Groupon Coupon: $5 Free For Signing Up Through Happy Hospitalist

I got an email today from Groupons.  In case you've never heard of Groupons, they are a site that will give you 50%-90% off local deals in over 200 cities across America.  In fact, word on the street is Google will make a multi billion dolllar offer to buy them soon.  I've purchase over $100 worth of food and services from them.  It's a great site.  In fact, it's fantastic. 

The email today offered anyone who signs up for Groupons  using my referral ID an opportunity to get their first $5 free.  Using Groupon.com is easy.  Sign up with the city of your choice.  Every day they'll send you a new local deal.  If enough people purchase a deal, it activates and you get extreme discounts on food and products you enjoy. You can pick an choose which deals you want and pass over the ones you aren't interested.  You never have an obligation to buy anything, but you'll want to take advantage of frequent deals from popular restaurants and businesses in your local area.

Once you join, if you refer people to sign up too, you get $10 for every referral as well.  It's great.  I've never spent a dime of my own money and have over $180 built up.   If you have lots of friends and family, you could live on free Groupon money for months.  And you can give them away as gifts.  It is revolutionizing retail.

Join Groupon today.  Get your free $5 and then get great deals and more free Groupon cash by referring others.  If you don't want to sign up through my referral, you won't get your $5.  But join it anyway.  'Cause you're missing out.

(You must sign up by 12/07/10 and subscribe to their daily email alert from the city of your choice (which you'll want to).  After you make your first purchase, you'll get a $5 credit toward your next Groupon).  

The State of Hospital Care in America.

Looking for a great story about the state of hospital care in America?   Look no further.  The Health Care Blog has a great article by hospitalist Dr Wachter that sums it up nicely.  It's about money.  Thats how how hospitals get paid.  That's how everyone gets paid.   It will always be about money.  We don't pay doctors, nurses, or administrators with smiley faces and candy canes.   We pay them with cold hard cash.  For example:

The question should not be how do you get profit out of medicine.  The question should be how do you get quality into profit.  We need profit.  The last thing you want in this country is universal VA health care.  Trust me on that.  Americans would never stand for it.

But how do you get both?  Everyone will define quality differently.  The only definition of quality that matters is the definition used by the one with the money.  If you're accepting third party insurance money, their definition is all that matters.  If you are a patient and you want quality care defined by your value system, you'll have to pay for it out of your own pocket.

Now,  If you have the money and influence, you can get the quality you want.  If you're poor, the quality you get is the quality that your insurance pays for.   You're going to have to live with that.  It's always going to be like that until the end of time.

I'm Heading To The Rockies This Week

To check out Grand Rounds from the great state of Colorado.    You should too.  Just don't break a leg.  All the orthopaedic surgeons are vacationing at the beach. 

Apologizing To Your Doctor: Patients Acting Badly.

I'm not sure if it's the holiday spirit or if Americans are just becoming nicer during the greatest recession in over 50 years,  but I've had two patients apologize to me in this month alone for acting badly. That never happens.  Patients never apologize.  

The first case involved a gentleman who was sent 200 miles "to see a surgeon because my gallbladder hurts".  I told him he didn't need a surgeon until the work up was complete.  I take that back.  He didn't need a surgeon until a work up was done.  The guy had pain and was sent in to see a surgeon because the surgeon in their town was on vacation and the patient was having pain and the nurse practitioner promised the patient they would see a surgeon to take care of the problem.  After yelling at me for 15 minutes straight:

Patient:  Why the Hell did I drive 200 miles to see you instead of a surgeon? 

Happy:  Well, sir.  I admit people every day who are told things that simply aren't true.  This is a case in point.  If you need a surgeon, I'll call a surgeon.  I'm not going to waste their time or yours until I know you need one. 

Turns out the patient didn't need a surgeon.  They needed a hospitalist.  The next day he apologized to me for his actions.  I think he genuinely felt bad

Patient:  Dr Happy, I'm sorry for the way I acted yesterday.

Happy:  Don't worry about it.  Being sick can be frustrating.  I get yelled at by patients all the time.  I don't ever take it personally. You don't have to apologize.  I've already forgotten all about it. 

Patient:  Thanks doc.  

Happy:  No problem. Sorry about your driving 200 miles for nothing.   Do you want to go home?

Patient:  I'd love to.  

I got yelled at later in the week by a woman whom I told probably had cancer, but we were waiting for the finaly pathology results.

Patient:  I came in here with abdominal pain  and now you're telling me I might have lung cancer?

Happy:  Yes.  The biopsy from your bronchoscopy  is concerning for cancer.  I've discussed things with the pathologist but they are waiting for some final stains.  It is concerning though.

Patient:  Sh*t.  So do I or do I not have cancer?  What the H*ll are you talking about?

Happy:  Again.  I'm concerned this is cancer but I'm waiting for a final tissue diagnosis so I can help decide what to do next.

Patient:  What kind of answer is that?

Happy:  That's the best I can do for now.  

The next day I was surprised to get an apology from the lady;

Patient:  I'm sorry for yelling at you yesterday. 

Happy:  It's nothing to worry about.  It's never an easy conversation to have.  I'm not the least bit offended.

Patient:  Well, I am.  I shouldn't have acted that way and I'm sorry.

Happy:  It's really nothing, really.  I've already forgotten about it. 

Patients often yell at their doctors and nurses out of frustration.  It comes with the territory.  I don't get offended.  I don't even really care if they write bad reviews about me.  Being sick just plain sucks. But it's nice to know that some patients actually have the strength to apologize for their actions when they know they've acted badly.  That's the right thing to do.  But I won't judge them if they don't.   They've already got enough to worry about.  As a nurse or doctor, have you ever had a patient apologize to you?

Commerical Door Stops (Picture): Hospital Grade Quality on the Cheap

If you're looking for commercial door stops with hospital grade quality, look no further.  Happy's hospital has the solution for you.  Here's a picture of how Happy's hospital has implemented commercial door stop technology to prop open their fire doors. Or I think it's a fire door.  I can't tell.  Don't tell the fire marshal.  We might have to abandon our door stoppers on the cheap. 

As you can see, they're secure, lightweight and highly functional. These commercial grade door stops aren't going to let you down.  Perhaps, we could save even more money by getting a few of the uninsured patients to volunteer instead of buying mannequins to use as door stoppers.

Now that's what you call using your head.

Hairdresser Smoking? What Would You Do? Take the Poll and Be Heard.

So I got my haircut the other day by a smoking hairdresser.   It was a heck of a haircut.  Just check out my haircut before and after pictures.  The only problem was that the lady cutting my hair was a smoker.  She wasn't actively smoking, of course, but every time she moved her right hand in front of my face to cut my hair, I got a giant whiff of third hand cigarette smoke. 

A recent World Health Organization study reported that 600,000  people died in 2004 (1 of every 100 deaths) from exposure to second hand smoke.  I can't even imagine how many more folks die every year from exposure to third hand smoke. 

So I'm sitting there getting my haircut from the hairdresser.  Every time the hairdresser passed her hand in front of my face, I felt like I was going to have an asthma attack.  After about five minutes of unbearable smoke stench, I started up a conversation.

