What Does SNF Mean? It's Secret Code For Nursing Homes With Nurses.

Here's how Medicare works.  Grandma gets admitted to the hospital for an emphysema attack.   Grandma stays for a few days  getting medical therapies.   Every day grandma is hospitalized she gets weaker and weaker and weaker.  It has now been 4 days  and grandma is now ready to go back home and smoke, but she's too weak to hold her own cigarette.  So where is grandma supposed to go?

Well, it used to be that grandma went to stay with her family until she was well enough to go home.  Now we have the Medicare National Bank picking up the tab.  They'll pay up to 100 days a year of room and board and therapies (insert laughter here) at a nursing home if grandma has at least a three midnight hospital admission in the prior thirty days.

It's called a skilled nursing facility.  Also known as the Sniff.  Also known as SNF.  Also known as a nursing home.  How convenient.  A nursing home.  A place with nurses.  In fact, they're so proud they have skilled nurses, they put that right in the beginning of the title. 

I find it odd that Medicare would differentiate between nursing homes with skilled nurses and those with just nurses.  I don't know about you, but if I'm going to a nursing home, I want my nurses to show up with my dinner tray and a skill set the size of Texas.

Tell a patient they're going to a nursing home after hospital discharge and they'll likely refuse.  But, have social workers come in and tell them that Medicare will pay 100% of all charges for up to 100 days of rehab and we usually families calling non stop to convince granny to get her free room and board.  

It's a bit of a cynical view.  But it's pretty much the truth however you try and slice  it up to serve to the American people.   I'd say probably 90% of my patients don't need rehab.  They need time.  Oh yeah.  And they need a relative to step up to the plate and be there for them.  But no.  We have Medicare.  The source of all that is free and great and wonderful.  It's the perfect family out.

Unfortunately, things are changing.  Medicare simply can't continue to pay for what it has in the past.  Unless you're a physician assistant who doesn't understand what SNF really is:  Medicare funded nursing home tax payer theft.

Physician Assistant:  Hello.  I have a 600 pound woman I'd like to transfer in to you guys.  She's been here at our nursing home  for just over 60 days getting Es En Ef.
Happy's Partner:  Es En Ef?  You mean she's a nursing home patient?
Physician Assistant:  No.  She's here getting Es En Ef.
Happy's Partner:  What do you mean she's getting Es En Ef?  She's 600 pounds.  How much Es En Ef can you do on someone who's 600 pounds.
Physician Assistant:  I don't know.  The chart says she's getting Es En Ef.
Happy's Partner:  Sounds like you have yourself a nursing home patient.

There's really not a fine line between SNF and nursing home.  They are pretty much the same thing.  It's just a matter of who's going to pay for it.   You see, Medicare will pay for it if you call it SNF and the patient has at least a three midnight hospital stay in the prior 30 days.  Medicare won't pay for it if you don't.

As a hospitalist, I see how this SNF game is played every day. Day after day, year after year, month after month.  It has the opportunity to turn honest doctors into criminals.

Expert Chart Reviewer: Your patient doesn't qualify for inpatient status so they won't be able to go to Sniff.  But, my book of criteria says that if you order Q 4 hour neuro checks and give them some IV blood pressure medication, they'll meet inpatient criteria,  which they need to qualify for skilled nursing.

Welcome the the real world practice of Medicare medicine where it's not about ordering things to get patients better.  It's about ordering things to get someone else to pay it.

PTSD Truck Decals and Truck Balls, Brought To You By Americans

Mrs Happy and I went to our first ever gun show last week.  Did you know you can learn a lot at a gun show?   I saw plenty of guns and grandmas.  And  Mrs Happy and I even discovered the origins of vegetarianism from a beef jerky salesman. 

Then there's this guy. Yes, this guy.  The guy with PTSD. What can I say  about him?   He's got his head on his shoulders and, well, his truck nutz hangin' low.  I'm pretty certain anyone who proudly displays  truck balls on their vehicle has a component of PTSD, whether they're a Vietnam Veteran, in the US Army, or just a redneck from the country.

As telling as this truck story is, the man has a point that is well taken.   With PTSD not all wounds are visible.  The truck balls clearly fill that communication gap.  Heck, if all Hell breaks loose at the gun show, at least I'll know to avoid the white guy with the gun. 

This got me thinking. Cruising through the parking lot at the hospital should be a part of every history and physical examination for hospitalists. I mean, come on, had this guy been admitted, I need to know about these kinds of things. You know. So I can request a room for him on the end, way away from all that construction. And for God's sake,  no IV fluids. That will just turn him into Rambo when it starts beeping.

I'm proud  to be an American, where at least I know I'm free...to wear truck balls without persecution.  Try gettin' that in Egypt, tough guy.

Trader Joe's Pesto Pizza: Nothin' But Organic Pizza Love and It's Delicious.

There she is. In all her Trader Joe's glory. It's the pesto pizza and it was delicious.  It's packed full of vegetables on a pesto sauce over an organic wheat flour crust.  No artificial flavors or preservatives.  You can check out all the ingredients in the last picture if you'd like.  I'd never had it before.  But I guarantee I'm going to make it a point to hunt this pizza down. 

Something tells me that vegetarian origins may have started with the socialist brain of a liberal Democrat shopping at Trader Joe's, not by a beef jerky salesman at a gun show. 

Carbon Monoxide Detector Going Off? What Should I Do?

It's that time of year again where having carbon monoxide detectors in your home could mean the difference between life and death.  Every year Happy's group is asked to admit at least a couple patients with carbon monoxide poisoning.  Most of the time there isn't a lot we can do except place them on high flow oxygen and observe them, minus the occasional consideration for transfer to an institution with a  hyperbaric oxygen chamber. 

Every year some poor mother and her children don't make it to the hospital and are found dead because they didn't have a carbon monoxide monitor in their home.

Last night, we had our own carbon monoxide detector scare.  It was 1:00 am and I was deep in REM sleep on my hospitalist night call  when my cell phone rang.  My cell phone never rings at one in the morning.

