Dear Angry Pharmacist

I really like your blog. In fact, I rarely comment because I almost always agree with you. Unfortunately, this means I can't remember which form of my Username I used to create an account to allow me to comment; either that, or my new computer has cookie issues. In any event, although your recent post about your hellacious Friday was heartrending -- and didn't actually say anything about me at all -- someone was kind enough (no sarcasm; traffic has been through the roof) to link to me in your comments. Many (many!) others have since come here and commented as well, so I'd like to address those folks directly.

I'd just like to point out that obviously many doctors are idiots. Uneducated front office staff calling in prescriptions must be maddening; illegible handwriting, nonexistent dosage forms and ridiculous quantities are certainly infuriating; waiting on hold over and over to clarify these things -- while saving the necks of ungrateful patients -- surely earns you millions of karma points towards your halo. That's why I like your blog; you put those doctors squarely in their place with great anger (obviously) but also with humor and panache.

I'm also certain you agree that patients are morons; many so stupid you wonder how they manage to breathe and blink at the same time. Of course they hear what they want to hear; often the exact opposite of what was actually said, whether by you or me.

It just so happens that there was this one particular patient who really really really needed a cholesterol medicine, and with whom I spent an inordinate amount of time carefully explaining exactly why he really really really needed it. So when this particular patient reported that a pharmacist (actually not one but two) told him he should stop taking it...I did not in fact go ballistic in front of him, but rather spent another extended visit explaining why he didn't have to take it if he didn't mind being at increased risk for another heart attack; and succeeded in persuading him to go back onto a different statin, as it happened. Still, there was exasperation, and the blog provided a fun way to let it out.

So for the record, I'd like to specify some things to those who so graciously commented on my humble rant:

1. I don't see drug reps, nor do I accept anything -- including food -- from them.
   
2. My handwriting is quite legible.
3. My office phone is answered promptly -- by a person.
   
4. I prescribe narcotics and other controlled substances with great caution, but
5. I try always to be acutely aware of patients in true pain who are not abusing their drugs.
6. I do not rush patients through my office, and in fact probably see only about half as many patients a day (usually the same day they call) as some other docs; of course I'm only making half as much money, but I believe it's worth it.
   
7. Some of my best friends are pharmacists; by which I mean that in person I have wonderful, respectful working relationships with my local pharmacists (which actually means I should call the one (or two) this patient spoke with and get their side of the story.)

Finally, to all those who called me things like "idiot", "tard", "moron", "lazy", "know-it-all" and "spoiled": please, I beg you, go peruse Cranky Epistles for a little while and come up with some original insults. Heaven knows Cranky Professor has elevated the epithet to an art form! The least you can do is exercise some creativity.

Miscellaneous

Miscellaneous #1:

Friend talking about his daughter's last law school exam (not CrankyProf; congrats to Mr. Cranky too, though):

It must be such a relief; I told her it must feel like taking a really good shit.

Miscellaneous #2:

Phone call at 4:00 am:

Patient's husband: "My wife just fell down the stairs. Should I take her to the hospital, or just put ice on it?"

Me: "How badly is she hurt?"

Him: (muffled) "How badly are you hurt?"

Later: sharing the exchange with my staff; one of them asked me, "What was she doing up at 4:00 am?"

The only answer I could come up with:

"Going downstairs."

Miscellaneous #3:

Darling Spouse got an obscure answer correct on Jeopardy.

Me: "How did you know that?"

DS: "I'm smart."

Me: "No, really; how did you know that?"

Grand Rounds; Present and Future

This week's edition of Grand Rounds is up at Health Business Blog, and a fascinating compendium it is of the finest in medical blogging.

Next week, May 20th, Grand Rounds will be -- of all places -- here, for only the second time. Looking forward to all submissions, emailed to notdeaddinosaur-at-msn-dot-com. All submissions will be included, in the order in which they are received, so hurry up and get those posts into the queue.

Reputation

I'm not sure why, but my traffic seems to have picked up lately. What that also means is that people are reading and commenting on old posts. (Thanks, folks.) Here's a recent comment by Dr. Sissy (no blog link; start one and I'd be happy to send you some linky-love) on my post about identifying drug seekers in the primary care setting:

Any advice for a new FP? The narkies are coming out of the woodwork. I offer referral for counseling, hospitalization, pain management and physical therapy, along with NSAIDs, tramadol and other lower risk meds and watch them leave in a huff.