Happy:  Are you a smoker?
Smoking Hairdresser:  Long pause.  Low shameful voice.  Yes.
Happy:  I can smell it on your hands.
Smoking Hairdresser:  I apologize.  We've been really busy.  Usually I have time to clean up after coming back inside from a smoke break but I was too busy this time.
Happy:  Have you ever had anyone file a complaint against you because of your smoking and exposing your clientele to third hand smoke?
Smoking Hairdresser:  No.  I haven't.
Happy:  I work in a hospital.    So I smell that sticky smoke smell all day long. When I try to get rid of smoking smell in the hospital I usually put on a surgical mask.  Do you have any here? 
Smoking Hairdresser:  No, we're fresh out.   
Happy:  I wouldn't be walking the walk if I didn't ask you, "Did you know smoking is bad for you?"
Smoking Hairdresser:  I've heard that once or twice.
Happy:  Just kidding.  I know you know.  It's just that most folks who come in here are nonsmokers and some have heart and lung conditions that could be set off with the smell of smoke.  If you want to quit smoking right now, there are options available.
Smoking Hairdresser.  I'm good.  Thanks though.
Happy:  It's probably a good idea that we stop having this conversation, since you're the one with the scissors in my scalp, right?
Smoking Hairdresser:  Laughing. 

I think I made my point loud and clear.  I think most businesses would agree their employees should be free of smoke smell especially the ones that come into close contact with their paying customers. Hopefully, I mentally  shook this smoking hairdresser enough to make her think twice about smoking at work and not cleaning up again. 

Most of her clientele will be nonsmokers. The next time I go into this hair cutting joint I'm going to specifically ask for a nonsmoker. That's who will get my tip.   Like I discussed in my doctor's waiting room,  TIPS are To Insure Proper Service.  I contemplated not giving this smoker a tip.  In the end, I gave this smoker a tip because she was a good sport about the whole conversation.  I thought about telling her not to spend it in cigarettes, but I didn't.  I figured that was a lost cause.  The next time, it's going to be a nonsmoker that gets my tip.  

As a nonsmoker in search of a haircut, what would you do if you were seated by a smoking hairdresser?  Take the poll today.

Pain In the Butt Patient: I've Waited Seven Years For This.

Seven years as a hospitalist  I've waited for this pain in the butt patient.  Chief complaint?  Bilateral buttock pain. No back pain.  No leg pain.  Just both butt cheeks were hurting.

ER Charge Nurse:  Dr Happy.  What's your admitting diagnosis?

Happy:  Pain in the butt.

ER Charge Nurse:  Seriously.  What's your admitting diagnosis?

Happy:  Seriously.  Pain in the butt.

ER Charge Nurse:  OK then.

I've had many patients who were a pain in the butt.  But this is my  first ever patient who was literally a pain in the butt. I wrote my admitting diagnosis as "Pain in the butt", billed a high level hospital admission code 99223 (RVU explained through a  99223) and moved on to the next patient.

Patient Relationships In the Hospital: Sometimes It's Better Not To Know.

Sometimes it's better not to know what kind of relationship your patient is in with other people family members in the hospital.  Often times, us physicians can figure it out.  If you have an old man as your patient and there is an old woman sitting next to him, you can usually assume it is his wife.    Just to break the ice I will often enter a room and introduce myself to the male patient and then look at his elderly wife sitting next to him and then ask the patient:

Is that your daughter sitting there?

I've had an assortment of responses over the years from the men

Yeah right. 

 is a common response. 

I've had a few ask me

Are you blind?

One guy even said

I bought her off the Internet for half price.

Most of the ladies aren't expecting Happy's charm.    A few take it as a compliment.  Most laugh it off as being silly.    For me, the worst part is when I confuse a daughter for the wife or mother.  There  ain't gettin' out of that one.

Sometimes, even I'm surprised at how patients describe their own relationship with their loved ones.  I once had the funniest response that I wasn't expecting.  It was a guy in the depths of decompensated heart failure with a full breathing mask and looking quite uncomfortable.  The woman in the room was answering most of the questions.  I thought it was his wife.  So I asked her

Happy:  What is your relationship with the patient?
Woman:  I'm not  sure. 

She looked at him.  He looked at me.  I could tell he just wanted me to intubate him right then and there and put him out of his misery.   Just one word of advice to all the future patients out there.  If you're going to sleep with someone, make sure they like you when it's time for them to give informed consent to all the doctors and nurses trying to save your life.    When you want to be intubated to avoid conflict in a relationship, that's when you know a little counseling may be necessary to patch things up. 

How Hospitals Get Paid By Medicare Simply Explained.

Have you ever wondered how hospitals get paid by Medicare?  The New York Times has  and simplified explanation of this highly complicated process.  It's simple really.  First the hospital labor component is adjusted for geographic location and then added to the capital depreciation expenditures adjusted for geographic location and then a medical severity adjusted diagnosis related group multiplier is added (MS-DRG).

Once this adjusted payment rate is calculated, the hospital is given a bonus to cover the costs incurred if they are a teaching hospital, through the indirect medical education payment.  Added to that is the disproportionate share payment for hospitals that see a lot of uninsured or Medicaid patients  (strange that Medicare subsidizes Medicaid, isn't it?).  If you have a patient that is extremely sick or spends mulitple extra days in the hospital, they may get an extra outlier payment.

I might also add that somewhere in all that mess the the NYTs left out that hospitals get  several percentage points of bonus or reduction in payments based on performance in quality indicators that the government has determined are important.

And that's how hospitals get paid by Medicare.  It doesn't get any easier that that.  Are you wondering how physicians get paid by Medicare?  It's all calculated through a completely separate process of calculating relative value units (RVUs).  Here is my post about how doctors get paid by Medicare.    

All this sounds fair and great in theory, but there is one problem with the whole government price fixing mantra.  They don't want to pay for what they've entitled the masses to believe they deserve.  This is exactly why Europe is crashing and burning. When you start by promising everything, you end by paying for nothing.

Chiropractic Quotes: Good Home Grown Grandmother Humor

Looking for a funny chiropractic quote? Look no further. I'm talking with my grandma the other day. She's talking about this and that and somehow she starts talking about a relative that is going to go see the chiropractor.

Grandma: Randy has an appointment to see the choirpractor for his back pain.

Happy: The choirpractor? Do they sing show tunes to you while they snap your back in half?

Grandma: Dumb ass. How do you say it?

Happy: It's pronounced chi-ro-prac-tor. Unless you want someone to sing a tune to you while you're getting your back worked on. Then you go to the choirpractor.

That's just a funny chiropractic quote all around.  You can visit Happy's other posts about chiropractors below. 

• Chiropracter vs Primary Care RVU Analysis
• Back Pain Solutions
• Chiropractic Back Pain
• Chiropractic Marketing at Trade Shows

Black Friday Shopping Funny Picture: Surviving Black Friday With a Baby Stroller

Mrs Happy and I took in a little early afternoon Black Friday shopping  where I bought a The North Face Men's Galaxy Triclimate Jacket when I snapped a picture of this baby stroller being carted through  the check out line  by an eager holiday shopper.  It looks like she left the kids at home and for good reason.  She'd have no where to place the baby. 

