Nosing Around (Picture Definition)

Three month old baby Zachary was nosing around the other day when he discovered my nose.  He quickly realized there was no food involved and became bored.  But it was still cute while it lasted.

Zachary Nosing Around

20th High School Reunion Golf Scramble Shot of the Day (Picture)

I've got my 20th high school reunion this weekend.  As part of our activities, I played in a nine hole scramble after flying through 16 patients in less than 5 hours of rounding with my iPad.  To the doctor who wanted me to call them for a physician to physician call for a planned Sunday discharge while I teed of on the eighth hole, I'm sorry I couldn't take your call.     I didn't have anything to tell you that would change anything at all with your Sunday accepting plans.  Our talk will  have to wait until tomorrow. 

I'm too busy winning flag prizes for the closest to the pin on the tee off shot.  Here's a picture of my almost par three hole-in-one.  I've never had a hole-in-one, but I have had a double eagle:  Driver-8 iron on a par five.  Not many golfers can say that.

Almost got a hole-in-one

I haven't swung a golf club in almost a year.  With my posterior labral tear and all, I didn't want to make my shoulder injury worse.  I am happy to say that swinging golf clubs had no effect on my shoulder.   

  

I Got Worms From a Nurse (Picture Proof!)

So I'm rounding with my iPad the other day, minding my own business when a nurse jumped out of nowhere and gave me worms.

I can't verify whether this nurse also gave worms to their patient too.   

Quitting Smoking After Heart Attack Equal or Better Than Any Pills, Say Italian Researchers

I've been telling my smoking patients for years that nothing I do for them is going to make an ounce of difference until they quit smoking for good.  And the Italians  are out to prove me right.  The American Journal of Cardiology reported July 11th, 2011 on the Effect of Smoking Relapse On Outcome After Acute Coronary Syndrome.   

In a study of just under 1,300 patients,  Reuters reports that just over 1/2 the patients started smoking within 20 days of hospital discharge, despite in-hospital smoking cessation consultation for all patients.   Researchers also found that resuming smoking increased  death 3-fold compared with those that did not relapse and quitting smoking had a similar lifesaving effect as taking cholesterol and blood pressure medications.  And I'm sure these folks all landed themselves back into the hospitals for a very expensive dying process.

That's why billing the patient or their insurance for smoking cessation (CPT® 99406 and 99407) is so important.  And that's why I give many of my smoking patients my smoking lecture.  You know how much Medicare pays for a ten minute consultation to help cardiac patients quit smoking right now?  About $20.  You know how much they pay for Plavix + Lipitor?  Over $3,000 a year.  At least they're both going generic within the next 18 months.

Perhaps Medicare should pay more for more counseling  and make patients who smoke pay more for their health care.  That means higher copays, higher deductibles and higher out of pocket expenses for office visits, hospital stays and medication in smokers. 

There's no excuse in this day and age.  If patients want the freedom to smoke, they should feel honored for the right to  pay for the consequences, both with their health and their wallet.  

Italian Greyhound vs Baby In Tummy Time Face Off (Cute Picture)

Last month, when Zachary was just under two months old, I brought to you tummy time exercises with Italian greyhounds with a cute video and picture of Zachary, Marty and Cooper having fun.

Italian greyhounds do well with new babies.  But, on this day, it looks like Marty has now had enough.  As you can see, he's challenged now three month old Zachary to a dual.  Get your tickets today before they sell out.  This Italian greyhound vs baby tummy time face off promises to be the most exciting event of the summer.  Don't miss it!  Get your tickets today.

For more Marty and Cooper action, you can read all their blog posts, catch them at their YouTube channel  or watch their two beautiful slide show presentations, the full color slide show and the all black and white slide show, both available for viewing in my side bar as well.

For more Zachary, you can visit all his blog posts and videos as well.  

Elephantiasis Nostras Verrucosa (ENV) Picture? Crowdsourcing Diagnosis and Treatment Help Request.

Most doctors, including subspecialists, spend over 90-95% of their daily practice treating common disease with common presentations or even common diseases with uncommon presentations.  This is our comfort zone. Most doctors, even the sub specialists rely  heavily on external resources for the evaluation and management of zebras, or conditions that aren't routine in the course of a daily medical practice, but are recognized as uncommon presentations of uncommon disease.