My mind is fairly well trained to awaken at the sound of my call room land line or my pager.  But not my cell phone.  I fumbled around for a minute or two before my mind realized that it was Mrs Happy calling.  The phone had already gone to voice mail.  So I called her back.

It sounded like a horrible connection, when in fact, what I was hearing was the loud screeching sound of the carbon monoxide detector going off in the background.  

Mrs Happy, Marty and Cooper were awaken to the sound of the carbon monoxide detector in our master bedroom.  Cooper ran behind the bed and shook in fear.  Mrs Happy called me.

She said the carbon monoxide detector was flashing "GAS" and a number of 220.  I told her to grab the dogs and get the heck out of the house.  And she did.  While at work, at 1 am, I got on the Internet and I searched for the contact number of our gas company.  I contemplated calling 911 like everyone else in this country would , but I figured the gas company would be more helpful.  So I called them and explained what was going on.  They said they wound send someone out immediately to check the situation out.

It turns out the gas company had to call in a third back up  gentleman  who lived on the opposite side of town.  Mrs Happy, Marty and Cooper sat in the car for about 45 minutes waiting patiently for the gas man to arrive.  

When he did, he took his  meter into the house and determined that everything was clear.  There was no carbon monoxide detected  in our home.  That's when Mrs Happy asked him

"Why did it flash GAS then?"

The gas man hadn't realized that.  It turns out many of the carbon monoxide detectors can actually detect both carbon monoxide and natural gas.  So he swept through the house once again on the gas mode  and even went outside of the house in search of a gas leak.

Interestingly enough, he determined that there was no gas leaking in the home,  but there was one in the gas line coming into our house.  He said  the leak was before our gas meter, so we weren't being charged extra for the lost gas.  Who knows how long that has been going on for.

As he wrapped things up he told Mrs Happy to make sure we take an air canister to the carbon monoxide detector filters at least once a year.  He said nine out of ten calls he gets now a days turn out to be nothing.  But he recommended calling every time with any concerns because when  you're dealing with a deadly gas, it's always better to be safe than sorry.

Wait a minute.  That sounds awfully familiar. It's always better to be safe than sorry. Right?   Except in my situation, it's usually a Medicare patient brought in by family at 10 PM on a Friday night as they're  heading out the door to catch the red eye for Vegas.    The only  thing we can ever find wrong with their mother is a severe case of  too old to go home.  But they come in under observation status anyway, because, well, that's just what we do in America.  We observe.

The kids go to Vegas while mom gets her own all expenses paid spa package at hospitel central.  Oh yeah.  I forgot to add.  If Mom leaves a bad patient satisfaction survey, the Medicare National Bank  (MNB) will be asking for some of their money back starting in a just a couple short years.  That's right folks.  I've been told that hospitals that fail to meet patient satisfaction goals will be giving back a whole lotta money to the MNB.

Because, well, it turns out pay for performance just doesn't work.  So it's on to ass kissing. 

Dancing in the Minefields Andrew Peterson Video.

What a great video by Andrew Peterson from his single  Dancing in the Minefields.  

here's the video.

Life is about navigating the  minefields with Grace.    When life explodes all around you, how you choose to dance will be defined by what you choose to value.  Live for your family, forever,  and they will dance with you 'til the very end, 

Or until you lose both your legs from smoking related peripheral arterial disease.  Then they'll just swing your arms around for you.

(This Sunday message from God was brought to you by The Happy Hospitalist through an unrestricted grant for giving)

Benefits of Pregnancy Underestimated (Picture Explanation)

Out of  all the benefits of pregnancy, I think I have found the most important one in this picture  of Mrs Happy's latest purchase. 

I think she got it off craigslist from one of the Playboy triplets.

Vegetarian Origins Discovered By a Beef Jerky Salesman, At a Gun Show.

It turns out that the origins of the vegetarian diet has nothing to do with the discovery of the socialist brain of a liberal Democrat as was once thought.  In fact, Mrs Happy and I happened to stumble upon the origins of vegetarianism while we walked from isle to isle at a gun expo packed full of guns and grandmas. I swear I  saw a couple old ladies walk out of there with semi automatics strapped around their shoulders.

Something tells me they aren't vegetarian, considering this beef jerky salesman says that vegetarian is an old Indian word that means bad hunter.  

That reminds me.  I went hunting for the first time a few weeks ago.  Didn't get a darn thing.  I wonder if that means I'm destined for the vegetarian lifestyle.

Or not.

Socialist Brain of a Liberal Democrat Graphically Defined (Picture)

I found this graphical representation of the socialist brain of a liberal democrat.  It's a fascinating look inside the politics of the central nervous system.The Socialist Brain of the Liberal Democrat

I think I'm going to start asking what political party my patients belong to during my history and physical examination. 

On second thought, why bother.  There is no treatment for central nervous system malfunction. At least that's what we learned in the dean vs medical student Xtranormal medical video.

Driving Home After a Night Shift At The Hospital (Picture)

Here I am driving home from the hospital after a hospitalist night shift.   The closest I've ever come to killing myself while falling asleep at the wheel while driving occurred after a long day at the golf course two decades ago.  I found myself driving 70 miles an hour through the middle of the Interstate median.  Talk about a rude awakening. 

I've heard over  a third of drivers after midnight on Friday and Saturday nights have varying degrees of alcohol intoxication.  But did you know 100% of drivers of  nice cars driving against the grain of traffic at 7 am on any given day are probably mostly asleep doctors driving home after a night shift at the hospital.

I just have a few words of advice.  Stay away from them.

Philadelphia Side Car: Prison Ostomy Sex Explained (Audio)

A reader sent me a link to an audio file from a  radio show that describes the Philadelphia side car. What is the Philadelphia side car? Think Osotomy + Prisoner + Sex.  

Holy Crap.  I can't say I've ever taken care of someone who got herpes in their ostomy from performing the Philadelphia side car.  And on Fox News the other day, I learned that an increase in tonsilar and tongue cancer among younger and middle-aged Americans is thought to be related to human papillomavirus (HPV) transmission from oral sex.  

