More on the Administrative Fee

Just to provide some more details about my new fee and my plans for implementing it:

Here are the "rules" as posted at the front desk and in the waiting room:

• $20 per person per year, payable at the first office visit of the year

That is, if you only come in once a year for a pap, you don't have to pay it until you come. I suppose I'll continue to comp you the phone call with the results, although if it's abnormal and it takes me 20 minutes to try and explain it to you, that's all uncompensated. If you never call for prescritions or advice on what to do for a cold or how early a pregnancy test can be expected to turn positive, then sure, I can see how asking for more money makes me look greedy. I plan to start out pretty lenient on this, gradually getting more hard-nosed about phone advice over the next year or two.

• Can be waived for financial hardship.

Duh. I also don't plan to charge it to Medicaid patients, although technically I don't have any. I still "officially" accept Medicaid, but I don't accept any Medicaid managed care, and all Medicaid patients in my state must be enrolled in a Medicaid managed care plan. It was an end run that bothered me morally at first, but had to happen.

• For new patients, payable at the second visit.

You're paying for excellent service. It only makes sense for me to show you how great the service is before asking you pay for it.

As for patient feedback, so far it parallels the comments. I had considered from the outset that those who complained enough to transfer out were folks I wouldn't miss anyway. Many patients have no problem with it. Several have said the fee is too small. I say there's nothing keeping it from going to $25 in a year or two, then maybe to $30, and so on. I have about 2000 active charts, and I was thinking that at the most, I can hope to get it from half of those patients. More conservatively, about 500. That's an extra $10,000, which covers about half my malpractice insurance. It's very much in the "every little bit helps" department.

Right now we're still working out the details of implementation: how to keep track of who's paid and who hasn't, and of those, who hasn't because they haven't been in yet and who has specifically refused to pay it. I know it would be a snap on an EMR, but I'm still paper-based, and will probably continue to be for the forseeable future.*

Thanks for all the support as I head off into this new phase of practice. Either it will be the last meteor destroying the atmosphere, shoving me off into the tar pit, or it will be the dawn of a new day; in which case I'll have to rename the blog, "Musings of a Phoenix."

*For a quick refresher on my issue with EMRs, here's a snippet from one of my P4P posts:

A man in the back spoke of the new EMR he had just purchased for $30,000. Once all the numbers were crunched, though, it turned out he was only going to see about $3,000 in P4P bonuses. The response, delivered somewhat more softly than the stentorian tones of the main presentation, was that his return was more likely to be in the areas of quality and lifestyle. I imagined presenting a proposal to an insurance company -- actually to any kind of business -- and saying, "Now, you'll only make back about 10% of your initial investment, but you're likely to see improvement the areas of quality and lifestyle."

Taking the Plunge

I did it. I said I was going to do it, and I finally did it.

I sent out a letter to all my active patients: beginning February 1st I am instituting a new office policy: a $20 per person per year Administrative Fee.

Not for medical care. For things like calling patients back with lab results (instead of bringing them back for return visits, like all the other docs do), mailing, faxing and calling in prescriptions, prior authorizations and referrals to the tune of dozens a day (all unreimbursed, and all -- if not part of a face-to-face encounter -- having nothing to do with medical care), for having the phones answered by a person instead of a menu machine* ("Suicide Hotline: press 1 if you have a gun, press 2 if you've overdosed, etc") and for my availability for telephone advice 24/7.

By now the letters have arrived and the phone calls will begin:

• Do I have to pay if I don't see you in 2007? (No; you don't have to pay unless/until you come into the office.) (But I won't refill scripts if I haven't seen you in a year.)
• What happens if I don't pay? (I won't call you back with labs; you'll have to come in for every prescription refill; filling out forms without an office visit will cost you $10; etc.)
• Send me my records.

That last one is obviously the one weighing on me. This could very well be the beginning of the end, I fear in the dark hours of the night. Then I wake up and go to the office and listen to the vast majority of patients I love tell me I'm worth it, whatever it takes to keep me in business, $20 is nothing, and so on.