So when a patient with  Elephantiasis Nostras Verrucosa (ENV), or at least what I believe to be ENV presents, I am not ashamed to say that a literature search was necessary to help me define the differential diagnosis and guide me through the plan of care from my initial hospitalist work up.

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 
• scheduling software
• technology, security and certifications

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

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 definition view

Case presentations on The Happy Hospitalist are always fiction.  However, this one is real.  With  the patient's permission for anonymous online discussion of his situation,  both publically and privately in  a physician only  online network, I am presenting a brief review of the details here, along with his approval for photographic visualization of his disease process, with the hope of finding  experts in our country  treating this condition or finding others afflicted with what I believe to be ENV and who have knowledge of available resources to  improve his quality of life.  I know a lot of doctors read my site.  All I need is one that can help.  This presentation uses the concept of crowdsourced diagnosis.  If two heads are better than one, then certainly a thousand heads are better than two. Crowdsourced diagnosis was used recently by a mother who's son's life was saved after a diagnosis of Kawasaki's disease was suggested by astute readers on Facebook. 

Here is a young male with a greater than 10 year history of progressive unilateral woody, nodular and odorous smelling skin changes of his calf.  He has obstructive sleep apnea from significantly elevated body mass index, defined medically as morbid obesity.    He  has no other relevant medical history, family history, social history, review of systems or physical exam.  His basic laboratory panels (CBC/BMP) offer no concerning abnormalities and carry a normal differential.  He has pain in his leg, which occasionally bleeds.  There is no significant itching.  He tells me a dermatologist opinion several years ago consisted of "put a sock on it and leaving it alone".

I used Google for a preliminary review of what I believed this presentation to be.   Google is interesting in that if you know what keywords to use, you can find a wealth of information to help define and refine your differential diagnosis very quickly.  If you don't know what you're searching for, it can be a black hole of worthless and dangerous information. Knowing what you're searching for on Google is different  from the lay person's online symptom checker which leaves too much to the unhelpful imagination.

In some ways, medical school offers doctors the skills to search rapidly and efficiently for defined subsets of uncommon diseases that are not a normal part of their daily practice.   The idea is not necessarily to know everything every time, but to know how to find what you need know efficiently and with accuracy.  That rings true whether you are an internist or an orthopaedic surgeon.  I believe I've made the diagnosis of Elephantiasis Nostras Verrucosa using my medical skill set and the power of observation.  Here is an image. 

Why do I think this is ENV?  After reviewing similarly described images and reviewing reputable medical databases with similar case reports of this presentation, I discovered my patient had many similar attributes, both visually and clinically.  Can I be sure?  No.  There is always some uncertainty in medicine.  That's why I'm seeking a little crowdsourcing help. I know there are no experts who treat this as a part of their routine practice day in and day out in my community because I would be seeing more than one  case in the last eight years as a hospitalist. Nor do I find telling the patient to put a sock on it and leave it alone to be an acceptable long term  management plan.

What are some other common names for ENV?   I have seen reference to ENV as

• Armchair legs
• Chronic recurrent streptoccocal erysipelas
• Deckchair legs
• Elephantiasis nostras
• Lymphoedematous hyperkeratosis
• Lymphoedematous papillomatosis
• Mossy foot
• Wheelchair legs 

Often, ENV is described as  cobblestone and lichened in appearance with a significant malodorous presentation on the distal extremities.  Often, recurrent bacterial infections may set up a continuous inflammatory state that causes chronic and progressive disfiguration of the skin.

A review of the literature suggests the lack of definitive treatment per say, except for therapies related to lymphedema, if this is in fact ENV.  So how about a little help.   If there are any experts out there who are familiar with a visual presentation of this condition or who can suggest alternative diagnostic possibilities that would significantly alter the work up or if there are any patients who suffer from a condition similar to this visual and clinical presentation and you have found significant help through resources or support groups that may not be readily known to most,  I would be grateful to hear your input and I believe my patient would be grateful for your help as well.

Log into your Twitter, Facebook or Google Plus accounts and ask all your medical friends and family if they have an answer for my guy.  He's looking for help and I'm trying to find an answer for a problem that has consumed his young adult life without any definitive plan.  I'm not willing to accept put a sock on it and leave it alone as his long term plan.  Perhaps you will be the one that changes his life forever.

Leave a comment or, if you would prefer to use private correspondence, with your thoughts you can click on my "contact" menu tab at the top of this page and send me a private message.  Alternatively, you can send me an email  at happyhospitalistATgmailDOTcom. 