That's a pretty clever way of surviving the Black Friday shopping madness.  I'm thinking about maybe extrapolating this helpful hint into the hospital to earn a little extra cash as a hospitalist.  You know, it's all about hospital amenities these days.  I figure I should just go with the flow.    I'll push around a baby stroller full of $2 candy bars and and $5 packs of Camel crush cigarettes while I talk to my patients about their need to quit smoking now and their immediate weight loss options.  There might even be a few hundred  nurses  that partake in the action.

Something tells me I may be on to something.  I might even get really good patient satisfaction survey and guarantee a steady flow of patients bouncing back day after day, year after year. 

Worst Social History Ever

This has to be the worst social history ever.  Everyone knows that in order to get paid under the evaluation and management rules (E/M medical coding) of the Medicare National Bank, the more nonsense information you obtain, the more you get paid.  Does it meet Medicare medical necessity?  Of course it does.  It always does.  If you want to make sure you can collect the charge for a 99223 (here's a secondary look at 99223) instead of a 99221 and not be accused of fraud, you have to make sure you have a social history component. 

So what do you do for your history and physical examination documentation for hospital admission dictations?  You write something, anything, just to meet the compononent requirements for the E/M, even if you think it has no bearing on the care plan going forward.  There is nothing anywhere that clarifies when a social history is not indicated.  It will always be indicated.  And to get paid, you have to include it.  That's why doctors document it.  I would much rather just move on to more important things when social history doesn't matter.  But the Medicare National Bank makes it matter, every time.

That's the way E/M roles.  So what did the worst social history ever look like?  It was done by an APRN in a small town out yonder.

Patient presents with her daughter.

I don't know what they're teaching in nursing school these days or if taking a social history is even  a nursing education requirement.  It's obviously not an APRN requirement. 

That's not even a social history.  That's an observation.  It's not even history.  It describes the present.  If you want to make it appear like you at least applied some effort, say that the patient was drinking or smoking with her daughter.  Now that's a social history worth documenting, if there is such a thing.

What's the worst thing you've ever seen documented for social history?

Thanksgiving In The Hospital? Time to Hunker Down. You're Here For the Weekend.

Are you spending Thanksgiving in the hospital?  If you were a patient of Happy's hospitalists, thirty twenty-nine (out of 60)  of you got discharged yesterday, the day before Thanksgiving to eat your holiday Thanksgiving meal at home, instead of hospital food.  It could have been 30, but the son of one patient "wasn't ready" setting up the home for pappy to come home.  

That's got to be close to a record.  If you're a patient, you should want to be discharged before spending Thanksgiving in the hospital.  Why?  Thanksgiving and Christmas are the two days of the year where community hospitals turn into de facto VA hospital systems.  Nothing happens on these major holiday weekends.   You could spend an entire weekend waiting to get your biopsy or waiting for a nursing home to staff one RN to accept you for transfer on Monday.  Holiday weekends are the king of inefficient hospital care.  Like I said, they become a de facto VA hospital. 

Spending Thanksgiving in the hospital is the last thing doctors want to do.  They, like everyone else, strive to be at home spending time with their family.   Look for more and more doctors who become employed to have contracts specifying paid holidays off.   It's the VA mentality in full effect.   In Happy's group, we have a rotating call schedule for Thanksgiving and Christmas.  Right now, I am in the middle of a seven day hospital rotation.  But I'm not working today.  A partner of mine is at the hospital seeing my patients.  

They've never seen any of my patients.  They are going to see them for one day.  Then I return tomorrow to take over.  They're just going to keep them alive.  It's a good thing I discharged 10 of my 15 patients yesterday so my patients don't have to spend Thanksgiving in the hospital.  Some of them may be back by the weekend with their partially treated end of life heart failure or COPD.  So what.  I can't control how much they choose to smoke or how much salty ham they decide to eat. Perhaps once bundled care arrives, it will have holiday exclusion clauses.  

My partners may come in at 4 am, round in the dead of night  before any family can show up and be gone by nine in the morning.  The only required in house hospitalist in Happy's group is the long call hospitalist who carries the code pager.  Everyone else is free to come and go as they please.  We got rid of our time clock last year. 

As for the subspecialists, many of them will be running around with their heads cut off.  Many of them utilize nurse practitioners and physician assistants, who have Thanksgiving Day off,  to take care of their daily pages, history and physical examination and discharge summary.  Many of them may reach their boiling point of frustration doing doctor stuff they do only two times a year.   I'm glad I'm not spending Thanksgiving in the hospital.  The doctors are just trying to get the heck out.  The nurses are operating on a skeleton staff and there are only two janitors cleaning 300 beds.

If you're a patient spending Thanksgiving in the hospital, just hunker down for the weekend and enjoy what VA patients experience everyday of their lives. If you have the opportunity to get out, take it.  Run walker like you've never run walker'd before.  But don't come back to the ER until Monday, 'cause nothin's gonna happen 'till then anyway.

To all the doctors, nurses,  and everyone else spending time in the hospital on Thanksgiving, thank you.  I'll probably be doing it next year.  Dr Wes once said it best.  You can tell who's really important in the hospital by asking yourself how many administrators show up for work on the weekends, or in this case show up for Thanksgiving in the hospital. What's 0 + 0? 

The Brain Is Amazing. Witness the Square Root Sign In Action

The brain is amazing. The more I do this hospitalist medicine gig, the more impressed I am with how complex upper motor neuron function can be.    I was taking care of an elderly 88 year old man who didn't know nothin'.  He didn't know what month it was.    He didn't know what year it was.  He didn't even know he was in the hospital.  The nurses were trying to get an IV in him.  Instead of doing my one question mini mental exam, I decided to kick it up a notch. 

Happy:  What's the square root of 16?

Old Man:  4?

Happy: What?

Old Man:  4.

Happy:  What's the square root of 25?

Old Man:  5.

Happy's shocked

Nurse:  He used to be an accountant.

Happy:  What's the square root of 144?

Old Man: 12
Happy: That's amazing.

The brain is amazing. And this guy is living proof.  Listen up doctors and nurses.  The next time you think your confused and demented old man doesn't have a clue, make sure you do Happy's square root sign before passing judgement as to their cognitive ability.  They might just surprise you.

If you're a student or a resident, it's time to tuck away Happy's other signs  in your diagnostic arsenal

• Handsome Sign
• Sleeping Husband sign
• O and Q sign
• Twenty sign
• MFer sign
• Texting in the ER sign
• Band-Aid sign
• Intact Humor Reflex sign
• Fibromyallergia sign
• Denture Stains sign
• How to find a lost cell phone in the hospital:  Happy's honesty sign
  
• And while you're at it, check out these funny homeless signs.

Medical Malpractice Attorney In the Family? That's Good, If You're a Doctor.