To summarize.  Don't smoke and don't have oral sex with people who have warts if you don't want to get head and neck cancer  and don't perform the Philadelphia side car on people with herpes. 

Consider this your sex education lesson for the weekend. And if I ever find out one of you is  having Philadelphia side car sex in the hospital, or oral sex in the hospital, I will prepare your discharge summary immediately.  

How Much Is In A Peck? And How To Know If You're Doctor Is Lying To You.

You've all heard the tongue twister:  Peter Piper picked a peck of pickled peppers.  I never knew how much a peck was.  Well, for the first time ever, I actually noticed how much 1/2 a peck was (see the picture)

It says right there that this container holds 1/2 a peck.  In this case a 1/2 peck will hold  about 7-8 medium sized oranges.  

That's a dry volume equivalent of 1/8 of a bushel or 8 pints or 4 quarts or 1/4 of a kenning or one gallon  or 268.8 cubic inches to you and me.  Or 4.4 liters if you live in England.

If you want to mess with your doctor, the next time they ask you if you are eating fruits and vegetables (which will never happen because doctors don't have time for that, but if they did), tell them you eat 1/2 peck a week.

If they sound like they know what you are talking about, chances are they're lying to you.  Time to find another doctor. 

Foods To Avoid During Pregnancy. Perhaps Even When You're Not Pregnant Too.

Mrs Happy  and I love yogurt. I think most folks would consider yogurt to be good pregnancy food.  Except when you accidently bring home coffee yogurt.  That's probably one food to avoid during pregnancy.  She wouldn't eat it.  So I did.

Let me tell you.  It was disgusting.   Note to self.  Next time make sure you don't bring home the Dannon all natural coffee yogurt, pregnant or not.  It looked like diarrhea.  And tasted like crap.

I think it would make perfect hospital food.  It might even prevent a clindamycin Clostridium difficile lawsuit or two.

Tax Deduction Onesie (Picture). Good Old Fashioned Humor

This tax deduction onesie is good humor.  Unless you're stricken with that ridiculous alternative minimum tax.  Then it's just not funny.  I take it back.  It's still funny.  But someone needs to make a onesie  for those millions of mothers who actually get more money in tax refunds than they pay in for taxes.  

You could have a baby wear a onesie that says He's My Sugar Baby.  Here's a picture of another funny onesie, a camouflage onesie, a Future Potbelly! onesie, a custom made onesie and a onesie tie business attire style, young buck onesie, a handsome like daddy onesie, a moose onesie with a hoodie, a  laughing my diaper off (LMDO), and a funny Halloween onesie:  I want my MUMMY!.

Italian Greyhounds Receive Their Morning Snacks (Video). Or Nackies as We Call Them.

Here are Marty and Cooper, our Italian greyhounds, receiving their morning snacks, or nackies as we call them.  We have healthy chicken strips that they just love.  They get one nackie in the morning, one nackie in the evening, and the rest of the day they get praise.  That and a healthy dose of constant  nuggles.  Just in case you're wondering, Marty's leg is not broken.  That's just what he does.

 For more  Marty and Cooper, you can see all their blog posts, their  YouTube videos and their beautiful slide show

Italian Greyhounds Like To Stand On Their Back Legs.

Our Italian greyhounds, Marty and Cooper, are not happy that a big dog is taking a dump in their yard.  And they are quite happy letting everyone know that.  Here's Cooper standing on his back to legs while Princess Marty paces  back and forth with nervous energy.  Cesar would not be proud

For more  Marty and Cooper, you can see all their blog posts, their  YouTube videos and their beautiful slide show

End of Life Care Discussion Should Occur Before Death, Cancer Society Concludes

In shocks heard around the world, the Journal of Clinical Oncology is reporting a dramatic change in position  from the American Society of Clinical Oncology for initiating end of life discussion choices with patients.

How do I summarize their position?  Patients with advanced cancer  should be presented with an  end of life care discussion  before they are dead.  I think it's a start.  Baby steps I say.  The alternative scenario is displayed here in  hospitalist vs oncologist.

End of life ethical issues are a constant presence for hospitalists.  As the inpatient doctor of default for many patients, we are often asked  to provide care for patients who are struggling to survive.   These are patients who are actively in the dying process. These are patients who are on the last leg of their journey, delayed only by days, weeks, or months by the heroic actions of their doctors in shining armor swooping in to save the day.  

I will be the first to admit that palliative care teams provide a phenomenal service, not for me, but for my patients.  I can't even begin to offer my patients the level of discussion my patients deserve when they are stricken with advanced stages of chronic progressive  disease.  In fact, very few of my requests for palliative care consults come  for cancer patients.  

Most of the time, I am asking for help to change full code status in 85 years olds to DNR.  I don't care how healthy you are.  If you are 85 years old, intubating you and performing CPR (CPT 92950)  is ludicrous.  It borders on assault.  

Most of my requests for palliative care or end of life care discussions come for patients with chronic progressive single or multi organ failure for whom no doctor in the world will ever fix, delay or reverse.  These are patients with heart failure, renal failure, lung failure, brain failure. These are patients for whom life has failed them.

The Medicare-Merry-Go-Round is filled with a whole lot of suffering for selfish reasons.  Families are selfish and often in extreme guilt and denial.  Patients are selfish, not because they want to live for themselves, but rather live for their loved ones.  Doctors are selfish because they think they are much better at what they do than they actually are.  

We can't end that suffering until we admit that we are a major part of  the denial process.  We are great at offering therapy options to patients because that's what we do.  We treat.  Physicians are absolutely horrible at offering prognosis of disease.   There is no formal medical school education training in prognosis.  It is a catastrophic failure of the medical education process. 

Why?  Because prognosis is not about the disease.  It's about the person.  There are a whole lot of factors that go into survival, morbidity and mortality for the individual case. Doctors treat the disease.  Palliative care teams  treat the person.  That's the difference between what we do and what they do.  This will always be the case.  We have to admit that and move on from there.   

As physicians, we do a great job of causing unnecessary pain and suffering, which we will readily deny, because we are treating disease, not  life.   If the bloodless surgery or the stent or the scope or the medication fixed the problem, we take credit for success because it worked.  We are treating the disease but the suffering goes on.  But we still succeeded because we treat disease, not life. 