Online Symptom Checker (Funny WebMD FAIL) Takes the Review of Systems to the Next Absurd Level.

One of the benefits of admitting a 90 year old demented patient to the hospital is documenting unobtainable review of systems  due to baseline dementia. This is allowed under the published CMS evaluation and management (E/M) rules.  This documentation will qualify the ROS component for the highest level of  care associated with that patient's evaluation.  

It's actually quite silly; that whole idea of paying a physician based on how many predefined questions they ask , not whether asking those questions is medically necessary or not.  In theory, asking all these silly questions every time  will always be medically necessary because you don't know if the questions have relevance until after the questions have been asked.  In practice, it's a waste of time and physicians ask questions based on their style of interview as well as back and forth give and take communication between patient and doctor.  

A list of questions called the review of systems is worthless, except in the eyes of payers who define effort, and therefor payment, based on ROS documentation.  As a hospitalist in the field for almost a decade,  I can tell you that the complete review of systems will always be medically necessary, but often irrelevant.  The same goes for the complete physical exam.  Always medically necessary, often irrelevant.  But these are the rules we have been given.  That's why I'm a huge fan of bundled care.  Pay me to care for patients the way I think is best, not the way payers thinks is worth it and I could double or triple the number of patients I see in a day without any lose of quality concerns. 

Taking histories and doing physicals is what all physicians have been trained to do.   And thoroughness defines our practice as physicians.  We ask questions in search of answers.  We examine in search of a diagnosis.  But telling us what's important and what we need to document in order to get paid isn't.  If that isn't the most inefficient distraction to the delivery of efficient, high quality medical care, then I don't know what is.  

A review of systems is  really not all that helpful in the clinical course of how physicians do their patient evaluations.  That might come as a shocker to new medical students brainwashed by their attendings with their three hour, six page evaluations  with no plan, on their first day of internal medicine, but it's readily apparent by the time you're trying to decide on your 4th year rotations to take in medical school.  It's time for the review of systems to die a quick death.  I am not a fan by any means.

The review of systems process is nothing more than a generation of  mostly worthless information that no one reads.  It has limited bearing in how we work through our differential diagnosis.  I presume the whole ROS process was created as a way to implement defined payment structures for E/M notes.  Documenting the ROS is really a documentation headache of magnificent proportions. 

Which is why I'm also glad CMS has allowed us the right to document something along the lines of "except as previously dictated, all other review of systems  were reviewed and are negative without further pertinent positives or negatives" and that statement constitutes  the requirements in place of a two page list of ROS dictated questions, at least if you aren't being forced to use the obnoxious Trailblazer criteria that some Medicare carriers have elected to adopt.    Who do these people think they are?   It's just one obstruction after another to get paid for work provided. 

I make that statement dozens of times a month because that's what I must document in order to get paid for the work provided. We do it because that's how we get paid.  It's medically necessary.  It will always be medically necessary.  But,  hindsight usually tells us it has no relevance to patient care or outcomes.  The next time you find a  cardiologist asking you if you have any  history of  pain with urination, you can be assured he or she has to ask you if he wants to get paid and not be accused of fraud,  not that he cares or that it matters one bit to the medical decision making process he's about to implement.

Now that I've established the complete idiocy of our review of systems process and how obstructive it is to our normal work flow in the course of daily patient care, I'd like to present to you how these online symptom checkers are taking the ROS to new unbelievable heights.  Instead of accepting the process as nothing more than a miserable attempt to quantify effort, they have taken the ROS  to the next level of absurdity.  Here's an example of how WebMD's online symptom checker has shown, in true form, how absurd the ROS has become.  

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

I suppose it's only a  matter of time before CMS starts accusing physicians of fraud for not documenting a patient's trembling associated with cannibalism in Papua New Guinea in their complete review of systems.  Because we all know how warped these Medicare fraud statistics really are. 

Viberect® Male Vibrator FDA Approved: Coming 2011 By Prescription Only

When do men stop thinking about sex? The answer is never. So you knew this was coming. It was only a matter of time before the FDA approved the very first male vibrator (I'm using the term loosely) as a medical device. It's called Viberect and it's being advertised as the first hand-held, non-pharmaceutical device to help men with moderate erectile dysfunction, poor maintenance and rigidity, or spinal chord injuries achieve successful erection and ejaculation at home.

