree, intentional.  It has to be because the rules established for it make it so.  It's not fraud by any means.  It's just the game that must be played. If you want proof of the game, just look at any post operative surgical note.  Surgeons are bundled in their care so they don't have to play this aspect of the  coding game.  Their notes are usually one or two sentences long.  This can mean only one of two things

1.  Surgeons are stupid and don't have anything to offer in their post surgical cares or
2. They aren't paid to write a lot in their hospital follow up visits. 

I'll give you one hint:  Surgeons aren't stupid.

You can find a bunch about hospital based medical billing and coding in my lecture series.  

How To Deregulate Narcotics And Prevent Narcotic Abuse. Demorphentanylaudid Is Not The Answer

Some physicians have been turned into drug dealers.  We are nothing more than licensed drug dealing pimps for patients out to get a fix.  I found out first hand the other day when I got a letter from a company that is administering a narcotic drug utilization review program on behalf of a Medicare prescription drug plan.  What a fantastic idea.  A program that is able to aggregate all the narcotic use by a patient in one easy to read detailed leter.

Then they have to go and ruin it by taking six months to send me the data.  What good does that do me now?  I haven't seen this lady in months.  Some states have a statewide narcotic data base  which doctors can access prior to prescribing narcotics. 

Such a program would be very helpful for hospitalists who are often asked to admit patients for uncontrollable abdominal pain.  Admitting patients for pain control is a horrible idea.   For those patients who view their inpatient hospital say complete with continuous narcotic drips, as the answer to their problems this positive feedback loop is unbreakable.  If they get admitted to the hospital every time they complain of a stubbed toe, they will never be forced to seek treatment.  My mantra is this: If they aren't throwing up, narcotic pills work just the same as intravenous narcotics.  They can go home and treat their chronic pain until they are ready to face their addiction.

When patients try and tell me that nothing works except IV Demorphentanylaudid, it's a clue to me that their desire involves more than pain control.  Intravenous narcotics have a very rapid onset with peaks and troughs.  If narcotic pain medication was really about pain control, one would seek out long acting, not short acting narcotics.  The long acting stuff keeps a constant level of pain medication in the body's system to try and minimize the peaks and troughs of rapid acting intravenous medications.  But it's the peaks that make you high as a kite.  

And I am not your drug dealer.

Any time I get asked to admit a patient for pain control, I will do a thorough review of the available records in our EMR, compare those records with the current clinical scenario and make a decision as to whether the patient can be treated as an out patient or not.  

My position is one of consistency.  If the patient has a negative ER work up and I decide that no further work up is necessary and the patient is not throwing up, pain of any kind can be treated as an out patient.  It doesn't matter were the pain is coming from.  If they demand admission, I tell them up front that I will not treat their chronic pain with intravenous narcotics. I tell them the hospital is not the place to manage chronic pain issues.  I tell them they need a comprehensive pain program including pain specialists and psychiatric care.

Often they will decide to go home.  Often they will ask for a narcotic script.  And often I will tell them to follow up with their outpatient primary care doctor during normal business hours to manage their narcotic pain meds. 

On the occasion that patients make it past my radar for hospital admission, I have to decide whether to write them scripts for outpatient narcotic medications on discharge.  Is there narcotic abuse going on?  Possibly.  But I have no way of knowing how many times they've filled a script for Oxycontin or Dilaudid in the last year.

Well, yesterday I got a letter from a company called "Prescription Solutions".  They apparently administer a narcotic drug utilization review program for  a Medicare prescription drug plan, with the goal to "improve outcomes and promote the safe use of medications."

What did I discover?  On that letter was  a patient (whom I didn't recognize) that I saw over six months ago.  Apparently, I had prescribed narcotics to the patient, one of over a dozen doctors to do so in  a three month period.