The problem is that although I clearly provide better service than other practices in my area, none of them have gone to this "prospective payment model" yet. They all charge for things like forms and mailings and records (which I don't) but they haven't yet gone that extra step. It's like a miniature version of "Concierge Medicine," where you pay $1000-2000 a year for the privilege of being a doctor's patient. I have been providing Concierge service at insurance prices. So now I shall begin to charge the nominal sum of $20 per person per year (maximum $100 per family; can be waived for extreme financial hardship) and away we go.

I am not generally on the front end of the innovation curve. I pride myself on being a "late adopter" of drugs and therapies, waiting until the biggest kinks have been worked out by other doctors. More times than not, my patients have benefitted from this approach, and I don't intend to change in that respect. But being the first on the block to try something like this new Administrative Fee is more than a little scary. I shall keep you posted on my progress.


*My father's favorite: "Incontinence Clinic: Can you hold?"

Someone Else's Laws

Thanks to another old dinosaur, one Dr. William Holt, orthopedist:

• First Law of Ortho: All bleeding stops.
• Second Law of Ortho: If you can't pin it, screw it. (great double entendre, that one)
• Third Law of Ortho: If it doesn't fit, force it (also works for auto mechanics.)

There was a fourth one, but I decided it was a little too grumpy, and took away from the fun of these three. Sorry, Bill.

Drug Reps and Skepticism

Dr. Anonymous thinks he can outwit drug reps at their own game:

Through my medical school training, I've been taught to question all information that is given to me - whether it's a patient's vital signs, or physical exam, or lab work, or whatever.

No you haven't, and neither have I. We've been taught to trust our findings and what the patient tells us, and only to go questioning them when something doesn't add up. (Patient says she has a fever but the thermometer reads 98.6. Patient says he doesn't drink but the transaminases are off the wall and his CBC shows macrocytosis. [blood test results strongly suggestive of alcoholism])

Drug reps are taught, trained and conditioned to tell you things in a way that makes perfect sense, using a style of presentation that is almost impossible to argue with. They are professionals, and many of them are damn good at it. It's just hubris to think that you can remain skeptical enough of a rep's pitch to take away only objective information. Look again at those studies you referenced.

As for not having time to keep up on the latest research, neither do I. But I read The Medical Letter religiously, and try to leaf through JAMA before pitching it. Besides, I pride myself on being a "late adopter" of new therapies. Let someone else's patients discover that some new drug makes their penis turn purple and fall off. Baycol; Vioxx; Ketek; the list goes on and on. Thinking of drug reps as a valid source of information -- especially the newest of the new -- can be as dangerous as it is inappropriate.

You'd Think it would be Obvious

Scene: Very nervous young woman about to have her first GYN exam.

I talked her all the way through it before she ever disrobed; I was at my most soothing and reassuring. Here's how I finished up my spiel:

Me: And whatever happens, remember to keep breathing.
Her: What happens if I don't?
Me: You'll die.

Of course I began cracking up as I said it, as did she. Tension broken. Laughed for weeks.

Speaking of Grand Rounds...

Grand Rounds is up over at Signout's new home on Science Blogs. An excellent job!

Another World

When I was a kid, my family got a Siberian Husky named Samson. Although he was a purebred, he grew too big to actually show, so he was never more than a great pet. Certainly he never had the chance to dash across an actual tundra; hauling a flying saucer filled with groceries over eight inches of snow in the suburbs of Washington DC was the closest he'd ever come to that. But he did love to run, and of course he adored snow. Thanks to some recent posts from Alaska, I've been thinking about him a lot lately.

I wanted to take this opportunity to thank my good friend, the Tundra PA, for her fascinating and exciting glimpse into the activities in a part of our planet so far removed from my everyday experience that it is truly a completely different world. There is no need for her apologies for the "neglect" of her medical posting while she follows the thrills of Alaskan sled dog racing (mushing) as the annual circuit comes to her little neck of the woods. The pictures; the stories; the people; always the writing -- what a pleasure!