I mean, come on. Give me a break. You give the FDA an inch and they take a foot. First cigarettes, now sex toys? What business does the FDA have regulating the male orgasm? I can just imagine these researchers   sifting through the data and having long and hard discussions about Viberect and what it means for public policy.

Heck, I bet they were a  bunch of old men sitting at a bar on the taxpayer's dime, downing a couple of stiff drinks, making decisions about how to stroke the coals of controversy. Perhaps they reviewed some head to head trials and decided it was time to pump a little satisfaction back into the lives of our elderly men and women.  

It's available by prescription and I suppose that's only fair. If women get breast reconstruction after cancer surgery paid for why shouldn't a man with erectile dysfunction after prostate surgery get a male vibrator device paid for with Medicare dollars. How much is Viberect® going to cost?  I've searched the maker's website (Reflexonic®) and I can't seam to find any price quote available.  But if it's paid for by Medicare, I suppose it will cost what ever they say it will cost.  You know, Medicare is going broke, but at least our senior citizens are going to have have a blast right up to the very end.

And, as a bonus, this male vibrator is made in the good 'ol USA. Man, it sure is nice to see manufacturing coming home to supply our men with jobs. Maybe these are the types of jobs Obama meant when he signed up to be President.

Childbirth Hospital Costs: Breakdown of Charges With and Without Insurance

Childbirth hospital costs these days aren't cheap. Some studies suggest the cost of raising a child exceeds $200,000, not including education expenses.   Most insurance companies charge women of childbearing age more for their insurance because the actuarial tables say so.  Mrs  Happy and I now have a 3 month old Zachary in our wings.  He is a cute little peanut.  His two brothers, Marty and Cooper adore him.

Forty-two days after his April 21st, 2011 delivery, we still had not received our explanation of benefits from Blue Cross Blue Shield for the midwife charge.  I had previously received a statement from them saying the charge was under review.  Perhaps they believed that delivering Zachary was not medically necessary.  I can't explain it.

When I called to ask them why this charge had not been approved,  they said they could not give me a reason why my explanation of benefits statement had not been finalized after 42 days.  I pressed for more information, but to no avail. I was given no reason other than to say that they had a lot of claims to review.   That's not an acceptable reason to delay a payment of a claim.  

 At the end of my conversation, I indicated to the nice customer service lady that I would be filing a complaint with my state board of insurance for failure to process claims in a timely manner.  Then came silence. And a pause.  She indicated they would expediate the charge through the review process.

I got off the phone, went on line and filed a complaint with my state.  Three days later, I received a finalized explanation of benefits form from Blue Cross Blue Shield.  As part of a high deductible HSA, we prepaid our midwife for the global delivery fee and for me to get my money back from them, as we had now met our deductible for the year,  Blue Cross Blue Shield needed to stop stalling and pay the midwife.  And they did. And I got confirmation this week that my prepaid money would be coming back to me shortly.  With that mess settled,  I now have a complete list of all our Zachary's childbirth hospital costs.

But not all hospitals stays are the same.  Here's a little background on the services that were provided for our hospital stay.

How did the hospital admission day begin?  We had been having a wonderful day at the dog park with Marty and Cooper.  But things changed rapidly that afternoon after we left the dog park and headed to Lowe's.  Mrs Happy was admitted to the hospital on April 20th, 2011 at 7pm (shift change) after her water broke at 37 weeks on the nose, at Lowe's, at 4:30 pm that afternoon while we shopped for a garden tiller. Because she  had not been tested for group B strep, a standard pre delivery test, she was initiated on Pen G every 4 hours prior to delivery.  She had pre delivery routine lab drawn, but I can't remember what it was. She also had an exam to check for amniotic fluid to confirm rupture of membranes.  It was confirmed.

After labor failed to progress over the next few hours, and because her membranes had ruptured,  she was initiated on pitocin at 3 am on April 21st, 2011.  Zachary was delivered by a midwife at 1:01 pm on April 21st, 2011 in an uncomplicated vaginal delivery without an epidural, no anesthesiologist, no radiology charges and no narcotic pain medicine. She spent just under 24 hours in the delivery room and 48 hours  in the post partum room prior to discharge before we headed home to start our life with Zach.

So, what did this uncomplicated hospital childbirth cost us and our insurance company?  Here's a table below detailing what all the childbirth hospital costs were with and without our insurance deduction for allowable contracted charges.  Note, these charges do not include other pre delivery office charges, lab work, ultrasounds and non global fee related midwife charges, which were billed separately and listed below the table.