• December 2009 Hydrocodone/APAP 5/325     #40 Dr #1 Pharmacy #1
• December 2009 Hydrocodone/APAP 7.5/500  #50 Dr #2 Pharmacy #2
• December 2009 Hydrocodone/APAP 5/500     #50 Dr #3 Pharmacy #2
• December 2009 Hydrocodone/APAP 7.5/500  #30 Dr #4 Pharmacy #2
• December 2009 Hydrocodone/APAP 5/325     #20 Dr #5 Pharmacy #3
• December 2009 Hydrocodone/APAP 2.5/500  #40 APRN #6 Pharmacy #4
• January 2010     Hydrocodone/APAP 2.5/500  #50  Dr #7 Pharmacy #2
• January 2010     Oxycodone 5                           #60 Dr #8 Pharmacy #3
• January 2010     Oxycontin 40                           #60 Dr #8 Pharmacy #3
• January 2010     Oxycontin 20                           #20 Dr #9 Pharmacy #2
• January 2010     Hydrocodone/APAP 5/500      #30 Dr #10 Pharmacy #2
• January 2010     Hydrocodone/APAP 7.5/500   #30 Dr #11 Pharmacy #2
• February 2010   Oxycontin 10                           #20 Dr #12 Pharmacy #2
• February 2010   Oxycontin 10                           #20 Dr #13 Pharmacy #2
• February 2010   Percocet 5/325                         #12 PA #14 Pharmacy #3

That's what you call doctor shopping.  That's over six tablets a day, every day, for three months straight.  Assuming one sleeps eight hours a day, that's one tablet every three hours, for three months straight.

Is this an argument for the deregulation of narcotic prescription drugs? Absolutely yes.  What you have here is a drug addict who has fooled the system.   They fooled me.  Who's the loser?  People who actually need pain medications must go through unnecessary hoops and delays, office visits, ER visits, copays and the likes just to get medication they need to control their own pain, while drug addicts get their fix regardless.   

What have we actually accomplished by putting doctors in the middle of drug addicts?  Have we made them any better or worse? No.  Have we prevented a drug addict from getting addicted?  No.  In fact, what we do is take the path of least resistance.  Give them 30 tablets here, 20 tablets there just to get them out of our hair and make them someone elses problem.  That's what ER medicine is notorious for.  Give them a two day supply of narcotics and send them on their way.  We have to make their pain go away, right?  

We have done nothing but enable their addiction.  It's a positive feedback loop.   Doctor gives narcs, go back to doctor.  We have turned doctors into drug addicts as the path of least resistance.  The solution is not to make doctors take classes on how to prescribe narcotics.  The solution is to take doctors out of the equation.

Some argue that making narcotics a controlled substance prevents abuse.  We know that's not true.  Look at heroin.  Look at meth.  If an addict is going to abuse, they are going to abuse whether the medication is regulated or not.

Here's my solution.  Instead of putting doctors in the middle of trying to decide whether a patient is abusing narcotics, it's time to deregulate narcotic prescriptions out of medical doctor's control and let patients get them directly from pharmacies themselves.  And it's time for patients to  pay a narcotic drug utilization review program tax to let those who need the medication pay for the right to have themselves monitored.

If you go to a pharmacy to get narcotics, your purchase will be placed in the drug utilization database.  The process should  be open and transparent.  The form letter I got in the mail detailing all the doctor shopping going on should be made available to the pharmacist and patient at the point of sale and any red flags from the utilization review program would decline the sale at the point of service.

And a physician prescription would be necessary to over ride the system. If you have end of life cancer pain, you get a free ride.  If you have pain that only responds to IV Demorphentanylaudid, you are going to have to convince a physician that you are dying.

Narcotic abuse problem solved. Patient are forced to face their addiction.  Doctors are taken out of the middle.  And the people who need pain medication the most have all their barriers removed.

Handicap Parking Permits For Low Riding Convertibles. You've Got To Be Kidding.

If you are disabled, having a handicap parking permit can mean the difference between being independent and suffering in isolation. Giving handicap parking permits to people who are disabled makes sense.  Giving them to people who con or scam their way into a lifetime of easy parking is appalling.

Giving handicap parking permits to people who just want to park close to the front of the store because they are too lazy to walk is ridiculous. I don't know the story behind this convertible with a handicap parking permit. Perhaps they really are handicapped. Although I'd find it really hard to believe that someone who is too handicapped to park in a normal parking stall has the ability to get in and out of a low riding convertible.

And walk a full service exercise club.

Because that's exactly where this care was parked.