On the off chance you missed any of it, pull up a cup of cocoa and start reading:

• Warming up
• Aily's here
• Race preparations
• K300 Race day
• Bogus Creek 150
• Update
• A lovely K300
• K300 Conclusion
  

We've all seen boils on butts, and many of us have more than a passing familiarity with pertussis. But only you can bring us along into another world: yours.

Thank you.

(Edited to add the "Conclusion.")

Grand Rounds: To Theme, or Not To Theme?

There are grumblings in blogosphere about Grand Rounds again.

First, we were yelled at oh-so-sweetly by Kim when the number of posts was getting too high to comfortably read them in a sitting or so, and to keep it real (medical, that is.) Her points were felt to be valid by the general public (defined as those interested in GR) and hosting has subsequently taken on a more editorial flavor. Well and good.

Now the concept of "Themed" Grand Rounds is being batted about. Two different things appear to be at issue: first is the style of presenting non-directed posts into a thematic presentation (Coffee Shop; Holy Grail; Charlie Brown; TV listings, etc.) Second is the practice of soliciting posts on a specified theme of the hosts choice. Both of these limitations (some would say "structures") on GR have been met with their admirers and detractors.

It appears to me that Themed Presentations run about 50-50 in terms of acceptance. Some folks think they're cute; others think they're silly. But overall there's a sense of "host discretion" and general acceptance.

GruntDoc and Dr. Sid have recently come out against Themed Submissions. Their commenters to date appear to agree with them, but this may be subject to "agreement bias" (people who disagree being unwilling to rock the boat, perhaps out of fear of being perceived as rude, or just not caring enough about it one way or the other.) Because their comments are still relatively new, it is not yet clear whether or not there is a true consensus on this point.

For what it's worth, I do give Nick Genes tremendous credit for continuing to give hosts full latitude and letting the chips fall where they may. I find it interesting that the actual work of Grand Rounds -- week after week of host interviews, talking nervous bloggers through the technical aspects; all in the midst of an ER residency -- seems to be such that he leaves these discussions to the rest of us. It's his baby; he's letting it grow and develop on its own. I find that impressive, whatever others may think of which way it's going.

Eyeballing the Grand Rounds archives does seem to confirm the rise of the use of a theme. Some like it; some do not. Those in the latter camp may stop reading or submitting, yet there seem to be plenty more willing to take their place. All things evolve; even, apparently, Grand Rounds. What better emblem of something truly "coming of age" than to have folks bitching about how it "isn't like it used to be"?

Marble Dinosaur Egg*: Assessing Medication Adherence

*My version of a "clinical pearl."

FIRST IN AN OCCASIONAL SERIES

"Clinical Pearl" is the name given to those little hints that may not be taught in medical school or postgraduate training, but have been discovered or devised over the years by us old coots who may still know a thing or two.

Via KevinMD comes this article about patients who lie, both about their medications and other things, occasionally to their severe detriment. Not knowing exactly what meds (and how much) a patient is actually taking can lead to fatal outcomes of prescription interactions.

Various ways of assessing medication adherence (a work I prefer to compliance, which sounds to me like bending patients) have been suggested, including specifically worded questions like, "“A number of my patients don’t take their medication as prescribed and they do it for a variety of reasons. What do you think might be going on with you?” Personally, I find that awkward and stilted; so here is what I have come up with.

First I ascertain medication name, dosages and frequencies. For folks who answer, "Whatever you've got down there, Doc" I smile and say, "This is sort of a quiz to make sure you know what you're taking." Most people are fine with that. Many have taken to carrying a small card or slip of paper with their meds, which I use to review and double-check with my chart. Once a year or so I'll ask them to bring in all their med bottles, and we'll go through them together. (The old "brown bag" review. One time I had fun teasing a long-time patient about her inability to follow directions; how could we do a "brown bag" review of her meds if she brought them in a plastic grocery bag?)

Finally, my magic "adherence" question:

(in a conspiratorial tone, face scrunched a little, with a tiny nod) How often do you forget to take them?