Yes, I do have some advice: keep it up; you're doing exactly the right thing. Here's why:

After I'd been in practice for only a few years, I saw a patient for a non-drug-related problem (bronchitis or something like that) who mentioned as part of her medical history that she was an active heroin addict. I looked up at her and told her point-blank I wouldn't prescribe any narcotics for her. Here's what she said:

Oh, I know. The word is out on the street: don't call Dr. Dino. No drugs to be had there.

My honest reaction was to swell with pride! That's obviously why the narkies were leaving me alone. Stick to your guns; once you establish your reputation, you're home free. By the way, I told the patient it was the nicest thing anyone had ever said about me. She didn't leave in a huff, either. Maybe someday, when she's ready, I'll be the one she comes back to. In the meantime, I treasure the reputation I worked so hard to achieve.

A Political Wish

Would it be too much to ask that sometime during the upcoming general election we can be treated to a debate -- between whichever two candidates end up running -- moderated by Jon Stewart?

John McCain has been a guest on The Daily Show numerous times. Barack Obama has been on at least twice. Hillary hasn't yet, and if she turns out to be the Democratic nominee, her handlers will probably try to dissuade her from appearing. But if the contest ends up being between Obama and McCain, I think there's an excellent chance they would actually agree.

And it would be fabulous! Stewart is funny but he's also brutally honest and incredibly straightforward. He regularly discusses issues of great substance, even as he cracks everyone up with his stealthy one-liners. After all, where is it written that a Presidential debate can't be fun? Heck, I wouldn't put it past him to stage an informal one on the Daily Show by inviting both of the candidates at the same time. Seriously, though; that's something I'd really love to see.

(And PS: Happy Mother's Day to all the mothers out there!)

Edit: Thanks to Blogger's new "scheduled" feature, I wrote this before I saw this, posted by Movin' Meat. Based on his comments, I would guess he'd agree with me, and would eagerly lobby for such a debate.

Rant Alert: Attention, Pharmacists

To the friendly, trusted neighborhood pharmacist who told my 74-year-old diabetic patient with coronary artery disease and arthritis to stop his Zocor because maybe that's what was making his knees and hips hurt:

You fucking moron! Do you have any idea how hard I worked to get this guy to take this stuff in the first place? Do you know how long it took, how many visits over how many months of teaching, explaining, describing, convincing, persuading, cajoling and begging to get him to agree to even try this medication in the first place? Are you even aware of evidence-based guidelines that recommend statins for patients with diabetes and CAD? I assume you're aware he has these conditions BECAUSE YOU FILL HIS FUCKING Avandaryl, Diovan and Procardia!

And guess what, asshole: his knees and hips still hurt. Think it might be osteoarthritis? You think you'd never seen that in a septuagenarian before.

So thanks for nothing, fucktard. No matter how hard I work my ass off trying to educate my patients about the need for their various medications, you go and undo it all -- why? Because you can? Just to prove to yourself that patients hold you in higher regard than they do me? Think I can get you named as a co-defendant when he has a stroke and the wife sues because I wasn't following the guidelines? No, of course not. You'll just keep smirking there behind your counter, saving poor patients like him from us arrogant docs whom you claim don't know one tenth as much about drugs as you do. Well guess what, you cum-burbling trout-fucker [thanks, CrankyProf!]: you may think you know all about drugs, but you don't know the first motherfucking thing about using them in people.

So why don't you go down a bottle or two of tylenol and chase it with a quart of vodka for good measure. Your basal metabolism is contributing to global warming, and there are slime molds who'd make better use of the oxygen you consume.

End Rant.

Managing Risk

Response to Just (Don't) Do It from the ER/Hospitalist camp (paraphrased):

I can't [fail to provide futile care]! I might get sued!

Yes. You might. So what? Heresy alert: being sued is not the end of the world.