If this man or woman really isn't handicapped to the point that they can't walk an extra 50 feet to get in and out of a low riding convertible to go workout they should be ashamed of themselves. Handicap parking permits are for handicapped people. The fines should be $1000 or more for people who abuse the system.

That means if you are driving around in your grandmother's car, which happens to have a handicap parking permit and your grandmother ain't with you, you have no business parking in a handicap spot that someone actually needs. There is no excuse, ever, to park in a handicap spot if you don't require it, even if you have scammed your way into handicap parking permits for all your cars. 

Whomever you are convertible handicap parking permit perp, if you are abusing the system, you are taking away the independence of your grandmother.  You should be be ashamed of yourself (if you aren't handicapped).  If you are, sweet ride!

Update To My Standardized Order Sets, In Response To Criticism

This is an updated response to the criticisms I received (both online and off line) on my original call parameter standing order set for hospitalists.  I am a visual person.  I understand why reading tables would be easier than reading lots of words.  So I've converted my call parameters into very simply to apply tables. I understand nurses are very busy.  I don't want them to have more work to do.  I want my protocols to be make their lives easier.

I've verified with my lab exactly what the critical call parameters are and applied my protocols for what I would tell the nurse should I be called with those critical values.

Now, instead of wasting their time and mine by calling rigid critical lab values established by a rigid med staff process, I've created my own standardized intervention tables.  Instead of calling me and interrupting their work flow and mine, when the laboratory notifies the RN of a critical lab value, they can implement my therapies immediately.

And as a bonus, it reduces the number of verbal and telephone orders that I must give, which is a major safety initiative at Happy's Hospital.   A bonus for all.  Less for the RN to write.  Less for me to sign off. 

They don't even have to look up the lab values every day because the parameters I've included  only kick in at hospital defined critical values. I've even given them direction should they feel they need to call non critical lab values at 3 am. 

It's WIN-WIN-WIN for doctors, nurses and patients alike.  I think they're going to like it.  It can't get anymore simple than that.

• Standing Orders During Hospital Stay  for lab and therapies ordered by Hospitalist physician to remain in effect until 7am on ___________________ at which point all these orders shall be discontinued.
• Any hospital mandatory lab notifications should be directed to the ordering physician or physician on call for the ordering physician or as directed by their notification parameters except as indicated below for Hospitalist physicians.  If the lab in question was not ordered by the Hospitalist physician, these orders do not apply. 

• All values are in standard reported units as reported by the Hospital laboratory.
• 
  

 Instead of calling  lab values, please initiate the following call parameters and  electrolye administration orders:

LOW Potassium Level	Cr >1.9 OR On renal dialysis	Cr < 2 OR Not on renal dialysis
If potassium level is less than 2.6 then give:	40 meq KCl IV or PO and recheck potassium level one hours after dose is complete	40 meq KCl IV or PO every four hours for three doses only and recheck  potassium level one hour after last dose is complete.
If potassium level is less than 3.1 but greater than 2.5 give:	40 meq KCl IV or PO and recheck potassium level one hour after dose is complete.	40 meq KCl or PO every four hours for two doses only and recheck potassium level one hour after last dose is complete.
If potassium level is less than 3.6 but greater than 3 give:	It will be addressed during normal rounds.  Calling is not necessary.	It will be addressed during normal rounds.  Calling is not necessary.

LOW Magnesium Level	Action Plan
If magnesium level is less than 1.0 give:	4 grams of Magnesium IV over 4 hours and recheck level one hour after infusion.
If magnesium level is greater than 1	It will be addressed during rounds.  Calling is not necessary.

LOW Calcium Level	Is the Corrected Calcium level less than 6.5? (see below)	Is the ionized calcium level less than 1.1?	IV calcium administration
If calcium level is less than 6.5 calculate the corrected calcium  (next column)	NO:  Stop.  No nursing action is necessary. YES: Have lab run an ionized calcium level and go to the next column.	NO:  Stop.  No nursing action is necessary.  YES: Next Column	Give one gram of Calcium Chloride  IV and recheck ionized calcium level one hour after infusion. If the ionized calcium level is still less than 1.1, repeat one gram infusions of calcium chloride IV as necessary.
If calcium level is greater than or equal to  6.5, STOP.  It will be addressed during rounds.  Calling is not necessary.

calculation for corrected calcium = (0.8*(4-patient's albumin))+reported serum Ca)  

• If no albumin level is available, have lab run an albumin on the serum used to run the calcium.