The implication is that everyone forgets now and then, I'm not going to be angry, and I really need to know. It works like a charm:

• "Sometimes on the weekends, but I'm usually pretty good."
• "Honestly, I only get that second dose in once a week or so."
• "I'll be honest with you, Doc; maybe 3 or 4 times a week."
• "Never! I take them every morning right after I brush my teeth."

and stuff like that.

Remember: the secret to getting patients to tell you the truth about meds -- or anything else, for that matter -- is to make sure they don't feel judged. And the only way to accomplish that is to refrain from being judgemental. (Although once more, the Tenth Law of the Dinosaur rears its impressive head: "Simple" and "Easy" are not necessarily the same.)

The Answer is: Money

A question from the comments:

Why do some specialists 'pad' their reports with superficial or even fictitious statements? Statements as you mentioned above, about performing certain physical tests, when the tests weren't done. Or embellishing what they say they explained to a patient. Are these specialists trying to impress the primary care doctor with their 'thoroughness', so as to keep the referrals coming? Are they trying to make themselves look better than their fellow collegues? Or are they simply filling out a quasi 'form letter' report, which is just slightly individualized for each patient?

The answer, as always, is: Money.

A quick primer on how doctors get paid:

You go to the doctor. The doctor asks you what's wrong. You tell him. He asks questions to find out more details about what you've told him, and perhaps more questions about other things you didn't even realize had anything to do with what's wrong with you. This is called "eliciting a history." Then he examines you. This is called a "physical examination." At this point, the doctor has begun to formulate a pretty good idea of what's wrong with you, or at least has some idea of what he needs to do in order to find out. This is when tests -- which may include blood testing, imaging studies like x-rays, ultrasounds or MRIs, stress tests for your heart, lung function testing, etc. -- may be ordered (and why it is inappropriate to order these studies before the "history and physical" parts have been done.) Putting it all together to make a diagnosis and deciding on a treatment plan is called "medical decision making." Explaining it all to the patient and/or family is called "counseling."

Each of those elements of an encounter -- history, examination, medical decision making, and counseling -- comes in varying degress of complexity, as follows:

• History: Problem focused, Expanded Problem-focused, Detailed, Comprehensive
• Exam: Problem focused, Expanded Problem-focused, Detailed, Comprehensive
• Medical decision making: Straightforward, Low complexity, Moderate complexity, High complexity

How to determine precisely what determines what level each component meets? Not to worry; those, too, have been elaborated:

• History: History of present illness, Review of Systems, Past/Family/Social history
• Exam: Each component of a physical exam has been listed as a "bullet point", and the number of bullet points determines the "level" of the exam.
• Medical decision making: takes into account the number of diagnostic or treatment options, Risk of complications and/or morbidity or mortality, and the amount and/or complexity of data to be reviewed.

Once you've assigned the level of complexity for each element of the encounter, there are grids you use to determine which level (1-5) of service you have rendered. Or more specifically -- since frankly, all this really refers to is the documentation -- what level of service your documentation supports. You then assign your service the appropriate code for level of service, bill accordingly, and hopefully get paid.

There's more to it, of course. If it's a new patient (includes someone you haven't seen for three years or more) you use a different line on the grid, do a little more, but get paid more. If the encounter is at the written request of another doctor and you send that doctor a written report, it's called a "Consult", which pays considerably more (for each level of service.) If you don't actually do a history or physical, but have an encounter, say, entirely for the purpose of "counseling" (discussing the diagnosis and/or treatment with the patient) then you can code on the basis of time, as long as said counseling account for more than 50% of the face-to-face visit time. Here are the times in minutes for an outpatient encounter:

Time	Level 1	Level 2	Level 3	Level 4	Level 5
Established	5	10	15	25	40
New Patient	10	20	30	45	60

I swear I'm not making all this up (although those who know me wouldn't put it past me.) (cough*Kensington fan*cough) Check out this document to see what we're up against.

The whole point of this is that a Level 5 visit pays considerably more than a Level 2 visit, especially if it's a consult. So the advantage to the specialist who over-documents is that he can code a higher level of service and get paid more. If the flip side of that malpractice catch, "If it wasn't documented, it wasn't done" is the assumption that all documentation is accurate until proven otherwise, then I have no idea what can be done about it.