So I'm talking to a doctor friend of mine the other day when I find out his brother is a medical malpractice attorney.  I found myself thinking that has  got to be a little odd during the holidays.  How often do you have a doctor and lawyer, and a medical malpractice attorney at that, in the same family?  

I can only guess what Christmas is like.  The doctor is  telling all those  crazy doctor stories about patients who are awake and can't move  or other record clinical findings and other oddities while the medical malpractice lawyer brother is taking hidden audio and video of the whole going down.  

But seriously, I asked the doc what it's like to have a brother for a medical malpractice lawyer and he said, his brother and him have an agreement.  

My brother will never sue me on behalf of a client.  On the other hand,  his partners  have no problem suing me.

How about that.  A lawyer with a  sense of loyalty.  Family over justice.  I'm not sure if I should commend him or despise him.  If you're going to be a medical malpractice lawyer in search of truth and justice, shouldn't your client's justice come before loyalty to your family, if in fact medical malpractice was really about justice and not winning the jack pot?

This doctor is either going to be either really busy or have nothing to do.  If all the doctors on staff found out he had a medical malpractice attorney for a brother and that brother had agreed to never sue on behalf of any patient his brother is caring for, the other doctors will either never consult him out of spite or consult him on everything so the lawyer brother  never sues.

See, there's always a glass half full in the legal system.  If you are a medical malpractice attorney and your relative was a doctor who screwed up big time, would you not sue on behalf of your client out of family loyalty or would justice prevail and bring havoc to the Christmas cheer?

Smoking With Oxygen Is Safe. Just Don't Light Your Cigarette.

There's a reason why you shouldn't be smoking with oxygen near by.  Oxygen is highly flammable.  It can spark.  If your oxygen canisters ignite, you can blow up your home.  Happy's grandma told him a story about entering a friend's home one day. She noted they were both smokers carting their oxygen tanks around their home while smoking up a storm.  

Grandma:  What are you doing?   You're going to blow us all up.  Put that cigarette out while you're on oxygen. 

Grandma's friends:  Ah, don't worry about it.  We've been smoking with oxygen for years.  Nothing's going to happen.

Some people are just playing with fire.  Get out granny and don't ever go back.  I once had a patient who  smoked with oxygen nasal cannula flowing freely, but not any more.  Why did he quit smoking with oxygen? 

Happy:  Why did you stop smoking with oxygen on?

Really long bearded man:  I was smoking one day when all of the sudden my entire two foot beard went up in flames. 

Happy:  So why did you quit smoking with your oxygen on?  Didn't you know you it was dangerous to smoke with oxygen near by?

Really long bearded man:  Yeah, that's what they say.  I guess they were right. 

Happy:  How did you get your beard so long again

Really long bearded man:  Now I chew tobacco instead. 

At least his beard isn't going to go up in flames again.  So he's got that going for him.  Which is nice.  Some people quit smoking for good with free chantix.  For others to quit smoking right now, they need to literally go down up  in flames.

UPDATE:  Chantix lawsuits, here we come.  

Oldest Alcoholic Hepatitis Case Ever, I Think.

So I think I happened across the oldest case of alcoholic hepatitis ever.  He was 99 years old and loved his vodka.  He even admitted to a "little vodka every night".  He came in with a classic 2:1 AST:ALT ratio on his liver enzymes in a non obstructive pattern.   But it didn't click with me at the time.  He's  99 years old.  What kind of 99 year old gets alcoholic hepatitis?  It's unheard of.

In the course of his ER evaluation, he was found to have a markedly dilated common bile duct of 25 mm, despite his previous cholecystectomy.  With a little conservative management By doing nothing but observing him for a few days all his liver enzymes returned to normal.  

That's how you diagnose alcoholic hepatitis in a 99 year old.   Patients lie to their doctor,  even the 99 year olds.  So what.  You're my hero, old man.   Don't let anyone tell you differently.  Just make sure the social worker sends you to a vodka friendly nursing home where you might even meet my patient who was drunk at the nursing home. You guys can be roommates. 

You can discover more oddities of medicine by checking out my  record clinical findings. 

First Facebook Grand Rounds Ever

Go check out the first Facebook Grand Rounds ever.  Is this this future?

My Arms Are Fat: I'm Talking Arm Pannus Fat.

So I heard a crazy story in the halls the other day.  It was about a case of a lady with  very fat arms.   Not that having fat arms is funny, it's not.  But having arms fat enough that it causes a pannus that must be retracted for a blood gas is scary sad and actually, on a purely unprofessional level, quite funny.

Most people who become obese gather their weight in their mid section.  They may get a six pack beer belly. Sometimes they also gain extreme weight on their upper thorax as well, which can make placing central lines an impossible task. 

But people who earn the title of super morbid obesity gain fat on their extremities as well.   That makes obtaining a blood gas difficult, even for the most skilled respiratory therapists, especially those that  didn't get an online respiratory therapy degree. 

In the case of this one lady, I heard the nurses talking about how her arms were so obese they needed an extra person just to stand there and hold her arm pannus up while the blood gas was obtained.  

I wonder if the patient names her pannus like some people do.  Perhaps for nurses, arm pannus retractor duty is one of the core nursing education requirements, equivalent to the right of passage for third year medical students navigating their surgical rotation as retractor extraordinaire on those four hundred pound patients getting their elective AAAs repaired. 

Ah, to be a medical professional in the new American reality where everyone is obese and the super obese create daily havoc in hospitals everywhere.  And it's only getting worse. 

Oxygen For Comfort PRN? Why Do Nurses Do It?

Everyday I have to ask the question,

Why do nurses place patients on PRN oxygen when they aren't hypoxemic?

I asked a nurse today, who was precepting a nursing student, why she did it.  The patient was 95% on room air, but was placed on nasal cannula oxygen because the oxygen made them feel better. Having oxygen on made them less short of breath.

Perhaps an oxygen expert, a nurse, or a patient could explain to me the physiology about how going from 95% to 97% oxygen saturation would make a patient feel better.  There is no physiological basis for introducing such a therapy.  It's one of those unnecessary interventions that drive up the cost of health care and increase the risk of complications.

As a hospitalist and a physician, my problem when nurses place unnecessary oxygen on patients is that it offers no therapeutic value and makes for a difficult discharge disposition.  With that said, having nurses give PRN oxygen for comfort would be the same as me ordering a sugar pill to cure sinus rhythm.  No insurance company, including Medicare, will pay for oxygen or oxygen supplies unless the patient has documented oxygen saturations of less than 88%.  I suspect the Medicare National Bank uses the the oxygen dissociation curve as the rationale for their payment cut offs for oxygen.   At least there is a rationale behind it. 

Placing a patient on a couple liters of oxygen causes me great difficulty in trying to decide if the patient is stable for discharge or if they are even stable in their hospital admission.   I can only assume that patients on oxygen are hypoxemic.  But when nurses start willy nilly placing patients on oxygen for comfort, I can't figure out if they really need oxygen and if an evaluation for hypoxemia needs to be done, or if I can just get rid of it and discharge the patient.