LOW Phosphorus Level	IV Phosphorus administration
If phosphorus level is less than 1:	Give 10 mmol over six hours and recheck phosphorus level one hour after administration is complete.
If phosphorus level is greater than or equal to 1	No nursing action necessary.  It will be addressed during rounds. Calling is not necessary.

HIGH Serum Bicarbonate (HCO3)	Arterial blood gas	AGB Results
If greater than 39	ABG in last 72 hours? YES: no nursing action is necessary.  Calling HCO3 level is not necessary NO:  obtain a stat ABG	Respiratory Therapy to call any critical ABG results as necessary.
Less than 40 but greater than 30, no nursing action is necessary.  It will be addressed during rounds.

• Instead of calling, please initiate the following hematological call parameters and action plans.

LOW Platelet Count	Evidence of active bleeding? (see below)	No Evidence of bleeding?
Greater than 50K but less than 100K, no nursing action is necessary.  It will be addressed during rounds.
Less than or equal to 50,000 but greater than 20,000	Call to notify	No nursing action is necessary.  It will be addressed during rounds.
20,000 or less	Call to notify	Transfuse one single donor pack of platelets and recheck platelet level one hour after tranfusion is complete.  Call if platelet count is still less than 20K

Active Bleeding includes brain hemorrhage, gross hematuria, active upper or lower gastrointestinal bleeding, muscular hematoma, retroperitoneal bleed, post operative bleeding.

LOW Hemoglobin level	Post operative surgical patient?	Evidence of  active  bleeding (see above)	No Evidence of active bleeding (see above)
Less than 8.1	Yes:  Call surgeon for recommendations No:  Next column	Yes:  Follow hand written call and  transfusion parameters.  If no parameters have been written, then call to clarify No:  Next column	If hemoglobin is greater than 7 but less than 8.1, repeat hemoglobin in six hours (times one) If repeat hemoglobin is less than 7.1 transfuse 2 units packed red blood cells and recheck hemoglobin one hour after transfusion is complete.

Greater than 8

If the patient is a surgical patient, call the surgeon if you feel the hemoglobin should be called.  Otherwise, only call hospitalist if the drop represents a greater than 2 gram drop from most recent prior hemoglobin draw.  If no prior hemoglobin has been drawn, order one time draw for six hours after first draw and follow call parameters.

Anticoagulation (PT INR testing value)	Active Bleeding	No Active Bleeding
3-4.9	Call	Hold warfarin.  Calling is not necessary
5-9	Call	Hold warfarin.  Give 2.5 mg of vitamin K enterally (PO or feeding tube).  If patient cannot take enteral vitamin K, give 0.5 mg of vitamin K  by intravenous piggyback. Calling INR is not necessary.  Re check INR in 12 hours.
Greater than 9	Call	Hold warfarin.  Give 10 mg vitamin K enterally (PO or feeding tube).  If patient cannot take enteral vitamin K, give 2 mg vitamin K by intravenous piggyback and recheck INR 12 hours after vitamin K has been administered.  Calling INR is not necessary.

• Disregard any standing orders from other physician order sets to call Hospitalist for urine output parameters and use  my urine output call parameters below.

• Low URINE OUTPUT Management (Excluding Intensive Care Units)

Do you feel you need to call low urine output?	Is the patient's heart rate greater than 99 or systolic blood pressure less than 96mm HG	Does the patient have a serum creatinine drawn in the last 24 hours?	Is the serum creatinine greater than 1.4?	Is the repeat Creatinine greater than 1.7?
YES:  Next column	YES:  Call NO:  Next Column	YES:  Next Column NO:  Draw a Cr and wait for results, then go to the next column	YES:  No action necessary. Calling low urine output is not necessary NO:  Give 500 cc NS IVC over three hours and draw a serum creatinine one hour after infusion is complete. Then  Go to next column	YES:  Call NO:  No action necessary.  Calling low urine output is not necessary.