But that's the answer to "Why do they do it?" And it sure isn't because they care about primaries' or colleagues' opinions of them.

Referral, Referral; Who's Got the Referral?

I love Medical Economics. I have been a devoted reader ever since residency. Not only did I find it fascinating enough to read cover to cover, but in those first few years I occasionally found checks (made out to cash, with no fancy fine print below the endorsment line committing me to three years of credit protection) tucked somewhere in the back. I didn't recognize the shameless marketing tactic back then, but I would have read the magazine anyway. I still devour each issue, though I now often skip over the finance articles. It's too depressing to read about stocks and mutual funds when I can barely pay myself.

One of their features is a column called Malpractice Consult; an advice column written by a malpractice attorney. After all these years their answers kind of blend into a general refrain of "document out your ass." I get it. I do it (mostly.) Because I began reading MedEc so early in my career, I've been running scared from the git go, so it's taken me a while to relax a bit and realize that although anyone could sue me, most people probably won't. The lawyers' chorus bleating "You Never Know," while technically accurate, has begun to feel like just a scare tactic, reinforced by the benign outcome of my single malpractice suit.

Malpractice Consult has taught me that I'm responsible for a lot of things related to medical care (which also need to be documented out my ass.) Suits have been brought for "Negligent Prescribing"; I need to explain the what-when-why and potential adverse effects of every single prescription I write. Suits have been brought for "Failure to Diagnose"; I'm supposed to document my thinking about every diagnosis I consider, what I did to rule it out or why I decided not to -- for every patient's every problem, every time. And suits have been brought for "Negligent Referral."

Not just "Failure to Refer in a Timely Fashion", "Inappropriate Referral" (to the wrong kind of specialist) but "Negligent Referral": sending someone to someone else who screws up. Apparently it is also my responsibility to keep tabs on the quality of care (per Dr. Bob, a simple, easily implemented concept) provided by the consultants I recommend.

Ok. Fine. I get the idea. Frankly, though, the only means available to me to express any dissatisfaction I may have with any given specialist is to withhold future referrals. But sometimes even that isn't enough.

I have three local options for ENT referral: a solo and a 2-person practice that I like very much, and another 2-man practice that I don't like. Not because they're younger/newer, but because I don't trust them. Why? For starters, the letters they send me always document a full head and neck exam on every patient, even when some maneuvers were clearly not done. (How do you perform a Rinne or Weber test on a two-year-old? And why would it be necessary when he's being referred for nosebleeds?) They write "Thank you for your referral" on self-referred patients, presumably so they can bill the visit as a "Consult" instead of as a much less lucrative "evaluation and management" visit. Other patients have confirmed that documented procedures weren't actually done. Another patient who met the senior guy in the hospital (where I have no control over the admitting doc's referrals, as I'm not on staff there) told me he was a "cocky little bastard." Suffice it to say, I don't refer to them.

However twice on recent occasions, imagine my surprise when patients went there instead of to the office I recommended (and documented.) Although awkward, I asked them why, and got answers like "Well, my dad goes there so I thought I'd try them." So much for my considered medical judgement about consultants. What could I say?

I'm not really worried about the lawsuit angle, because I've clearly documented that my referral was to A and not CLB. But the guy gave a toddler double the recommended dose of an antibiotic (and gave me lip when I called -- politely -- to point out his error) and then sent the kid for an infectious disease consult for a non-condition I had been explaining to the parents for weeks. She did fine with the tonsillectomy, but geez; what's a poor dinosaur to do?

I suppose I could refer you...

BIGGEST PET PEEVE EVER

I got my January 2007 issue of Family Practice Management today. I enjoy this little throwaway journal, and I generally read it cover to cover before throwing it away. But today, right in the middle of a perfectly fine little article about the finer points of documenting a level 2 vs. level 3 visit, I nearly threw it across the room!

There it sat, right in the middle of a table of documentation examples, staring out at me:

Exam: tonsils enlarged with exudative material, shoddy [emphasis mine] cervical nodes.

NO! AARRRGH!! STOP IT!!!