The lack of systems processes in place to help facilitate end of life   and palliative care discussions are a  catastrophic failure of magnificent proportions.  The delivery of health care is in autopilot because nobody wants to take responsibility for this process, which often is the most important treatment we can offer.    And I hate to say it, but I would suspect a big part of this failure has to do with how hospitals get paid by Medicare and how doctors get paid. 

Starting in 2013, the Medicare National Bank will start taking money back from hospitals that have a higher than acceptable readmission rate for three primary diagnosis related groups

• heart failure
• acute myocardial infarction
• pneumonia

I guarantee to you as sure as I am that The Happy Hospitalist is all that is whole and pure that hospitals everywhere will be integrating  palliative care systemic processes into their hospital admission process to guarantee that they will not suffer under declining Medicare payment proposals going forward.   Taking the payment process one step forward, I guarantee that bundled payments and gain sharing agreements between hospitals and physicians will generate lots of  physician interest in palliative care for their patients.  Unfortunately, I think, that's what it's going to take.  But it's WIN-WIN.  The Medicare death squads are coming.  They're just coming out of necessity because hospitals and physicians will push them just to survive. 

How ironic.  In order for hospitals and physicians to survive, they will have to present the treatment option of allowing natural death.  It changes everything.

Nobody gets admitted to the hospital onto a palliative care service, but they should, because often times that is the most appropriate treatment available.   In fact, it should  often lead the decision making process.    I for one commend palliative care for often times providing the only  quality medical care in the hospital.

Why so many doctors are against admitting that their patient is in the dying process and should be spoken with frankly and honestly about the lack of treatment options to make them feel better, is beyond me.  Having an end of life care discussion should always happen before the patient is dead.  

Med Student vs Dean Xtranormal Medical Video. You'll Pee Your Pants

This has to be one of the funniest Xtranormal medical videos ever.  It's called Med Student vs Dean.  You're going to pee your pants.  It's  that freakin' funny.

This is not a Happy original.  Go here to  find all my other original, and not so original Xtranormal Medical Videos.

Bedside Manner and The Patients Who Cry For Their Hospitalist.

Some patients love their hospitalist.  Some patients hate their hospitalist.  It's all about bedside manner.  You could be the worst doctor in the world, or the best, and your patients will love you if your bedside manner excels.   Here's an interesting conversation I had the other day about a patient I saw, but handed off to my rounding partner for the next day.

Partner #1:  Happy, your patient loves you.  I walked in there and she said, "Where did  Dr Happy go?"

Happy:  Oh.  That's nice of her.

Partner #1:  She started crying when I told her I was going to be her doctor for now on.

Happy:  Oh.  That's really sad.

Partner #2:  Are you sure the patient wasn't confused and demented?

Yes folks.   Happy has a patient fan club.  Here's how to join:

• Smoke with a passion every day, like it's your last day of life.
• Stuff your face daily with food. 
• Veg out nightly on the couch

I guarantee to you even you will have the opportunity to experience my exceptional bedside manner.  Just give it some time.  Don't be too anxious.  Once you join my fan club, you're never going to leave.  Or at least until 2013 when Medicare implements their no pay 30 day readmission rules.  Then, you're on your own.  Every Medicare patient for them self.

Cycle of Poverty Defined (Graph)

I took this picture of America defined after a reader sent me their version.

This picture  got me thinking. Where does this  box of DiGiorno Pizza & Cookies combination food product fall into the American cycle of poverty?  I have your answer right here.   Here's my representation of America's cycle of poverty, graphically defined.

Just follow the money.  We get exactly what we pay:  Indentured poverty from cradle to grave. When will this madness ever end? 

Pets Have Purpose: Marty and Cooper Reporting For Midnight Blanket Duty (Picture)

Here's a picture of  Marty and Cooper, our Italian greyhounds, reporting for their midnight blanket duty.  As you can see, they're very good at what they do.  Who says sleeping with your pet can be dangerous?  Hogwash.  They're safer than any spouse infested with 4th hand smoke.

Pet's have purpose. This is one reason why, if you're in the Atlanta area, you need to head down to Atlanta's finest new upscale thrift store, Second Life  (501 (c)(3) IRS status approval pending) located at 1 North Clarendon Avenue Avondale Estates, GA 30002  # 678-974-5671.  Second Life is getting rave reviews and they're being over run with high quality donations.  

In fact, they are looking for volunteers to help sort through all their stuff.  If you're looking to make a difference in a pet's life and want to help out,  contact Lucky, Chief Smile Officer,  for more information at contactus@secondlifeatlanta.org and start making a difference today.  Perhaps your purpose is to help an animal bring joy to a loved one's life.  Life is all about giving back more than you take.  Unless you're Marty and Cooper.  Then life is all about getting your love tank filled. 

Atlanta's best new nonprofit upscale thrift  store. Shop for high end goods at 60-70% off retail.  Buy or donate today and help save a pet's life while giving back to your local animal community.

Jack LaLanne's Life Graphically Defined. 96 Years of Living and Dying On His Own Terms.

Jack LaLanne, the guru of fitness,  has died in his home at the age of 96 from a one week battle with pneumonia.  He passed his time spending two hours a day lifting weights and one hour a day swimming.  He was the ultimate old man running.  Life is about living strong.  This man got it right.  

Some people claim that smoking and obesity cost society less because people die sooner. Jack LaLanne is a classic example of how wrong these people are.  When you live right, you live well.   Your odds of dying doubles every eight years.  When, where and how you  end  depends strongly on how well you choose to live your life.  

Growing old isn't about  growing into a nursing home.  It's about enjoying the golden years  the way you want them to be enjoyed.    Jack LaLanne is a testament to the power of exercise in finishing strong.  I have experienced the power of exercise in my life.  It's why I have my own running log and why I talk about it often on The Happy Hospitalist.  