Oxygen prn for comfort should never be in the nursing arsenal for patient care.  As with any medication, oxygen therapy can come with its own complications and it's not cheap.   Using prn oxygen for comfort is about as bad as having telemetry cardiac monitoring when it's not necessary.  Just stop it.  Stop it right now.  

Stop putting oxygen on patients who aren't hypoxemic.  There is no physiological reason to do.  Correct me if I'm wrong, but is placing unnecessary oxygen on patients a nursing education requirement handed down through generations of nursing students who repeat the cycle to infinity? 

Doctor's Waiting Room TIPS: How to Move to the Front of the Line

So you're tired of twiddling your thumbs in your doctor's waiting room?  You show up at eleven for an 11:00 am appointment only to sit in your doctor's waiting room for another 45 minutes?  Well, has Happy got a solution for you.

I had myself a little football party this weekend.  Imagine half the town trying to pick up hot wings all within a half hour period.  I called ahead for a   3:00 PM pick up and showed up at 2:50 for my wings.  The place was a mad house.  There were hundreds of people dining in and multiple people waiting in line to pick up their carry out orders.

Some guy was out of control.  He was yelling and screaming.

I had a 2:30 PM pick up and I've been waiting a half hour.  What's wrong with you people?

I looked at him and smiled.  He asked me what time my order pick up was and I told him 3PM. He said, 

Good luck, these people don't know what they're doing.

The nice lady behind the counter asked me for my name.  I gave it to her.  "Happy", I said.  She gave me the total, I paid with my Capital One credit card.  But I did something most people probably wouldn't.

I assessed the situation.  There were multiple parties waiting half an hour for their carry out orders.  It looked like everyone was upset and running late. I could tell the staff was flustered and upset as well.   So I left a $3 tip on a $30 order of hot wings.  

My aunt, a Vegas show girl in her day, used to tell me that you give tips to people To Insure Proper Service. And wouldn't you know it, the guy yelling and screaming that he was waiting 40 minutes now for his order stormed out of the restaurant without his wings and without paying.

Happy picked up his wings in eight minutes flat with a thank you and a smile on the folks just doing their job.  It looks like $3 moved Happy to the front of the line.  Sometimes a little gratitude gets you a long way.  In this case, all it took was three bucks.

If you're tired of waiting in line in your doctor's waiting room or the emergency room or in the hospital, it's time to start tipping your doctors and nurses.  You want your call light answered quicker?  Just leave a $20 bill on your hospital tray.  You want the hospitalist to get your admission paper work done faster?  Just leave an extra $100 bill

The future of health care is here.  Doctors now charge for phone calls, emails and filling out FMLA paper work.  And that's just the beginning.  If you want hospital amenities, you're going to have to pay for them.  Insurance will never provide you with the service you expect. You can try the concierge medicine model.  However, if you aren't ready for that and you want to stop waiting in your doctor's waiting room, it's time to start tipping them to ensure proper service.

What are you waiting for?  Happy accepts cash, credit  and local checks with driver's license only.  And there is a $40 returned check charge (in addition to any bank fees you may get dinged with).

Plastic Surgeon Sues Patient For Bad Online Physician Review: The Lawyer Says Her Boobs Look Awful

If you're a patient and you're not happy with the work your doctor or surgeon does and you leave a bad review on one of those online physician  review sites, be prepared to get sued.  Chicago plastic surgeon Dr Jay Pensler has filed a defamation lawsuit against three women who left anonymous reviews on online medical doctor review sites (Yelp and Citysearch).

Here's my thought.   First of all, online medical review sites are a one way street for patients.  With anonymous reviews, doctors, even if they know which patient the anonymous poster  was, can't respond to their case because that would constitute a violation of HIPAA regulations. 

Doctors are at the mercy of the public when it comes to online reviews and they can't defend themselves in the public eye against unhappy patients.  So the next best thing they can do is to fight fire with FREE=MORE.

Don't sue your patients.  That just makes the lawyers rich and you're not likely going to win.  And even if you do win, you're going to be known as the doctor that sues unhappy patients.  Instead,  the best thing to do is use your office  as an opportunity to overwhelm these sites with positive comments.  If you think these sites are important, then do something about it.  Happy people are less likely to take the time to hunt down review sites than folks with an ax to grind.  It's the same with Happy's nursing and patient surveys.  Unhappy people naturally gravitate to the desire to speak out.   Take them with a grain of salt. 

Instead of fighting back with lawyers, fight back with positive comments.    How you ask?   By giving your clients a discount for leaving comments on these online review sites.  If you are a physician in a a mostly insurance business, nobody cares about online review sites.  Most physicians wouldn't care either.  Their offices are booked weeks to months in advance.  

If you are a physician in a  cash business, online reviews may be the difference between success or failure.  So play the game.  Offer your patients a discount for leaving online comments and reviews.  By paying the happy people to leave comments, your  going to get a much more balanced view from hundreds, if not thousands of happy customers every year. Here's how you get your patients involved. 

1. Inform your patient client up front about your payment for honest reviews at the online review sites.
2. In the case of pre paid cash services, offer your patient a rebate if they place a comment on the most popular online review sites. Offer them an extra bonus if they are willing to use their real name.
3. Create a unique and identifying moniker that only your client and you, the physician, would know about.
4. Have the patient inform your office when their comments have been made using the agreed upon moniker.
5. Once you have verified that your patient has left a comment on the online review sites, send them the agreed upon rebate check.

I'm sure most people would respond to a $100 rebate.  That's a small price to pay if you're going to use these review sites as a form of advertising.  My opinion?  These online review sites are mostly garbage.  I'm sure there are suckers here and there that use them in their decision to find a doctor.   But if patients who aren't happy with their results are going to flame doctors who have no ability to respond, then doctors should fight the fire with FREE=MORE, not with lawyers.  A little incentive goes a long way.

Haircut Before and After Pictures, Happy Style

Here's a couple haircut before and after pictures, Happy style.  I'm six foot, six-five with the afro.

Which hospitalist would you rather have showing up to discuss your new diagnosis of metastatic lung cancer while trying to get you to quit smoking right now (and billing a high level hospital follow up 99233 and a  CPT 99406) while he does it?

Happy before his haircut?  Or Happy after his haircut?  Or would it matter to you?  Not that you have a  choice. I'm going to show up either way.   Your outpatient primary doctor has left the hospital forever.  It's just me and you kid.  Whether you get Happy before his haircut or after his haircut is a luck of the draw.  Just be glad I test positive for the handsome sign.  Some patients aren't so lucky.

Circumcision Ban Proposed In San Francisco? Next Up: Missionary Position.

Have you heard? First San Fransisco banned toys in Happy Meals.  Now CNN is reporting there is a  circumcision ban proposed in San Fransisco as well.

Boy oh boy.  What a hot bed topic circumcision is.  Mandating a ban against all circumcisions is like mandating a requirement that all boys be circumcised.  Nobody is right.  Everyone is an expert.  You're either for it or against it.  But making circumcision a crime?  I don't know.  Can you imagine what that prison conversion would look like?