• If home medications have not been addressed by 10 pm, they shall be addressed by the day shift hospitalist the following day starting after 7am.  Please do not call to address home medications after 10 pm.
• Please do not call to obtain a DNR order.  If the patient wishes to be DNR, notify the physician during rounds the following day for an order.  If the patient becomes critically ill before then, contact the physician at that time for a DNR order.
• If the patient has an admitting diagnosis of sepsis, severe sepsis or septic shock, please do not call a positive sepsis screens to Hospitalist. 
• If you are calling to notify the physician of positive blood cultures, please have the patient's antibiotic regimen available.  If the infectious disease physician is managing the patient's infection issues, contact them for any necessary positive culture notifications, or per their call parameters.  In that case, please do not call the Hospitalist. 

Health Insurance For $2 a Year. Rwanda Has An All You Can Eat Health Care Buffet

Yes folks, it's possible.  Where can you get health insurance for $2 a year?  Rwanda.  Here's why the economics add up

• The average life expectancy is 52 years old (not much room for heart disease, stroke, cancer, diabetes, dementia, osteoarthritis and all the other conditions that are endemic in western society).  Their most common causes of death are pneumonia, diarrhea, malaria and malnutrition, not exactly the most expensive conditions to treat.  And not exactly chronic either.  Chronic disease is expensive.  If you don't have chronic disease, it doesn't have to be expensive.
• You won't find brand name drugs.  Everything is generic.  They had better be for $2 a year.
• Radiology scans are rare. I mean, you can't get radiology scans.
• Don't even think about getting dialysis.
• If you're fat, you aren't from Rwanda
• Free doctors travel into Rwanda to offer their services.
• There's one neurosurgeon and three cardiologists in the entire nation of just under 10 million people.  See point number one.  If you don't need them, you don't have to pay them.
• The maternity ward has labor rooms without running water.  But they do have a mosquito net.  If you don't have to install flat screen televisions, you don't have to pay for it.
• The government can't provide what it wants for $2 a year.  Total health expenditures in Rwanda are around 300 million dollars a year, half of which is donated by charity organizations.

I'm sure Happy's hospital generates revenue more than double that in just one year.  But even with all the stripped down offerings of a $2 a year insurance plan, even the people of Rwanda are not immune to FREE=MORE. 

Just wait until they get flat screen television. They're going to hate paying $100 a year.  At least for now, Rwanda has an all you can eat health care buffet for just $2 a year.  It's no wonder why everyone is so skinny.  And if they can't pay their $2 a year?  You guessed it.  Alternative medicine.

Nice. But in America we put the Rwandans to shame.  We have everything in the world you could possibly imagine.  And you don't even have to pay your $2.  You just go to any American emergency department in this country and your care is free.  And they'll even throw in a flat screen television for your viewing entertainment. 

I think anyone who is seen in an American ER should be mandated to watch a video on what it's like to visit an ER or hospital in Rwanda.  Maybe some of them will feel so bad, they'll sign out AMA.

Does Farting In the O.R. Increase Risk Of Post Operative Wound Infections?

The emergency room is always full of good humor.  Take for example this middle of the night discussion with one of Happy's friendly neighborhood ER docs.

ER doc:  Did you hear the one about Dr Smith farting in front of a patient?

Happy:  No. 

ER doc: So Dr Smith had this patient that always came in just to talk.  A really anxious woman, she always felt better when she left.   She's completely deaf, but reads lips really well.  Dr Smith had her in his office one day when he realized he had to fart.  He figured she wouldn't be able to hear it so he just let one go.  A big fart right in front of her.

Happy:  LOL

Er doc:  After about a minute or so, the woman starts sniffing in the air wondering what's going on.  She said, "Doc, do you smell that?  Something smells really funny"  And that's when Dr Smith, realized that while she couldn't hear anything, her smell was in fact,  still intact. 

Happy:  Did he document olfactory nerve  intact and bump his visit to a 99244?

Have you ever farted in front of a patient?  I can't say I have.  I've had plenty of patients fart in front of me.  And they're always embarrassed when they do. I pass gas in front of Mrs Happy all the time. Sorry honey.  That's what men do.

What if you're a surgeon?  Does farting in the operating room break sterile field?  Does just the smell of fart in the operating room place the patient at risk of post operative wound infections? 