Exercise is all about living. Jack LaLanne understood that.  His passion helped millions of people finish strong.  He died after a brief and rapid illness, on his own terms.  That's the way it's supposed to happen.  He defined his own mortality.  God Bless you Jack.  You are an inspiration.  Here's Happy's tribute to your life, graphically defined.

This Is Why I Blog

This is part of what makes all the long hours of blogging worth while.  Because some people do listen to my smoking lecture day in and day out.  

Happy,

Although I am not a physician, I do read your blog about once a week. I am a physician recruiter, and your blog helps me get a sense ( somewhat, and I STRESS somewhat) of what a day in the life of a Hospitalist is like. Which is good because I work with residents and practicing Hospitalists every day.

Anyhow, I have read so many of your posts regarding smoking, and how terrible it is. So after stressing about it, I quit, simple as that. On January 1 2011, I quit smoking, so thanks, and know that at least you helped one of your readers. And although 24 days, is not a long time, I know I’ll never smoke again, and a lot of it has to do with what you write.

Now if only I could drop 300 pounds I would be the ideal American ( haha jk)

Have a great one!

This is why I blog.  24 days is a lifetime for smokers, but you are well on your way to removing yourself from being a slave.  Thank you for your story.  I hope you the best on your life journey. Because that's what life is.  And quitting smoking for good is part of your story.  I am happy to say, with the help of some free Chantix that one of my patients refused to pick up, my sister-in-law- has now passed the 200 day mark of being a nonsmoker.  Everyone has hope.  You just have to try.  Congratulations for trying.  This is a new, and better, chapter in your life.  

By the way, one of the best methods to quit smoking right now is to start exercising.  There is something about exercise that takes away the craving to smoke.  So, if you're looking to knock out two birds with one stone, begin your very own 120 pound journey today.  It really is that easy. 

UPDATE:  Chantix lawsuits, here we come.  

Hospitalist Consult Battle Preparation Pose

Here I am posing as I prepare for another  hospitalist consult (CPT 99253, 99254, 99255) for diet controlled diabetes. As you can see, these consults can be complicated. They can take hours of preparation and literature review. Sometimes, I even have to put on the lead apron to protect myself from the hidden dangers of  diet controlled diabetes. 

Not a bad hospitalist battle pose, I suppose, if you're looking for some  physician marketing humor. 

Pillow Pets™ at Blockbuster. Not Too Big To Fail.

There's just something strange about going in to rent a movie at Blockbuster and finding Pillow Pet™ upon Pillow Pet™ stacked on each other ready to find a new home.  I've been fascinated over the last few years watching  this American corporate icon die a slow and painful death.  Netflix and Redbox have transformed the industry and left Blockbuster in bankruptcy.  Now Blockbuster is a candy and pillow store trying to rent Blue Ray and DVD discs to anyone who's willing to stop by.

This is the beauty of America. This is the beauty of innovation.  The winners thrive and the losers declare bankruptcy and sell Pillow Pets™ and candy bars.  Unless, of course, you're a bank too big to fail.  You'll never have to try and survive selling Pillow Pets™.   You can just steal money from the American people by buying off your elected officials.  

Fast forward to the crushing hospital consolidation that will be coming our  way.  Maybe this is how hospitals will survive in the new Medicare reality.  Perhaps we'll have government defined  hospitals that are too big to fail.

Think that kind of talk doesn't exist?  Look only to the banks to find your answer.  It's going to happen.  Some hospitals will get bailed out.  Others will be allowed to fail.  Which ones will be decided by how close those hospitals are  and how important they are to the relatives of your elected officials.  How are all the other hospitals going to survive as the Medicare National Bank goes down in flames?  Hospital pillows, that's how.   Pillow Pets™ to the rescue.  For only $20 plus tax.

Now, if I start seeing the Brest Friend pillow, I'm never going back.  

Sleeping With Your Dog Dangerous But Less Dangerous Than Sleeping With Your Husband or Wife.

It turns out that sleeping in the same bed with your dog, cat or other pet might be dangerous.  So says a new study from the journal Emerging Infectious Diseases.  Given our love for Marty and Cooper, a reader pointed me to this article in Time Magazine describing these dangers of sleeping with your pet. 
What are the dangers of sleeping in the same bed with your pet?

The article does admit that the risk is low, considering the number of people that sleep with their pets.  In fact, I believe the risk of contracting a disease from sleeping in the same bed as your dog is probably lower than it is from sleeping in the same bed with your husband or wife.  

Happy's family not included. 

iPad iBand Concert Video Awesomeness (Bringing Church Bands To The 21st Century!)

Is this the future of music? Check out this iBand Christmas concert created with nothing more than  iPads and iPhones and a little creativity courtesy of North Point Community Church (video). This is awesome stuff here.

This got me thinking. Now that I'm so efficient doing hospital rounds with  an iPad, after Marty and Cooper are finished seeing patients with their pet therapy dog service, I have plenty of time to also offer music therapy to my patients.  I think I'm going to start my own one man hospitalist  band.   I think I'll call myself  Happy Tunes.

I  can even bill for music therapy  (and possibly get paid)  for my Happy Tunes personal patient concerts

• 97150 Therapeutic Procedure(s), Group Group therapy procedures involve(2 or more individuals) constant attendance of the physician or therapist, but by definition do not (Report 97150 for each member of require one-on-one patient contact by group) the physician or therapist
• 97530 Therapeutic Activities (one-on- Direct patient contact by the provide rone), each 15 minutes (use of dynamic activities to improve functional performance)
• CPT 97532:  Development of Cognitive Skills Improve attention, memory, problem
  (one-on-one), each 15 minutes solving, (includes compensatory training),
  direct patient contact by the provider
• 97533 Sensory Integrative Techniques Enhance sensory processing and promote (one-on-one), each 15 minutes adaptive responses to environmental demands, direct patient contact by the provider

I just have to figure out what old people listen to these days.  This is the future of hospital care.  It's not about heart caths anymore.  It's all about hospital amenities.   

We All Make Spelling Mistakes, Sometimes.

We All Make Spelling Mistakes, Sometimes.

iPad Addiction and the Wives Who Suffer Through It

Nurse:  Cool Happy.  I see you've got an iPad.