Prisoner:  I'm in for life.  I killed my sister. What you here for?
Father of a circumcised baby:  Genital mutilation of my baby. 
Prisoner:  I'm gonna kick your ass.  You're a sick dude.

I've had a couple circumcision posts in the past.  They always bring out the passion in people.  I'm not sure why.  It just don't get it.  It's kind of like the crazy using cloth diapers vs disposable diapers debate.   

If you want some more crazy circumcision information and passionate positions read

• How much does a circumcision cost?  This is cutting edge technology.  Of course it's expensive. What did you think?
• Should all boys be circumcised and mandated?  Well, apparently San Fransisco's proposed circumcision ban thinks no boys should be. 

Oh yeah, word on the street is that  next week, a local activist in San Fransisco is working on banning the missionary position.  Or was it missionaries.  I can't remember.

Awake and And Can't Move: Paralyzed But Not Sedated for Intubation.

A reader sent me their horrible experience of being awake and paralyzed while getting intubated for respiratory support for a COPD exacerbation.  And now, a bunch of lawyers are getting involved.  It didn't have to come to that:

Hi Happy.  I have a  horrific story I wanted to tell you about.  It was the worst day of my life.  I am a long time smoker, who quit last year thanks to your daily harassment of smokers.  I am one of your quit smoking success stories.  But you and I both know that my lungs aren't normal.  That's where the worst day of my life came into play.  I'm 67 years old.  Four months ago I was admitted to the hospital because I couldn't breath.  They called it a COPD attack.  I got put on one of those breathing machines and that's where my Hell started.

While they were putting the tube in, something must have gone terribly wrong.  I'm just a lay man, but even I know you aren't supposed to be awake when they do it.  I couldn't move.  I couldn't talk. But I was completely awake and aware of everything going on around me, including when they jammed that damn tube in my bladder.    I felt like I was drowning and being buried alive at the same time.    But I was paralyzed and couldn't do anything about it.

They only realized something was wrong when my blood pressure shot up.   I could hear the panic from everyone in the room.  Finally, they realized that the medication that is supposed to make me go to sleep never made it into my vein in my foot.  My vein had blown  and I could tell no medicine had made it into my system because I could feel it.

This was the worst day of my life.

Have you ever heard of this happening?  The hospital thinks I made the whole thing up.  I know I didn't.  It really happened. What do you think?  Now it's all up to the lawyers to sort it out.

That sounds horrible.  I can't say I've been involved in an episode of patient care where the patient was paralyzed from being given paralytic medications but still awake because the sedation medication didn't work. I can't even begin to imagine what that must feel like.   I would suspect that all the nurses and doctors must feel awful about the possibility of having their patient paralyzed but not sedated.

I believe you.  And in fact, it wouldn't surprise me that this series of events probably happened.  Considering your IV was in your foot, you likely had very difficult IV access and the nurses and anesthesiologists did the best they could to stabilize you with the veins they had to work with, during your near death illness.  They saved your life under the least optimum conditions.  It sounds rude, but it's not your doctors' or nurses' faults that you had bad veins.  Perhaps, if they had a vein light at the bedside, things would have been different.  But that's not something every hospital has the money to fund.

Unfortunately, a foot IV is not the best of circumstances, but when you're in an urgent situation, you deal with what you have to the best of your abilities as a nurse or doctor.  Because you were paralyzed, they really had no way of knowing you were awake.   Their main focus, I'm sure was to get a breathing tube in you and secure your airway and maintain your hemodynamic status.   Everything else was secondary.  You couldn't thrash around.  You couldn't reach up and pull the tube out, which would be the natural response to suffocating.  You couldn't do anything. And it's unfortunate you had to go through this experience.  But I'll say it again.  They saved your life under the least optimum circumstances.  That you are here today to discuss the whole thing says that things worked out.

The unfortunate part about this whole story is that the physicians and nurses and hospital administration should have simply acknowledged that your IV had likely blown and you were awake during the whole ordeal.  They should have said:

I'm sorry.  You had a complication of our life saving therapy.  We meant you no harm.  We wish it wouldn't have happened but it did.  We are grateful you are here today to discuss it.   We don't think there is anything we could have done to prevent it, but we will treat it as a sentinel event and we will investigate our systems processes to see if it can be prevented in the future. We are willing to discuss compensation for your pain and suffering if we can determine that what you experienced was preventable given the urgent condition of your near death experience.  

I suspect if that's the course your hospital had chosen to take, that's the course you would accepted as well.  The hospital culture is a major determinant of how they respond to adverse events.  Now, instead, we have doctors and nurses and hospital administrators who provided the supplies to save your life lawyering up and hunkering  down for a lawsuit.  Nobody, except the lawyers, will come out ahead with this one.

As a physician, I view your experience with a different set of glasses.  I know this could very well happen to me during a middle of the night intubation.  The bottom line is these people saved your life.  You experienced a horrible complication, but one that was not likely to be preventable, unless an honest review of the process determines it was. 

You had unintentional suffering.   Was it preventable?  Was it somebody's fault?  I don't know.  Sometimes, medical care doesn't go as expected. If there is one thing I've learned in my last seven years as a hospitalist is that we, as doctors and nurses and all the other care providers, can only do so much to prevent bad outcomes.  Sometimes bad stuff just happens, despite our best intentions and there isn't anything we can do to predict or prevent it.  But if there is, we should do everything in our power to implement those changes.

As a patient, the last thing I would want is to sue a hospital, doctors and nurses who will likely be taking care of me for the rest of my life.  You will always be known as that patient who sued.  They will always treat you differently and probably not in a good way.  They will be more aggressive and more likely to intubate you for fear of your legal trigger finger.  You are more likely to get more of everything.    Sometimes forgiveness is the best course of action.  Your graciousness could perhaps place a seed in the hearts of other doctors, nurses and administrators to compel them to do the right thing the next time, for you and others.  It's amazing what happens when you let down your guard and spread  good will to others, even when they don't feel compelled to do the same for you.  When you take the higher road, you take a win for everyone. 

Record Traffic At The Happy Hospitalist

The Happy Hospitalist has officially entered his next phase of world blogging domination.  He has found an audience hungry for truth and justice involving everything from hospitalist medicine and gardening to Italian greyhounds and Disney and Hawaiian vacations. The Happy Hospitalist is now on track to routinely enter the 3,500-4,500 total daily page view mark with 2,000 unique daily visitors. 

That's over 100,000-130,000 page views a month.  Not bad for a humble hospitalist trying to spread the word of truth and justice sprinkled with a little humor along the way.  Come back everyday for Happy's take on life.  You might learn a thing or two along the way. And you might even laugh.  If you have a problem understanding Happy, the most perfect hospitalist that ever lived, you can read all about him. 

If you're into social media, you can also keep in touch with his RSS, Twitter or Facebook accounts as well.  And if you want to advertise on The Happy Hospitalist, you can always contact him at his email address at  happyhospitalistATgmailDOTcom

Make sure you keep coming back. He's got a list 500 deep of potential posts to write about.  And they just keep coming.