To answer that pressing question, they could do a study and  call it the F.A.R.T. Trial:  A Randomized  Controlled Trial To Compare Rates Of Post Operative Wound Infections In  Flatus After Removing Tissue.

Now that sounds like a trial acronym only a cardiologist could come up with.

Disruptive Physician Policy At Your Hospital? You'd Be Surprised What Is Considered Disruptive.

I recently learned about the disruptive physician policy in force for most hospitals across this country. I recently applied for hospital privileges at another hospital in search of other  internal medicine opportunities.  The physician credentialing software process was unbelievable.  Doctors were being delayed credentialing because they failed to notify the hospital of their ticket they received ten years earlier for fishing without a license.

As part of the large packet of information I received, I was to review the hospital's "Disruptive Conduct" policy.  Several years ago the Joint Commission established requirements for hospitals to have policies in place to deal with disruptive physicians and other providers of care. 

So it came as no surprise that the hospital for which I was applying for privileges made sure reviewed their disruptive physician conduct policy.  And what did I learn?   My jaw dropped when I read what the hospital considered disruptive.

1. Hostile , threatening, angry or aggressive confrontational voice or body language
2. Attacks (verbal or physical) that are meant to threaten, intimidate or harm (physically, emotionally, socially)
3. Inappropriate expressions of anger such as destruction of property or throwing items;
4. Abusive language or criticism directed at the recipient in such a way as to ridicule, humiliate, intimidate, undermine confidence, or belittle;
5. Criticism of employees, other Practitioners, the Hospital or other healthcare professionals in front of patient or patient's family, and
6. Writing of inapporpriate, critical or litigious comments/notes in the medical record.

Wow.  I'm shocked at the lengths this hospital bylaw has gone.   Angry body language?  Who says what's angry?  Undermining confidence?  Who's confidence? Silencing of criticism?  What if the criticism is justified and required for patient safety?

Some of the stuff makes sense.  Some doesn't.  This language is unbelievable.  I don't think a hospital can prevent a doctor from openly criticizing another employee or hospital policy in front of a patient, if what they say is the truth.  The truth prevails.  If the hospital or another doctor screwed up, the patient has every right to know about it.  If I was a patient, I would want to know.  

A physician has an obligation to speak the truth, no matter how many feelings are hurt.  No matter how critical they are of another's position.  Hiding behind a disruptive physician policy could even potentially increase hospital liablity.

Patient's Lawyer:  Doctor, why didn't you tell the patient they got a DVT because the surgeon refused to order anticoagulants

Doctor:  The hospital's disruptive conduct policy specifically states "criticism of employees, other practitioners, the Hospital or other health care professionals in front of patient or patient's family" is considered disruptive.  Furthermore, hospital policy states I will be considered a disruptive physician if I write "critical comments in the medical chart", even if I'm right.

Lawyer:  I see.

Hospital Lawyer:  No comment.

When I tell a patient they are morbidly obese and they meet every medical criteria for morbid obesity and life threatening obesity, I could be perceived as disruptive.  When I document in the chart I disagree with a surgeon's choice of VTE prophylaxis and recommend a different course of action, I could be considered a disruptive physician.  When I tell a nurse not to call me  about X or Y, when they have an order not to call me about X or Y,  because it interferes with my work flow on other patient care issues, I could be considered a physician with disruptive conduct.  

This whole disruptive conduct  thing got me thinking.  I hope my call parameter standing order for hospitalists  doesn't label me as a disruptive physician.  That would be a shame.  Because patients win.  Protocols work.  And standardization of systems processes save lives.

Hungry Baby Bird Pictures From My Backyard

I thought it was a little late in the year for baby robin birds.  But I guess I was wrong.  The other day I let Cooper, our Italian greyhound, out in the backyard and a robin started dive bombing him.  He was scared to death and wanted back into the house. Later on I found a dead baby robin bird in our yard.

It seems mama bird must have still been trying to protect her baby.  I'm not sure why it died.  Perhaps Cooper got hold of it earlier in the day.  I've seen him once before get hold of a bird and he tried to tear the wings off it. He played with it just like a squeaker.  I think he's a hunter at heart. In fact, squeaker toys probably represent something quite similar to birds.