Happy:  Yeah.  I've had it for a couple of weeks. 

Nurse:  Do you like it? 

Happy:  Yes.  the efficiency of hospital rounds has increased dramatically since I stared using it.

Nurse:  That's great.  My husband has one too.  He loves it.

Happy:  That's great.  

Nurse:  Well, not really.  I tell him he touches Paddy more than he touches me. 

Happy:  That's too funny. 

I laughed.  Although it's kind of sad too.  I get it. 

Funny Money Bank (Picture). Think Sperm Bank.

Looking for a funny bank to save that extra change for a rainy day? Here you go. Just drop your load of cash in the sperm bank and before you know it, you'll have enough money to pay for vacation.

Or child support, which ever the case may be.  Get your own funny money sperm bank today.

medGadget Medical Blog Awards Nominations For 2010: Ethics Baby.

It's that time of year again:  The seventh annual  medGadget 2010 Medical Web Log Awards are upon us.  This year's contest is sponsored by  Epocrates® and Lenovo®.   They have a bunch of different categories up for consideration this year.

Best Medical Weblog
Best New Medical Weblog (established in 2010)
Best Literary Medical Weblog
Best Clinical Sciences Weblog
Best Health Policies/Ethics Weblog
Best Medical Technologies/Informatics Weblog
Best Patient's Blog

Here are the time frames for getting your nominations in and when the finalists and winners will be announced.

Nominations will be accepted until 23:59:59 Sunday, January 23, 2011.
We will announce the finalists on Monday, January 24, 2011.
Polls will be open from Thursday, January 27, 2011 and will close at 23:59:59 EST on Sunday, February 13, 2011.
Winners will be announced on Friday, February 18, 2011.

I am proud to say that some fine reader nominated The Happy Hospitalist for the Best Health Policies/Ethics Weblog category for 2010.  Happy's honored.   It's his  second go around in this category and his  third nomination overall.   Someone forgot to nominate him last year.  He  knows that must have been an oversight.   The Happy Hospitalist was a finalist for the Best New Medical Weblog of 2007. Happy didn't win, but he thinks the voting was rigged.    In 2008, The Happy Hospitalist was nominated for the Best Health Policies/Ethics Weblog award as well. Somehow he didn't make it past the nomination stage. He  thinks someone got paid good money to make that happen.  There are no other alternative explanations.

Truth is hard to avoid.   I'm sure this year The Happy Hospitalist will go all the way and take home the big prize.  If you think Happy, Mrs Happy, Marty and Cooper are  worthy of consideration for any other category, make sure you go to their nomination page.   Here is their explanation on how to nominate. 

Nominations are now accepted in the comments section of this post. When nominating, please indicate the blog's name and URL, nominating category, as well as your thoughts why this particular blog deserves recognition. A blog can participate in more than one category, so please be precise which one(s).

I'VE EVEN CREATED YOUR VERY OWN TEMPLATE FOR YOU!  Just copy and past this text  below and place it in the comments section of the nomination page linked right above.  And you're done. 

I would like to nominate The Happy Hospitalist  at http://thehappyhospitalist.blogspot for the Best Medical Weblog, Best Literary Weblog, Best Clinical Sciences Weblog, Best Medical Technologies/Medical Informatics Weblog, and Best Patient's Blog because Happy is The Best at everything.  His site is the best.  He writes great stories.  He is a wealth of information for clinical stuff.   He loves to write about his iPhone and iPad and he's patient with all his readers.  Go Happy.  I hope you win it all!

Now get out there and help Happy spread his word about truth and justice. 

Major Complicating Conditions (MCC) and Complicating Conditions (CC) with CMS and The Nurses Who Round On Patient Charts.

Here is a classic example of the ridiculous documentation that hospitalist and hospital based medical care has become. I say every day that 80% of what I document has nothing to do with taking care of patients and everything to do with making sure that income is maximized and for protection against allegations of fraud.

In this example below, I remember documenting  that a patient had oxygen dependent COPD.  There were some dramatic changes in  2008 to the inpatient prospective payment system (IPPS) that defined  how hospitals get paid by Medicare.  The over 800 diagnosis related groups (DRGs) now carry  modifiers for Medicare Severity-Diagnosis Related Group (MS-DRG)  Medicare has a list of  disease states that will increase hospital payments  based on whether the primary DRG diagnosis also carries a complicating condition (CC) or major complicating condition (MCC) that determines the MS-DRG.

If a physician can document, in the official chart, that you the patient, have one of these several hundred Medicare defined  MCCs or CCs, then your hospital can collect extra money. It's not chump change.  It can run into the millions of dollars a year.  I've seen some simple data and have extrapolated, in my mind, what the potential hospital income could be if all doctors cooperated with this madness. The dollar: documentation ratio is phenomenal.  A little physician effort is worth millions to the hospital's bottom line.  As a physician, instead of bitching about it, just document the truth according to Medicare and you might help your hospital pay for a brand new doctor's lounge or maybe even help pay doctors for being on hospital call.  

Every smart hospital in this country has hired nurse specialists to sift through hospital charts looking for evidence of diseases that, while documented, are not documented in a way that allows for an MCC or CC to be submitted when it comes time for the Medicare National Bank to pay up.   It's all perfectly legal.  In fact, if you're a hospital and you haven't implemented this type of program, you're going to lose the game.    CMS knows this.  In fact, they've even accounted for this by reducing their increased severity of illness adjustment payment to account for an expected improvement in physician documentation compliance.  In other words,  CMS says they are going to pay you more, but not as much as you would expect because you're going to be better at playing the game.  It all just sounds so silly, doesn't it?

So it is. It is what it is.  This is what inpatient medical care has become courtesy of people y'all voted in.    It's one of the hospitalist advantages that many administrators don't factor in when they balk at paying $100,000 a year in hospitalist subsidy.  Trust me.  A hospitalist service that understands this cooperative effort can make a hospital more than 10x that amount by following these robot documentation rules.  This is how you run a hospitalist program.  This is how not to run a hospitalist program. 