Whole Body TSA Body Scanner Health Concerns Exposed By Experts

After my recent  post about an airport passenger who told a TSA pat down employee "Don't touch my junk", a reader responded with a link to a report exposing the concerns, by experts, of critical health risks and health concerns with the new whole body TSA body scanners in airports everywhere.  Here is the actual PDF file of the letter sent to the Obama administration regarding the serious concerns about the health risks of whole body scatter X-ray airport security scanners.  

The Letter of Concern was sent to Dr John P Holdren, Assistant to the President for Science and Technology, on April 6, 2010 by medical doctors and professors at the University of California San Fransisco (John Sedat, PhD, Marc Shuman, MD, David Agard, PhD, Robert Stroud, PhD).  

 Given what we now know are the CT scan radiation exposure risks, one has to wonder how many of these whole body TSA body scans frequent travelers can undergo before significantly increasing their risk of cancer.  This almost sounds like a modern day Tuskegee experiment. 

Maybe these beaming high doses of cancer causing radiation with whole body TSA scatter X-ray scanners is what Obama meant when he wanted a more transparent administration. Maybe he's just Hoping nobody gets cancer.

For some good TSA humor, check out the Miss TSA x-ray pinup calendar, 12 high heeled beauties in provocative skeleton poses.  

The Handsome Sign: A Great Prognostic Indicator

So I'm rounding on a morbidly obese 84 year old admitted with acute delirium on advancing dementia. It's kind of sad. Here's a lady who's family hasn't made one appearance in the seven days she's been in the hospital. Not one.

She's called a few of the nurses whores. She's even used the "N" word a few times. You'd think she was crazy and needed committed right?  You'd think she had a few harsh words for Happy, given his no nonsense approach to medical care, right?   Well, not exactly.

Mrs Smith: Who are you?
Happy: I'm your doctor. I've seen you everyday for the last week
Mrs Smith: You don't look familiar
Happy: I'll see you tomorrow Mrs Smith. I have to go now.
Happy walking away
Mrs Smith: Come back here son. I want to tell you something.
Happy walks back to listen closely.
Mrs Smith: You sure are a handsome young thing.

Something tells me she's not as confused as everyone thinks she is. In fact, given that she tests positive for Happy's Handsome sign, I think she's ready for discharge back to the community.   The question is, did she catch me in my haircut before or after state.

If you're a student or a resident, it's time to tuck the Handsome sign away along with these other great medical signs:

• How to find a lost cell phone in the hospital:  The Honesty Sign.
• Sleeping Husband sign
• O and Q sign
• Twenty sign
• MFer sign
• Texting in the ER sign
• Band-Aid sign
• Intact Humor Reflex sign
• Fibromyallergia sign
• Denture Stains sign
• Square Root sign
• And while you're at it, check out these funny homeless signs.

Funniest Birthday Cake Ever (Picture): Everything Turns To Sh*t After 40 Toilet Cake.

Here's a picture of what has to be the funniest birthday cake ever.  It's a toilet with poop in it and it says "Everything turns to sh*t after 40".   That's just good humor, I don't care who you are. 

I think this is one case where you should ask for an end piece.

Running Before Going To Work Advice For Hospitalists.

Here's a little free medical advice about running before going to work:  If you feel like  going for an eight mile run  before heading in for a twelve hour hospitalist night shift, and you haven't run eight miles in a very long time, just don't do it.  Stupid.  Stupid.  Stupid.

My legs feel like marshmallows tonight.   I almost feel like I need a  tech to push me around in one of those $350 PVC walkers just to get me through the night shift.  Well, at least I ate healthy tonight.  Soy buffalo wings and soy corn dogs from Trader Joe's. All natural and wholesome food for the heart.

Cerebral T Waves EKG (Picture) From Intracrantial Bleeding Stroke: It Was Once A Boards Question, I'm Told

Here's an example of an EKG showing inverted cerebral T waves as a consequences of an intracrantial hemorrhage (bleeding stroke). Cerebral T waves are known to be symmetric and deeply inverted.  This patient had a  cardiac echo confirming  normal wall motion.

I have no idea what the physiological basis is for getting inverted T waves on an ECG from a stroke.  However, the ABIM thought it was important enough to throw onto boards a few years ago. An ECG showing cerebral T waves  as a consequence of an intracranial hemorrhage was, apparently, an internal medicine ABIM board question years ago. I know this because I was told by some of my attending physicians taking their boards years ago.  They missed the question.  I don't think a single resident from my program will miss that question ever again.

It's the phrase heard over and over again as a resident. "This is a boards question".  Learn it.

Now that I've divulged an ABIM boards question, I wonder if the academicians four times removed from  community based clinical medicine are going to hire blog police to catch cheaters finding knowledge on The Happy Hospitalist.   What do you think?  Am I a cheater for repeating what my residency director told us?

By the way, I still can't figure out why I'm paying over $1000 to take a test and annoy my life with unnecessary busy work to prove value if the federal and state rules and regulations are doing the same. I have yet to find someone show me evidence that taking recertification boards makes me a better doctor or provide better care.  And since we're all about evidence, I think it's time someone proved it one way or another.

Otherwise, what's the point of taking boards other than to provide four vacations a year for academic doctors to travel to sunny places and make up boards questions  on a beach front terrace for one hour a day while surfing the rest of the day for an all expenses paid work vacation.

Dr Who Is Grand. Grand Rounds That Is.

Visit the Dr Who version of this week's Grand Rounds for all the Internet's greatest medical offerings.

Hospitalist Job Opportunity of a Lifetime. Come Work With Happy. We're Hiring!

If you are a hospitalist looking for a job, stop looking. Happy and company have the hospitalist job opportunity of a lifetime. This isn't your ordinary run of the mill hospitalist job opportunity. We are a well run, well organized hospitalist program with a fantastic administration that understands the value of a top notch hospitalist program.  Since many of you residents are now in the job hunting phase of your last year of internal medicine training, consider coming to work with Happy as a blessing from above.

Here are some pertinent specifics of Happy's hospitalist group.