HOSPITAL MOM 4/20-4/23	CHARGE (NO INSURANCE)	ALLOWED CHARGE (WITH INSURANCE)
Private Room after delivery (<48 hours)	$2,970	$1841.40
Ancillaries	$1,371.53	$663.97
Laboratory	$321	$199.02
Delivery Room (<24 hours)	$3082	$1910.84
TOTAL	$7,744.53	$4,615.23
HOSPITAL BABY (4/21-4/23)	CHARGE (NO INSURANCE)	ALLOWED CHARGE (WITH INSURANCE)
Nursery	$1,240	$768.80
Ancillaries	$164.43	$101.95
Laboratory	$422.45	$261.92
TOTAL	$1,826.88	$1,132.67
MIDWIFE	CHARGE (NO INSURANCE	ALLOWED CHARGE (WITH INSURANCE)
Global delivery charge	$2,800	$2,221.41
PEDIATRIC CARE	CHARGE (NO INSURANCE)	ALLOWED CHARGE (WITH INSURANCE)
4/22 Newborn care	$140.00	$89.93
4/22 Circumcision	$653.00	$263.10
4/23 Hospital visit	$129.00	$105.69
TOTAL	$922	$458.72
TOTAL HOSPITAL CHARGES	$9,571.41	$5,747.90
TOTAL PROFESSIONAL CHARGES	$3,722	$2,680.13
GRAND TOTAL	$13,293	$8,428.03

In addition to these childbirth hospital charges, we also incurred three days of home health care biliblanket therapy hospital charges of $1,069.20, with the allowable charges insurance discount reducing this cost to $555.  This was due to treatment for  jaundice of the newborn.

In addition, other pregnancy related charges incurred  included prolonged progesterone therapy, used in light of two prior miscarriages.  Some doctors believe in progesterone therapy during pregnancy and some don't.  Our pharmacy charge for this was $489.75.  Progesterone therapy was continued right up to the 34th week of pregnancy due to persistently low progesterone levels, the cost of these frequent lab draws of which totaled $251.59 during pregnancy.  Add in five additional unbundled office visits with  four medically necessary  ultrasounds at  a post insurance allowable charge of $1,583.73 and the total cost to bring Zachary from pregnancy to birth (not including pregnancy tests, gender determination IntelliGender test, an expensive "miscarriage blood testing panel" and all the prior fertility treatments and therapies) was  $12,377.30.  

Little Zachary cost $12,377.30  from conception through the  first few days of life.  That is in addition to the over $12,000 a year in health insurance premiums paid.  With a  health savings account with a $3,500 previously met high deductible for things like my posterior labral tear and electrical stimulation shoulder therapy, which I got this year in anticipation of deductible stacking (one of my HSA tips), Blue Cross Blue Shield has thus far paid over $8,000 of this year's charges.

Childbirth hospital costs are expensive.   Not to mention his first 2 month visit for initial vaccinations.  

Wenckebach Video Justin Timberlake YouTube Cult Classic Will Help You Make The Diagnosis!

If you aren't a medical student or fan of cardiac physiology, this Diagnosis Wenckebach video won't make much sense.  This YouTube video was made by a bunch of medical students from the 2010 University of Alberta medical school class.  It's based on Justin Timberlake's song SexyBack and it is a masterpiece.  

I'm not sure how I missed this sure to be cult classic.  It's awesome. I'd pay good money to see  electrophysiology cardiologist extraordinaire,  Dr Wes,  do some of those moves like those professors did at the end of the video.

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 
• scheduling software
• technology, security and certifications

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

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 definition view

Wife Thinner Than Husband Study Says Marriage More Satisfying This Way (Reports University of Tennessee Research).

Here's a bombshell sure to upset many women in this country.  Half our country gets divorced, but the journal of Social Psychology and Personality Science has found one thing husband and wife can agree on:  Marriages are more satisfying when the wife is thinner than the husband.

That's right women.  If you are like the couples in this study, that means a super morbidly obese woman is less likely to be in a satisfying long term relationship, unless she can find a husband bigger than herself.

This four year longitudinal study from the University of Tennessee followed 169 newlywed couples  under 35 years old by looking at their own and their partner's body mass index (BMI).  After controlling for depression, income, education, and whether the relationship ended in divorce, the study found that husbands were more satisfied initially and wives were more satisfied over time when the wives had a lower BMI than their husbands.