Ok, Dino; calm down.
Breathe.
Move along, folks; nothing to look at here.
You ok now, Dino?

"Shoddy." Much as I wish it were, that was not a typo. So what am I talking about and what's the big deal?

A frequent finding in pediatrics is a row of small, firm, slightly enlarged lymph nodes along the front edge of the sternocleidomastoid muscle in the neck -- the "anterior chain." They aren't usually tender and tend to occur frequently with viral upper respiratory infections in kids. They are different in size and location from the tonsillar nodes, which are often enlarged in cases of strep throat.

This row of hard little nodes can feel kind of like buckshot under the skin; buckshot, of course, being small metal balls used as ammunition for a shotgun. A descriptive shortcut is to call them "shotty" nodes. Although when spoken aloud this word sounds the same as the adjective referring to poor quality or slipshod, "shoddy", THEY ARE NOT THE SAME!!!

Whoa, Dino; settle down.
Did you forget your meds this morning?
Alright then.

So pediatricians, FPs, residents, nurses, med students, all of you: please, I beg you. Don't call them "shoddy nodes." They're SHOTTY. "T." Two of them. Like buckshot. Got it?

Good. Thank you. Because if I ever see another reference to "shoddy" nodes, I am going to get angry. And you wouldn't like me when I'm angry.

The Meme of Six

Thanks (for nothing) DP, for the tag. I confess it took me awhile to figure out exactly what the game was (tell a story in six-word sentences?) but thanks to Fat Doctor, I think I've got it.

The task: Tell a story in only six words.

Here goes:

Flying Spaghetti Monster sighted; Pope baffled

As is my habit, I shall refrain from tagging anyone. Anyone who feels like it, come on into the pool. In fact, anyone who wants to play but doesn't have a blog (cough*Dad*cough; I hear my brother is a regular lurker as well) go ahead and post one in the comments.

"Uncomplicated Problems"

"I know just what I need."

Does this sound familiar?

"When I go to a doctor I know exactly what's wrong and just what I need. I know my body and I've read all about my symptoms on the internet. I know when I need antibiotics. What I don't need is some high-and-mighty doctor with an overinflated ego trying to tell me something different. I think those new Walmart clinics are great!"

These are the patients who are heading off to all those new retail medical clinics opening soon at a CVS near you, where the NPs have "evidence-based protocols" for "straightforward, uncomplicated" problems like earaches and sore throats.

Sore throats, eh? Like this:

25 year old Marine previously in perfect health with a sore throat and fever of 102. On exam his throat is red without exudates or tonsillar hypertrophy; no cervical adenopathy (no "swollen glands"); strep test negative. What would you do? In-office mono test? I didn't have one at the time, but the blood test I sent out came back negative.

What would an NP do here? Probably diagnose a viral infection and send him home with symptomatic care, per protocol. Thousands of identical patients before him had viral infections, as have thousands of patients since. How often would a protocol recommend a blood count?

I did one, though. Any guesses?

• WBC 1.1 (4% polys, 86% lymphs; absolute polys: 44)
• H/H 9.9/27.7
• Platelets 86,000

(For non-doc readers, those are all very low; white blood cells dangerously so.) Pancytopenia (bone marrow suppression) from a viral syndrome? Nope.

Acute lymphoblastic leukemia.

To shorten the ensuing sad story, he was admitted, transfused and treated aggressively. Chemo got into remission several times, once long enough for a bone marrow transplant, although he eventually succumbed to his disease in less than five years.

No way to pick that up on a protocol, unless you're going to do CBCs on everyone with a sore throat, fever and negative strep test. There goes all your cost containment. (Pure coincidence: as I sit down to write this, Dr. Bob has a post on the value of CBCs in diagnosing sore throats. It looks like an inpatient study, though, so I'm not sure how it generalizes to the office.)

So perhaps I can be forgiven for cringing when I hear of NPs in retail clinics following "standard protocols" for "uncomplicated problems." Maybe every febrile patient with a sore throat doesn't need a doctor, but how would you feel if it were your husband/brother/child whose leukemia was missed in a Walmart?