Does me writing chronic respiratory failure with continuous home oxygen use required instead of O2 dependent COPD annoy the Hell out of me?  Not one bit.  It is a   waste of my time and offers no  benefit to the patient care.  But it is what it is.  I've come to accept that as a major part of my daily existence as a hospitalist.  Most of what I do on a daily basis is a waste of time.  Until we change the way we pay for health care, this will always be the case. 

The future is not going to be pretty.   We got exactly what we paid for in Medicare. In America, we  have to pay nurses north of $60,000 a year in salary plus benefits to round to round on patient charts in order to make sure we can collect more money to pay for more nurses to round on more charts.  

This is comedy at its finest, if it wasn't so sad.  I would like to take this opportunity to formally welcome the millions of new Medicare Baby Boomers who will enter Medicare's Comedy Central this year.  Good luck. It's five -o-clock some where and there's a hospitalist just waiting  to welcome you to your new home.

For more information on hospitalist salary, visit

• Hospitalist compensation salary survey 2010 (SHM/MGMA) based on 2009 data
• Hospitalist subsidy and support payments update for 2011, based on 2010 data.

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

EMR Comparison

Successful software implementation starts with choosing the right system. This  checklist contains over 50 of the most important features to look for when evaluating:

• electronic medical records
• medical billing software 
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• technology, security and certifications

Download now and get started today Other useful information is available at my EHR Resource Center.

Hospice Benefits With A Catch -22: Let Us Know Five Days In Advance if You're Dying.

We had everything ready to go. Except apparently the  hospice benefits.   The patient's traumatic brain injury  had declared itself with defined intentions.  The day of reckoning was near.  I recently wrote about barriers to palliative and hospice care when a nursing home couldn't (or wouldn't, I'm not sure) accept a patient because they weren't staffed with registered nurses to manage an NG.  

You think that's disgraceful.  How about a hospice benefits policy from an insurance company that says  in order for hospice benefits to be paid at a rate greater than 50% of expenses, five days notice must be given of the intent to implement hospice benefits.   I can't make this stuff up.  That's what I was told.

Remember, if you're going to die, and you have certain  policies, you have to notify them of your intent to enter hospice at least five days in advance or they will only pay half of your hospice expenses.  That's the ultimate death tax, if you ask me. It's a good thing that was only their supplemental plan.  This kind of policy is a disgrace to humanity.  How do states allow such a thing?

Typing Speed vs Age in the EHR Revolution (Cool Graph): Perhaps a New CME Initiative?

Everything is moving toward a computer interface.  Someday, it may all be audio driven voice recognition via an iPad touch screen technology.  Until then, you're going to have to compare EHR notes that you typed yourself, with your very own fingers on your very own keyboard.

Dr Wes, EP cardiologist extraordinaire did his own highly unscientific post about typing speed of people in medicine.  He generated this cool scatter plot graph. 

His conclusion?  The younger you are, the faster you finish.  Nothing new here. At least, that's what she said. 

Go take his typing test.  Maybe we can get him to make a new graph with more data points.  I'm intrigued.  He might be on to something.  Maybe this is why so many of the older doctors are against the new age of physician driven platforms for disseminating health care, ie physician order entry and computerized notes.   The computer is the doctor's new pen.  Perhaps the best solution  for moving forward is as simple as providing typing classes.   

The new CME for doctors.   Maybe they're just too embarrassed to show off their lack of typing skills.  Everyone knew they were master of the scalpel.  Nobody knew  they couldn't type worth a darn.

Pediatric ICU Art For Kids In the Intensive Care Unit (Picture)

I was alerted to these art like posters of dogs and cats that are hanging on the front glass doors of Happy's pediatric  ICU rooms used for kids admitted into the intensive care unit.  I'm not sure about these choices of soothing characters.  Dogs and cats are wonderful.  With that said, do you think a young child  waking up from their propofol drip after a motor vehicle accident  that killed both their parents is more likely

to feel soothed or agitated from seeing giant art posters of cats and dogs with their razor sharp teeth waiting to pounce on them.  Stick with clouds and fluffy dinosaurs people.  Leave the cats and dogs for the vet hospital.  I think Marty and Cooper would love them. 

Hospitalist Medicine Has Arrived. What's Wrong With You Other Docs?

A reader sent me this little tidbit they experienced a couple years ago.  How do I know that hospitalist medicine has arrived?  Read on:

Hi Happy.   I love your site.  I want to share with you a story that warrants mentioning.  A few years ago I was working the  hospitalist night call at Big Name Hospital Central when  I got a call from a surgeon who had just finished an OR case for a complicated bowel perforation requiring extensive resection.     He called to request a central line, by me, to continue routine fluid and nutrition management in this post operative patient.  I thought that was a bit unusual, but whatever.  I do central lines.  Why not me?

Having already passed through the claws of an anesthesiologist and a surgeon, I was appalled  when  the patient arrived  on the floor, after surgery, with 20 mcg/kg/min of dopamine running through a peripheral IV  just to keep their blood pressure above palpable.  Shocking would be an understatement.  I got the line in, because, well, they needed a line.  And I do lines.  And I take care of patients.   This kind of crap has to end some day. Keep fighting the fight Happy.

One  of my biggest pet peeves as a hospitalist is my constant witness to under resuscitation of conditions where time is of the essence.  I can understand under resuscitation due to ignorance. That can be fixed by education.  Unfortunately, my experience  says laziness, not ignorance is the road block to appropriate care. And there is no cure for laziness. 

Hospitalists  do more than just medical management for the clownfish doctors.  This story is beyond shocking.  The hospitalist did what they had to to make sure that patient got the care they needed.  They placed the central line  and they succeeded in resuscitating a dying patient.  It looks to me like the only doctor worthy of carrying the doctor badge that day was the hospitalist.  I commend you Dr Hospitalist.   All you other doctors should be ashamed of yourselves.

What if that was your daughter, mother, wife or sister?   Would you provide the same substandard level of care to them too?  I'm appalled to the core of my existence that this kind of medical care still happens today.  If you're going to take care of patients, take care of them.  If you're not, get out of the way so someone else can.   Hospitalists save lives, because that's what we do.  What is a hospitalist?  This is a hospitalist.  What is an internist?  This is an internist. 