That's interesting.  As time went on, women became more satisfied when they were smaller than their husbands. Men are usually the ones who get a bad rap for discussing their wife's weight after pregnancy.  But it looks like it's actually the women who care more about being smaller than their husbands as time goes by.

What does that mean for the men and women out there? We've always known that women generally prefer a man who is at least as tall as she is (no midget jokes please).  So it would seem to me to make sense that both man and woman would feel more satisfied in their marriage when the man is bigger than she is.

Maybe weight gain after pregnancy, for both men and women,  does have something to do with the high divorce rate in America.  It just so happens that women often gain more than the men because of  well, carrying the baby, of course.  And being bigger than your man apparently is dissatisfying for woman.

It's just so easy to let things go when a new baby arrives.  It takes hard work and diligence for both mother and father to prevent weight creep from setting in.  Perhaps, if men and women both want to be in a more satisfying marriage, they should both read my advice on how to lose weight after pregnancy.  And that's why Mrs Happy and I try to make exercise part of our daily routine.

Looks like all the married couples out there have a little discussin to do tonight while eatin' dinner in front of the television.

This post does not apply to Mrs Happy.  She's perfect in every way. 

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 
• scheduling software
• technology, security and certifications

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

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 definition view

Italian Greyhound Cancer or Skin Infection or Autoimmune Pemphigus (Ear Picture of Marty)

We took Marty, our little eight year old Italian greyhound angel,  to the vet today because of several skin lesions that showed up on his ear during the course of the last week.  As an internist, I had my own differential diagnosis running through my mind.  It started as one solitary pearly bordered lesion.  I thought for sure  it was a basal cell cancer in the making when Mrs Happy first pointed it out to me.

Iggys are prone to skin cancer, among other conditions, such as hypoglycemia, seizures and broken bones.  Over the course of the week, he got two more spots in his ear as well as several on his legs and back.  This isn't a classic skin cancer presentation.  

But, I wasn't sure what was going on.  Was this cancer? Was the vet going to freeze these things off?  Was Marty going to be a cancer survivor?  I'd never lived with a cancer survivor.  How was he going to take it?  Would he ever be the same?

Marty was scared.  His poor little legs shook while the vet examined him.  After his exam and getting weighed he ran into my arms for comfort.  It turns out the vet says these common lesions were consistent with a staph infection.  The vet sold us five tablets of Albon (sulfadimethoxine) for $8.  Patient Marty will take 1/2 of a scored tablet once a day for ten days, wrapped in a piece of cheese.

I don't know how Marty got the staph infection.  I don't know if staph is ubiquitous on dogs' skin like it is on humans.  I don't know if it's MRSA, but I know I'm not a MRSA nasal carrier because I drink a lot of hot coffee.  And I hope it isn't VRSA.  

After hours of intense internal debate and deep thought, I have come to the only possible correct conclusion.  Marty lives in America.  There's only one possible way Marty got his staph skin infection.  He got it because someone else screwed up.  He must have picked it up three months ago at his last visit at the vet's office.   I know our vets are nice, but I know they are to blame.  It's the doctor's fault my Marty is suffering greatly today.  How do these people get licensed to treat my loved one?  It's a travesty of justice.

With all those sick dogs floating around, I've never once seen a vet wash their hands when we enter the room.  Dogs coughing everywhere without covering their mouths.  No isolation rooms. No gowns.   What kind of racket are these vets running? They should be ashamed of themselves.   I'm thinking it's time to lawyer up and demand payment for all the mental anguish, lost wages, pain and suffering Marty and us have experienced at the hands of a staph infection obviously contracted by poor vet clinic hygiene.

Don't you worry Marty.  We're going to make things right for you.  We're going to get to the bottom of this terrible injustice and make sure no Italian greyhounds or their masters ever suffer again at the hands negligent doctors.

I just hope you don't got colitis from antibiotics, because then we'll have to sue them twice for negligence.

UPDATE 20 Days Since This Post:  After 10 days of antibiotics, Marty wasn't getting better, so we took him back to the vet.  His skin lesions seemed to be spreading.  The vet's partner suggested the possibility of pemphigus, an autoimmune skin disorder which often improves with steroids.  We put Marty on a tapering dose of prednisone 5 mg twice a day for a week, then 5 mg once a day for a week and then 5 mg every other day for a week and then stopping.