In the first place, you almost certainly won't be. Despite its bad rap, the legal system really does work more often than it doesn't (excluding the John Edwardsian bad baby cases and such.) Besides, there's far more to a "lawsuit" than just "being sued." The chances of a case being filed, having it go all the way to trial, actually losing at trial AND having the verdict upheld on appeal are vanishingly small. As I mentioned previously, you seem to have no problem ignoring identical threats from patients requesting narcotics when you feel they're inappropriate. Why? Because you know damn well that their chances of finding a lawyer stupid enough (even given the median lawyer IQ) to take such a case is somewhere between slim and none. Guess what: failure to provide extraordinary, futile care to a patient who is clearly in the terminal phase of life (again, I'm not talking about borderline cases) is also NOT breaching the standard of care anywhere in this country. That irate family is going to have just as hard a time as the druggie finding a lawyer to file it. Grow some gonads and stand up to those families who use empty threats of lawsuits to demand inappropriate care.

You could be sued -- as could anyone; anytime; for anything -- but there is no way such a suit could prevail. In fact, the more you/we stand up to them, the more firmly we establish that the "standard of care" for terminally ill patients is indeed NOT providing futile care -- which will further lessen the chance of a successful lawsuit.

I know, I know:

Getting hit with a lawsuit is so traumatic, even if I'm in the right, that there's no way I'm going to risk it. Besides, people are wrongly convicted of things all the time.

Think about this: there is a small but finite chance that a healthy patient undergoing a routine screening colonoscopy will suffer a perforation of the colon as a direct result of the procedure. It is also possible that he will then require surgery for the perforation, during which complications could arise; he may even die. So how are you going to address the patient with the lower GI bleed who needs a colonoscopy but refuses because, "I could die from it!" You explain to her that the risk of death is remote, and the adverse consequences of not having the study are much greater. Believe me, your chances of being successfully sued for not torturing granny to death are lower than having a colonoscopy complication.

In this case, though, there's the other side of the equation: however much suffering you endure as the result of a lawsuit, I can guarantee it pales before what you've inflicted on each patient whose death you prolong so painfully. How much torture -- actual physical and psychological pain -- are you willing to inflict just to avoid possibly enduring an unpleasant but incredibly unlikely event?

Just for the record, I have indeed been sued, and no, it wasn't the great psychic rape/trauma everyone reads (and shudders) about all the time, because I knew I hadn't done anything wrong. Granted, one needs to take some common-sense precautions: make sure your policy specifies that the insurance company can't settle without your consent, and then refuse to settle frivolous and nuisance claims. Treat your patients well; keep good records (and NEVER alter them); cooperate with your defense team; (don't blog about your trial while it's going on); all the usual advice.

As it was, hearing that jury foreman say "Not Liable" was an empowering, vindicating experience. Sure, I had better things I could have done that week, but running and hiding and doing things that weren't medically appropriate just to avoid the possibility of a lawsuit would have left me much worse off emotionally in the long run.

If a bully threatens to beat you up, acceding to his demands is understandable. But if you never stand up for yourself -- even when you're in the right -- eventually everyone makes the threat, even those who have neither the intention nor the ability to carry it out.

Isn't there a case to be made for standing up for what's right?

The DNR Code

You get what you pay for.

Medicare pays for procedures, so by FSM, procedures are what you're going to get. If the American people decide that futile care is indeed futile -- and that something needs to be done about it -- I have a proposal:

Medicare should pay for DNR orders.

Recognizing the sensitive, difficult and time-consuming nature of the effort required by a physician to discuss end-of-life issues with patients and families, Medicare (and by extension, all other insurers) should create and pay for a procedure code for obtaining a DNR order. This payment should be significant; I'd suggest on the order of at least a Level 4 office visit ("25 minutes face to face time") given the time usually needed for these conversations. Not bundled into a hospital or office visit for other problems or discussions, but a separate, identifiable service that culminates in a DNR order being entered into the patient's medical record. To the extent that a DNR limits futile care, this code should easily pay for itself many times over.

This code should not be limited to use by the primary care provider. If Fat Doctor is the one who takes the time to talk about these issues with the family, she should be paid for it -- above and beyond the DRG hospital payment. (I'm ok with limiting it to once per hospitalization, but not once per patient; people do change their minds.) Same for the ER docs. Would the financial incentives be worth it for the surgeons and subspecialists to take time away from their lucrative procedures? Probably not, though I have no doubt they'd try to claim the payment one way or another. Systems are meant to be gamed, after all. Still, I think it's worth considering.