For other posts about central lines visit here:

• I place central lines in anticoagulated patients all the time.
• How much does a central line pay (RVU)?
• How to bill  for unsuccessful procedures, like that central line you couldn't get. 
• Vein light technology.  Maybe the surgeon should stick to nursing.
• Needle stick anxiety:  It happens to all of us.

Favorite Admitting Diagnosis: TOTGH (Too Old To Go Home)

I used to have a favorite discharge diagnosis I used that got straight and to the point: 

Catastrophic noncompliance.  

Then I was alerted to my next favorite admitting diagnoses: TOTGH.  It stands for Too Old To Go Home.  It goes along with another  popular and growing problematic diagnosis a pulmonologist once alerted me to:  TFTB which stands for Too Fat To Breath.  

Some days it seems like my entire service is filled with patients who are TFTB and TOTGH.  I'll even occasionally get the patient who is TFTGH.  What are hospitalists supposed to do with these folks? They're growing older and larger and more homeless by the day.  Their families don't want them.  Even the nursing homes can't support their needs.  

You know it's bad when we can't even send hospice patients to nursing homes because of their  barriers to palliative and hospice care.   The Medicare National Bank (MNB) has, in some ways, turned into a giant Merry-Go-Round of pin the tail on the hospice donkey.   And to make matters worse, starting in 2013, the MNB is going to demand money back if we can't keep these patients who are TFTB, TOTGH and TFTGH from bouncing back into the hospital within thirty days of discharge.   

Perhaps the solution lies in a creating a new breed  of physician at the front lines of palliative emergency medicine.  I call them the  pallERtive care doc.   They are there to help grandma get off the Merry-Go-Round for good.  What better place to put a pallERtive care doctor than in the ER, home base central for the nursing home Medicare Carousel of Life.   At first glance, what  usually looks like an emergency when it comes through those double doors, isn't.  It's actually natural death diverted for another day, week or month. Emergency rooms aren't for emergencies any more.  They are some of the most expensive hospice agencies the Medicare and Medicaid National Banks can buy.

Since there are no longer emergencies in the ED, what better way to transition into the new reality of American health care than to start staffing EDs with pallERtive care docs. They'll staff the ED between 9 pm and 7am.  Why?  Because the only folks who ever come in during those hours are folks who should get off the Merry-Go-Round but can't.  They need someone at the front lines to take control of the process and make it happen once and for all.   TFTB?  TOTGH?  Don't worry, the pallERtive care doctor is here to help you.

Addendum:  I've been alerted to yet another admitting diagnosis:  TDTB or Too Drunk To Breath.

Barriers to Palliative and Hospice Care: Denied By the Nursing Home

Ever wonder what kind of barriers us hospitalists run into when trying to do the right thing?  How about an 89 year old woman with widely metastatic cancer who presented with a bowel obstruction.  She was actively dying and her family desired here to be transferred 60 miles to her home town nursing home under full end of life, symptom driven, comfort care measures so she could be close to family and friends in her final moments.

 Sounds reasonable to me. That's the family we should all strive to be.  So what's the problem?

Nurse manager:  Happy.  The nursing home won't accept the patient because they have an NG.  Can we get rid of it?
Happy:  You've got to be freakin' kidding me.  The gal is dying from a catastrophic bowel obstruction and necrosis and the nursing home won't accept her because she's got an NG hooked to suction for comfort?
Nurse Manager:  I guess it has something to do with state and federal laws that require a registered nurse to be on site for patients with a nasogastric tube.

She's dying.  Let her die in peace.  It doesn't matter who's staffing the nursing home.  Nurse.  LPN.  Med  aide.  Who cares.  You just can't screw this up.  Here's a perfect example of rigid, irrational government regulations that cause unintended consequences of pain and suffering when lawyers trump common sense.   She's checking out of this earth and your Senators in shiny  protective armor won't let her die in peace because they think an RN is necessary to manage a dying patient's nasogastric tube and God forbid the Joint Commission would frown upon a dying families wish for their mother to be close to home.

I wouldn't wish this inhumanity on anyone. 

Orthopedic Surgeons Are the Clownfish of Medicine

This is great stuff.  An infectious disease doctor, with great priorities in life by the way, sets the record straight about orthopaedic surgeons:

That's good stuff.  But mostly, it's true.  I know orthopaedic surgeons are smart.  We're all smart.  That's how we got through medical school.  Although, I think a lot of the issues are not  that they can't, but  that they won't  be bothered with the non surgical aspects nonpaying aspects of medical care.  I would hope my surgeons have the basic medical skill set all graduates of  medical school have to take care of routine hospital care.  Perhaps that is something their Board should address in their competency of recertification.

If surgeons are not going to manage even the simplest of medical needs of their patients, insurance companies  should adjust their bundled fee downward based on the additional cost of other medically necessary unnecessary physician services, like the hospitalist charge for medical management in a patient with no acute  medical issues to address.

When I am asked "to follow" an orthopaedic admission for multiple chronic stable medical issues, I kindly do my level three CPT 99233 follow up note, search for any issues to address, write a bunch of PRN house keeping orders and sign off when I determine, as a physician, that my daily MD level services are not necessary.  These kind of patients would do just fine if orthopods would hire their own primary care PA and NPs to do their rounds for them and to consult the hospitalist  (CPT 99253, 99254, 99255) when actual medical decision making exceeds the skill set of their mid levels.  I would be perfectly happy giving up my rounding duties for medically unnecessary care.

There is no reason for a hospitalist to follow a patient with stable medical issues any more than there is for an orthoapedic patient to follow my CHF patient for stable osteoarthritis.  If an issue arises that requires a medical doctor to address, I should be called.  Otherwise surgeons should hire their own NP or PA, as their out, to handle the day to day annoyance calls that are part of being a surgeon doctor. 

Go read the rest of this docs post.  It's an exceptional read and helps put the orthopaedics vs anesthesia Xtranormal video into context.