I thought  having a dead baby bird in our backyard was kind of strange this time of year,  so I went to the tree where we have a nest and where multiple birds were hatched earlier this spring and wouldn't you know it.  Packed full of new baby birds.  Round two.  I did not realize nests were recycled in the same year.

I also found one bird that had escaped from the nest and was running around in our back yard.  While picking weeds from my garden, this  bird below thought I was going to feed it.  And that's when it opened its beak to be fed.  I could see mama bird sitting on the fence, with a worm, waiting for me to get the heck out of there.

A face only a mother could love.

Medicare Doomsday Politics Set In Stone For November 30th, 2010

UPDDATE June 18th, 2010 at 6 PM EDT:  Medicare Cut Reversed, Once Again For Six Months,  Doomsday set for November 30th, 2010

 I had just finished writing a post yesterday about the 21% Medicare cut going through on June 18th, 2010,  when the Senate responded with a six month delay.   The Senate has approved legislation that will reverse the 21% Medicare cut implemented on  claims since June 1st, 2010 and claims which Medicare carriers began processing hours before the Senate action was announced, with the the 21% cut intact.  What are the guts of the Senate deal from late today?

• The Medicare cut will only be delayed six months, now expiring on November 30th, 2010.  After that, SGR economics kick in once again. Unless SGR economics is repealed, doctors face a 33% Medicare cut by 2012.
• The current 21% cut will be replaced with a raise of 2.2% through November 30th, 2010, retroactive to June 1st, 2010.
• Because the House still must  vote on the proposal next week, Medicare carriers have been instructed to process claims currently on hold  since June 1st, 2010 with the 21% cut intact.  That means your cash flow could be significantly affected, since the fixed costs of your business expect their payments in a timely fashioin.

What does this all mean?  It means assuming the House and Senate agree to these principles, November 30th, 2010 is Medicare dooms day for America's seniors and doctors alike.  By then, the economy will be deep in a deflationary slide of epic proportions.   A massive deflationary depression will be well on its way to turning our lives upside down.  And it's only going to get worse.  Much worse.

A massive American uprising will be well on its way to demand a reduction in deficit spending.  A contagion of European austerity measures will be full steam ahead on our mainland with the tea party politics (and teabonics)leading the charge. State, counties and cities  will begin defaulting on their bond obligations and  their daily cash flow operations and funding of future pension contributions will be severely threatened.

And nobody is going to want to pay billions of dollars to give doctors a raise.  Just the thought of spending multiple billions of dollars to fix a doctor formula that was always broken will invoke rage in the populace.  Our economy is heading into the crapper, once again.   Correction, it was never out of the crapper.  Nothing has changed.  We've spent trillions of dollars of stimulus and received nothing but a guarantee of devalued dollars or gasp, debt default.

The writing is on the wall.  Look at how hard it was to get a 21% cut reversed for just six months.  It took a last ditch effort on the last hour of crisis, and they failed to prevent Medicare carriers from processing current claims at the 21% reduction.  By 2012 the cut, as stated in SGR rules, will be 33%.  That's 33%.

At 50% overhead, that means any doctor currently earning 200,000 a year will earn just $66,000 for a 60 hour work week.  That's $20 an hour for your doctor to care for you.  And no benefits.  I made more than that delivering pizzas, and at least Obama will guarantee me free health care while I deliver pizzas.

I don't work (as a physician) for $20 an hour.   I'm sure just about every doctor in the country could comfortably say the same thing.

Doctors.  You had better prepare yourself for what's coming.  November 30th, 2010 is going to be the day that American health care imploded.   It will be the day of reckoning that destroys Obama Care and everything it tried to stand for.   We have no friends in Congress.  Our patients don't care as long as they have someone to care for them.

Perhaps this is exactly what needs to happen.  Perhaps it is economic destiny.

Medicare doomsday is November 30th, 2010.  Merry Christmas to ya (in advance).

Drug Screen Tests Positive For Amphetamine. You're Fired! But Doctor, I Didn't Take Meth

What do you do if you're a patient and your drug screen tests positive for amphetamines?  You swear up and down you've never even seen meth.  You don't know how to make meth.  You don't know how to snort it or melt it.  You've never even seen it.  What do you do if your doctor sends you a fire my patient letter.  Here's one reader's experience.