This is a huge dose of prednisone for an Italian greyhound.  It's equivalent, on a weight basis, to at least 50mg twice a day for a normal sized human.  Wouldn't you know it, within three days of starting the steroids, Marty's lesions were rapidly healing and resolving.  They are all completely healing.

We've been told to finish off the prednisone taper and watch to see if the skin lesions come back.  These things, apparently, can resolve or recur.  Hopefully, little Marty won't have to be on suppression treatment for ever.

One interesting side effect, that the vet warned us about, was he may have to pee more than usual.  We hadn't seen that until these last few days when he's been getting up 4-5 times a night needing to go outside to pee.  Perhaps, the twice a day steroids caused him to retain significant amounts of fluid and now that we are at once a day treatment, he's starting to urinate out the excess volume.  We shall see if this continues...

For more Marty and Cooper action, you can read all their blog posts, catch them at their YouTube channel  or watch their two beautiful slide show presentations, the full color slide show and the all black and white slide show, both available for viewing in my side bar as well.

What Do Patients Want To Live For? The Funniest and Craziest Reason Ever!

You can learn a lot about a patient by understanding what motivates them.  For patients trying to lose weight, it could be getting small enough to get the three clicks secured on the roller coaster or a 120 pound journey to freedom.

For those trying to quit smoking for good, it could be to save a pet from smoking related cancer or to keep from getting those nasty diseases seen on the new graphic cigarette box warnings. 

For the romantic folks out there, there is always the power of love that keeps a patient going, even if it means indefinite pain and suffering.  The oldest married couple I have ever been honored to grace their presence had been together for 69 years.    That's phenomenal.  How do you tell a 93 year old woman that their husband is about to pass away?  He's all she's ever known.

When you're a physician in the ICU dealing with ICU palliative care, you will have seen 'em all.  Some families want grandpa to live past midnight just so they can collect one last social security or disability check.  All of us health care folk have seen it.  It's quite sad to watch.  Even when a catastrophic brainstem stroke leaves their loved one forever gone. 

We've all had the opportunity to take care of folks in all these categories.  There's the popular wanting to see the kids and grandkids grow up and get married.  And traveling.  And doing charity work.  There are lots of reasons patients have the desire to live.  But, these are all common reasons patients why want to live.  I'm going to give you the craziest and funniest reason ever for a patient wanting to live.

Frank:  I know I'm sick.  I can feel I'm getting weaker.  But I just want to make sure I live through November of 2012.
Happy:  Why is that?
Frank: So I can vote the SOB out of office.
Happy:  Obama?
Frank: Yeah.  I made a mistake the first time.  And I'm gonna fix it.
Happy: NURSE!  Come quick.  We need to start a million dollar work up on Frank's weakness stat!  He's got important business to attend to.

Now that's a guy with a head on his shoulders. The will to vote.   I guess he's been cured of Peggy Joseph Syndrome.   Time to add voting to your arsenal of motivational tools to convince hospitalized patients to take their medications and do what you ask of them. 

Hospitalist Subsidy/Support Payment 2011 Update: Hospitals Know Value When They See It.

Hospitalists have transformed the delivery of hospital care in America.  It's WIN-WIN on all fronts and hospitals have recognized the value they bring by supporting  (some call it subsidizing) income and compensation to correct for the catastrophic compensation failures of evaluation and management which can viewed in relationship to the hospitalist RVU benchmarks and standards  and the hospitalist compensation /wRVU standards. 

Hospitalist salary and compensation survey data collected by a collaboration between the Society of Hospital Medicine (SHM) and the Medical Group Management Association (MGMA) for 2011 (using 2010 data), officially reported at the May 2011 HM conference and scheduled for sale in September, 2011,  indicates that hospital payments to hospitalists have sky rocked almost 40% higher in the last year.

How high is the average hospitalist support payment now?  Try $136,400 per hospitalist, per year.  That's more than double the $60,000 reported in the original SHM data survey almost a decade ago and almost 40% higher than the average $98,253 subsidy payment per hospitalist per year reported on last year's Hospitalist Salary and Compensation Report for 2010 (SHM/MGMA).  You can also review this years 2011 Hospitalist Salary Survey by Today's Hospitalist for great information.