In a way, it's the ultimate pay-for-performance. You walk into a room and come out with tangible evidence of your ability to help someone understand a difficult inevitability.

So who's with me? Our train leaves for DC in the morning.

A Proposal: NHP = DNR

Think for a moment what the world would look like if everyone admitted to a nursing home was immediately considered a DNR (or, perhaps more acceptably, "AND" as in "Allow Natural Death.") What if the whole concept of Hospice was applied to the nursing home setting? Comfort care only; living life to its fullest, each day. No invasive medical interventions except to relieve suffering.

It would solve a lot of problems.

No more fishing through mounds of paperwork from the nursing home in the ER trying to determine a patient's code status; hell, if they're all DNR, why send them over in the first place? How much of a dent might be made in ER overcrowding by eliminating the nursing home traffic altogether?

Sure, families may balk at the idea of "nursing home as a death sentence," but it might also provide that extra incentive to keep caring for the elderly at home until it's clear that they are in the last stages of life. Certainly with the rise of assisted living facilities, there shouldn't be any problem applying Hospice principles to the final stage of care in the nursing home portion of the facility.

There's no down side here. All I'm talking about is an injection of honesty and realism into our national discourse about the end of life. People die eventually; nursing homes are frequently their last "home." Why not admit it and let death come with peace and dignity, instead of the medicalized nightmare that all too frequently ensues from our refusal to address the issue.

Just (Don't) Do It

A previous post of mine discussing the fact that the "last year of life" is a retrospective designation was not, as some have misinterpreted, meant to be about futile care. This one is.

Futile care can be defined as medical intervention with no hope of prolonging life or easing suffering. Although there seems to be substantial agreement that determining the futility of a specific intervention for a specific patient can be difficult at times, many practitioners (or at least several bloggers) feel quite confident of their ability to do so. The Happy Hospitalist has said (in my comments) that he is 100% certain he can predict on admission who will not leave the hospital alive. If so, then why does he proceed to hook these patients up to nine IV pumps? Panda relates similar stories of demented grannies (his term) sent over from nursing homes to be tortured to death scheduled for surgeries and other endless treatments that are clearly futile.

So why do it?

Why do you go ahead and admit someone to the ICU if you know they won't live? [Note: I'm not talking about borderline cases; I mean those patients you really do *know* won't make it. You claim to know who they are, and I believe you.] Why do you consult the surgeon when nothing he does will make a difference? Why don't you stop? Why don't you say NO?

I know what you're going to say: "We don't know the patient. The families are strangers to us. We don't have the right to say no; to initiate these kinds of discussions. That's your job; the Family Doc. It's your long-term relationship with the patients and families that makes you the person to have those difficult talks, helping the families come to grips with the idea that medicine can't do anything more. It's not my place."

Bullshit.

You're the treating physician. You seem to have no difficulty forming relationships quickly enough to tell someone they need emergency surgery, and heaven knows you have far more experience than I conveying tragic news in the case of horrific trauma. You're the one standing there in the room with the patient, certain that nothing you do matters [a determination I'm agreeing with, mind you.] Whether or not there's a formal DNR order in front of you, all 50 states have legal protections for physicians who refuse to provide futile care. Yet you go ahead and intubate; start the pressors; call the ICU. Somehow you manage to grow a backbone and refuse inappropriate narcotics to blatant drug seekers. This is no different, no matter how you protest.

If managing the problem if futile care is important (and given the demographics of aging Baby Boomers, I would say it is rapidly becoming critical) then we all have to step up to the plate and do something about it, by not doing what shouldn't be done in the first place. I have two concrete suggestions (to be discussed in future posts) but first and foremost, you -- the ER docs and the hospitalists -- must stop passing the buck back to us, the primary care docs, to help patients and families make end-of-life decisions.

Don't tube that demented old granny. Explain to the family why it's not appropriate to put dad in the ICU. For heaven's sake, stop thinking "Hospice" is a synonym for "we give up"! When faced with a terminal patient (and yes, we all know dementia is terminal; why can't we face that?) just don't do it.

It is your job.