•  We are currently looking for two full time equivalent hospitalist positions starting August (or so) of 2011.
• We are looking for internal medicine boarded or  eligible physicians.  Most of Happy's partners started right out of residency.  We are a mature program that started in 2002.
• We are a private practice hospitalist practice.  There are twenty board certified hospitalists in our group.  We have a contract with our hospital system to be the  provider of hospitalist care across a two hospital campus setting which is the largest regional referring center in our state. Our hospital offers coverage for everything, except dental abscesses (fricken a).
• We have three nursing coordinators who are invaluable to our group.  They keep everything running smoothly.  And they do a fantastic job taking care of everything that drives doctors crazy.  They help with all the annoying insurance requests, paper work, discharge medications and communication between nurses and the rest of us hospitalists.  I don't know what I would do without them.
• Between both hospitals, we have  seven daily rounders  plus a swing shift that helps with admissions and consults.  I have kept track for several years now as to what our normal daily census is per day doc and night doc.  While the time of year makes it variable, on average, the day shift does not average over 15  encounters (that includes new admissions, consults and follow ups) per day and the night shift averages under seven new encounters per night.  This coverage keeps us highly efficient and helps with dramatic reductions in length of stay, when compared against our colleagues.
• We will consider nocturnist positions if you are interested. PLEASE BE INTERESTED!
• We will consider part time options as well, if you are interested.
• We work a combination of 8, 10, or 12 hour rotating days and nights (7am-3pm, 7am-5pm, 7am-7pm, 7pm-7am).   We make our own schedule.
• We have a fantastic administration who understands how much value we provide.  I couldn't ask for a better one that understands the value of hospitalist medicine to hospital economics.
• Starting in August 2011, we have changed our schedule so we will have no more than five day shifts in a row ( with no more than two of those five day shifts at 12 hours)  and no more than 2 night shifts (7pm-7am) in a row and no more than one weekend in a row.  It is a very family friendly schedule.  In a 15 week block, we have a least three periods of eight days or more off, which makes for nice travel plans.   The average over a year is a 40 hour work week.
• We are stationed in a mid size (300,000 or so population) major University community with great schools, low cost of living, low unemployment and a very stable housing market. It is a fantastic place to raise a family.
• The restaurants and shopping are decent and tolerable, but less than an hour drive from excellent opportunities to waste your money.  We have all the big box stores, in duplicate.
•  We are about a 2 1/2 hour all interstate drive to an international airport.
• We offer 100% paid health insurance premiums,  competitive retirement contributions and a  CME/work expense fund.
• We offer a very competitive compensation package mixed with salary, productivity and partnership opportunities.

If you are internal medicine trained and looking for the hospitalist opportunity of a lifetime, email me your life story to happyhospitalistATgmailDOTcom and we'll take a look at you.  This is an H1 but not a J1 opportunity.  Fate brought you to The Happy Hospitalist and let The Happy Hospitalist land you the best job you could ever imagine.

Update:  We are not currently hiring at this time

Free Medical Advice For Only $150,000. It's a Bargain.

One of the benefits of being a doctor is getting free medical advice from other doctors.  That's right folks.  If you can't afford to go to the free clinics your community has set up in town, you can always get a medical school education, spend $150,000  in tuition and lose a decade of your youth studying  the medulla oblongata just to hang out in the doctors' lounge to watch You Tube videos like Robert De Niro's Funny Terrorist Names SNL skit while getting free orthopaedic medical advice about painful shoulders and posterior labral tears.

You see, I've been experiencing quit a bit of shoulder pain for the last few months.  I think it started this summer when Mrs Happy and I took organized classes at the local full service gym.  I'm pretty sure I injured my shoulder sometime between  my first ever spinning class,  toning class, circuit class and pilates class. 

But have no fear.  Now that I'm a doctor, I get free medical advice by hanging out in the doctors' lounge.  That's the real benefit of going to medical school.  It's easy access to all the free medical advice you could ever want. Back in August, I discovered first hand how expensive  hospital based care could be when I started a quest on how to find the real cost of hospital and doctor charges.  

I never followed through and figured either my shoulder would get better or I'd need bloodless surgery.  With Mrs Happy pregnant and all the associated delivery costs coming n 2011, I decided to do a little HSA deductible stacking and wait for getting an orthopaedic consultation, MRI and possible surgery in 2011 when 100% of all charges would be paid by my insurance without any out of pocket expenses on my part.  That's FREE=MORE at its finest and a side effect of a high deductible plan.

Then it hit me.  Maybe I could get the ball rolling with some free medical advice.  Where does a doctor go to find other doctors?  Why, the doctors' lounge, of course.  So I decided to hang out in the doctors' lounge where all the R.A.P.E.R.S hang out and wait for an orthopod to show up.  Wouldn't you know it.  It didn't take long.  There he was.  The go to shoulder guy.  So I pimped him for some free medical advice.  He did a few maneuvers with my shoulder and then told me he thought I had some posterior instability of my shoulders, probably congenital and a rare infraspinatus  strain or partial tear and or a labral tear as well.

I asked him if it was a surgical issue and he said no.  Mrs Happy was happy about that.  He suggested an MRI and physical therapy and gave me the name of a good reference  right down the hospital from where I work.   He gave me the name of an outpatient radiology center that charges $750 cash for T3  MRI.  Much cheaper than the $5,000 he said my hospital would charge.  

I suggested not doing the MRI and just starting with physical therapy, if an MRI was unlikely to change the management plan at this point.  He agreed.  

A big thank you goes out to the orthopaedic surgeon who gave me free medical advice.  I think I'll start my physicial therapy  January 1st, 2011 when it won't cost me a dime.  Heck, this free advice has already cost me $100,000 in student loans. And in retrospect, I realize I could have gone to nursing school instead and become a nurse practitioner or a surgical tech and still gain access to the doctors' lounge where free food and free medical advice and occasional gripes about ObamaCare flow freely.  

Quit Smoking RIGHT NOW! The Most Rapid Tobacco Detox I've Ever Seen

Are you wondering how to quit smoking right now?  Are you deep into a nicotine addiction trying hard to get off the cancer sticks but can't seem to muster enough energy or will power to quit smoking right now?  Have the tobacco farming hooligans got you so jacked up on pesticide residue that you can't think straight? Have no fear.  Happy has discovered the most rapid tobacco detox program ever.  Witness this  miracle of quitting smoking for good unfold right infront of mine own eyes.

Happy:  There's a smoke smell in your hospital room.  The hospital smoking policy does not allow any tobacco on campus. The smoking vaccine is not yet available and you don't meet income requirements for free Chantix when you leave.    Do you need a nicotine patch while you're here?

Smoker:  That would be great!

Happy:  I need to know how much you smoke so we can decide what strength nicotine patch to start you on. 

Smoker:  I smoke one half pack per day.   That's pretty good for me doc.   Last year I was smoking four packs a day.

Happy:  OK then.  I'll talk with my resident physician and we'll figure out what strength of nicotine patch to start you on.

Leave the room

Resident Physician:  That's funny.  When I did the hospital admission in the ER two hours ago, he told me he smoked one pack per day.  I think by dinner he'll be a nonsmoker. 

Happy:  Wow.  It looks like he's going to quit smoking right now.  That's the most rapid tobacco detox program I've ever seen. 

UPDATE:  Chantix lawsuits, here we come.

What's the quickest way to quit smoking right now?  That's easy.  Just lie about it.  You're not alone.  Over 40% of patients lie to their doctor.  Maybe smokers can't help lying, given that smokers are linked to lower IQs.  

If you want to quit smoking right now but can't, the perfect plan is just to lie about it.  When you get cancer of the lung, esophagus, pancreas and bladder, make sure you lie about your metastatic spine tumor when the cardiothoracic surgeon  is trying to figure out if your heart attack therapy should consist of a four or five vessel bypass intervention.

And don't forget, which ever doctor you are who's going to see Mr I Quit Smoking Right Now, you might as well get paid for your smoking cessation counseling with a CPT 99406 or 99407, even if your patients lie about their tobacco use.  Even if their plan is just to lie to you about their plan to quit smoking right now.