Richard Quinn over at  The Hospitalist reports his take on this trend by suggesting  that this trend is not sustainable.  I disagree with that assertion and here's why. I think it has taken a decade for hospital administrators to stop viewing hospitalist support payments as an expense and to start viewing them as an asset. They are just now realizing how valuable we are.  That's right folks, it's not every day an expense can be considered an asset.  But it is for hospitalists.  I believe the people writing those checks are just now getting it and you're seeing that with the rapid rise in support payments.

Strictly speaking, providing $136,000 per hospitalist per year seems like an extraordinary expense and burden for hospitals that are being buried under negative hospital Medicare margins and an expanding Medicaid program.  Hospitals cannot survive on Medicaid and they know what's coming.

Hospitals have a lot of head winds in their future.  Yet, they continue to cross subsidize hospitalists at rising rates not seen in any other area of medicine.   There's only one reason why that makes sense.  We are undervalued. The market is telling you we are undervalued.   In fact, I'd liken hospitalists to a bar of gold:

We are expensive, but our value keeps rising with every peripheral event. Hospitals are paying a lot to hoard us knowing that their expense now means they will have an asset that protects them against the coming economic calamity they see brewing.

If you look at the 57 million dollar return on investment, administrators who get it understand that a great hospitalist group is worth their weight in gold.  Is $136,000 a lot of money to pay a doctor to provide care?  Yes.  Is it a lot in the context of the direct and indirect benefits a hospital will see on the back end, now and into the future?  Not even close.

I contend that hospital administrators could double  or triple that support payment and still feel strongly that their return on investment is better than every other expense in the hospital, including their own salaries.  Hospitalists are cheap and their return on investment would shock anyone who has actually sat down and understood the numbers.

Since this is an effort in collaboration, here's what hospitals can do for hospitalists.  Make our jobs easier to provide excellent care at an affordable price.  That means, you need to remove obstructions to our work flow.  We need wireless, on the go, at the bedside access to patient information, past and present 24 hours a day with high reliability.  We need systems that seemlessly implement quality measures without making our lives one obstuctive headache after another.  

We need physicians deeply involved in  every step of every IT initiative at all times and we need you to understand that the path of least resistince will be the path most often taken.  That means, if the path of least resistance produces bad quality care, you're going to get bad quality care.  Don't let that happen.  Make it right from the beginning.  We don't have cheap residents and medical students doing our work for us.  Make our job hard to do and it's going to be very expensive for you to fix.

Now, if you can provide this amazing environment for us, and our patients, you will not only increase your market share, you will also need fewer hospitalists doing the same amount of work.  That's how you can bring hospitalist efficiency to the forefront and save yourself some money on the back end.  Because we're only going to get more expensive.  That's what the market is telling you.

That's why I'm a fan of rounding with my iPad.  That's why I'm a fan of the checklist prompting study.  That's why I'm a fan of the computerized whiteboard.  

Without IT support in our day, our patients lose.  And you have to pay for more hospitalists to realize the same return on your investment.  Spend the money.  Make it right the first time and let us do our jobs.  You'll realize no matter what you pay us, it will be worth it.

Also check out the effect of hospitalist salary vs productivity.

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 
• scheduling software
• technology, security and certifications

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

Code Blue Hands Only CPR Music: Comedy Gold Video Presentations

ZDoggMD (aka fellow hospitalist Dr. Zubin Damania UCSF, 1999) is at it again with his comedic gold humor.  He's given us some classic education and entertainment  with  Hospitalist Anthem, Immunize, History of the Robot Dance and he is also proud provider of one of the funniest medical school graduation speeches ever.  This guy needs his own studio.

But, before I prepare you for his next video, sure to be the next cult classic for medical students, residents and attendings born after 1970, I give you comedian, actor and ER physician Ken Jeong's (The Hangover et all) public service announcement version of hands only CPR with the help of the Bee Gees Stayin' Alive and a couple women with big boobs.

However, it's not the American Heart Association or Ken Jeong that is going to transform CPR.  It's ZDoggMD.  Without further delay, I am proud to say  this hospitalist has provided us with the biggest technological break through in CPR since the Hangover I.  This new method is sure to  provide entertaining end of life CPR to  millions of  ICU palliative care patients all across America.   Need to save a dying soul but can't seem to get the right CPR beat?  

What are you waiting for?  Get your copy of  Code Gold:  CPRs Greatest Hits! today.




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 
• scheduling software
• technology, security and certifications

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

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 definition view