I had been with my doctor for 17 years. She also treated my wife and mother. I went in for lab work to recheck cholesterol, sugar and urine tox because I was prescribed Norco for chronic back pain after a drunken teen hit me while  I was crossing a driveway. I have had numerous drug screens that I willingly submitted to but this time she called me and said that I was positive for amphetamine.  I've never taken it in my life. What's worse she let me go from her practice and wouldn't let me submit for a hair test in a month from the urine tox (in order to let it grow above the scalp). I knew it was worthless to repeat urine because of clearance. Now, the urine was sent for GC-MS (gas chromatagraphy mass-spectrometry) and it was still positive. Now I appear as a substance abuser when I'm not. I cannot explain why it is in my urine but I believe a hair test is my only way to gain my new doctor's trust because the trust has to run both ways. I can definitely see the doctor's point of view but I've never even smoked pot and I'm 44! Any advice on how to approach this with the new primary care doc? I want to be honest and have everybody's hands on the table. Suggestions?

Man.  GC-MS.  I haven't heard tha abreviation for 15 years since I worked on my undergraduate chemistry degree. At Happy's hospital, If I have any suspicion of drugs of abuse, recreational or prescription, I usually order a urine drugs of abuse screen. But I also understand there are many drugs and even non pharmaceuticals that can interact with the drug screen assay to give a false positive screen.  I've seen the list.  It's pretty extensive. 

For many doctors, taking care of patients on chronic narcotics can be a complicated process.  When I confront folks on really high doses of oral narcotics requesting intravenous name brand narcotics by name, I tell them they are physiologically addicted and  have built up an exceptional tolerance  as witnessed by higher and higher titrated doses of ineffective medication.  I tell them quick acting intravenous medication is not the solution to their problem.  It's a major part of their problem.    I recommend they seek drug counseling and psychiatric assistance as narcotic dependence often involves comorbid psychiatric depression or other supratentorial disease processes.  Pain and the perception of pain is a highly emotional process.   What causes intense pain for some causes no response from others.  The solution is often multi modal in approach not simply more narcotics.

And frequently I'm told to get lost.  Occasionally I have patients who respond well.  I once had a patient send me a thank you letter for me playing hard ball and making them face their addiction head on.   But I've also had patients file complaints for not playing their manipulative games.

In your case, once the trust between you and the physician is lost, neither you nor the physician can continue  effectively in a broken doctor patient relationship.  It's time to move on.

Being open and honest is all you can do from a patient perspective to try and gain the trust of another physician.  Even if you're right and the physician is wrong, if the trust is gone, there is no sense in trying to hang on.  As long as the state and federal governments require licensed physicians to prescribe your narcotic pain medications, you are at the whim of their decision.  If they don't want to deal with you anymore or don't want to take you on as a patient, you have no recourse.

Physicians can't be forced to see you any more than you can be forced to see them.  The relationship is a volunteered relationship.  I personally believe that patients should be able to get all their own medications as they see fit without a physician prescription. If you can get a paternity test without a physician order, why can't you get your own medication as well?  

We have an epidemic of addicted patients despite the highly controlled nature of narcotic medications.  Deregulating them will only make them cheaper and more accessible by people who actually need them.  Those who are addicted will continue to be addicted until they seek treatment.  If they are going to overdose, they will do it whether they need a prescription or not. I suspect suffering would decrease as a whole, not increase if narcotic pain medications were made available over the counter. Addiction will continue to require treatment whether pills are freely available, obtained in the black market or under tight regulation.

By the way if you have good paying third party insurance, you probably won't have any problem finding a new doctor.  If your drug screen tests positive for meth and it's a false positive, the real problem you should concern yourself with is nixing the false positive drug screen from your report.  Who knows, it might come back to haunt you in the future (applications, licensure, jobs).  Just look at how out of control physician credentialing software has become, where failing to document that you got a ticket for fishing without a license means you're hiding something much more sinister.

By the way, most offices have to give you a reasonable time (usually defined as 30 days) to find another doctor.  I suppose you could have had her pluck some hair on day 29.