Step Away From the Card Catalogue...

...I'm having way too much fun.

Tip-toeing through the blogs: from Respectful Insolence to Retrospectacle (great blog!) to this: make your own library card.

Here's mine:

Apparently this began as a meme. Sorry, Shelley, but I wanted to play.

That Explains It

One of my favorite blogs -- duly listed off to the right -- is The Well-Timed Period. I've actually given patients the URL and sent them there for a fuller discussion of continuous contraception than I have time to review in the office.

Today's post links to some anti-abortion propaganda that was so outrageous, I found myself laughing out loud.

Finally! A scientific explanation for "mother's intuition":

The phenomena [sic] is called “human microchimerism”. Early in the pregnancy an exchange of cells begins between mother and child. We are not positive what the means of cellular exchange is, but we know it happens. At the time that the child leaves the mother’s body, whether as the result of an abortion, a miscarriage, a cesearean section or a vaginal delivery, even more cells are sent to the mother. It also seems that if the pregnancy ends early, an even greater number is transferred.

These cells seem to be some type of stem cell and are stored in the medulla of the mother’s brain—where instinct lies, but also throughout her body. They have been found even 37 years later so they appear to be replacing themselves.

Wow. That's pretty cool. I knew that red blood cells can cross the placenta, thus causing problems like Rh sensitization with an Rh negative woman and an Rh positive baby, but RBC's don't last more than about four months. (And they can't replace themselves, because they don't have nuclei.) Besides, there isn't any actual blood circulating until at least 6 weeks into the pregnancy.

But actual cells from every child ever conceived lodging throughout the mother's body? And in the medulla of the brain, no less, "where instinct lies." (I didn't realize "instinct" had been defined neuroanatomically.)

Let's think about this for a moment.

By definition, these cells are from another person; a unique individual with his or her own unique DNA. Even though half of it derives from the mother, half does not. The resulting combination is what makes people more than clones of their parents. Because of this foreign DNA, the maternal immune system must see these cells as invaders and thus it would be expected that they would be ruthlessly sought out and destroyed, as is the function of the immune system.

What would happen if these cells somehow managed not only to evade the immune system, but continued to "replace themselves"? There's actually a term for this when the cells involved are bacterial: it's called a "resistant infection." It seems reasonable to suppose that cells with foreign DNA which continue to replace themselves while evading the immune system could be called a form of cancer.

Therefore one of the causes of cancer in women who have ever been pregnant is most likely these cells from every child she has ever conceived that have somehow passed into her body. (I'm still trying to figure out why a shorter duration of gestation should result in more cells being transferred. I shall leave that as an intellectual exercise for the reader.)

But this conclusion should come as no surprise. It demonstrates a universal truth that every mother knows all too well:

Your kids make you sick.

Call for Contest Submissions

Alternative post titles were:

• Lessons from my Father
• How to Say "Fuck You" So Elegantly They Don't Even Know You've Said It

Inspired by Medblog Addict, #1 Dinosaur would like to announce a contest to see who can write the classiest "Screw You" letter. First prize is a copy of my book (which includes disclosure of my true identity.) (Second prize is two copies of my book, but with my name redacted.)

Rules:

• Open to all bloggers
• Submissions to consist of classy "Screw you" (or "Fuck off and die," for the euphemistically challenged) letters of no more than 250 words. (Edit: Not limited to medical or legal; may be on any topic.)
• Must have been written (or received, if you have the nerve) by the submitter.
• Do NOT have to have actually been sent (ie, yes, you can just make one up for the contest.)
• Email submissions to NotDeadDinosaur-at-msn-dot-com.
• Contest deadline: January 31st.
  
• Must include "Ok to post on the blog" in the email.
  
• Entries will be posted anonymously, (edit: after January 31st) without the submitter's name or email address.
  
• All judges decisions will be final and completely arbitrary, although feedback from the comments may be taken into account.
• (Must provide a real name and address to actually receive the prize. Yes, I'm willing to spring for overseas postage, mainly because I'm dying to see what the likes of Shinga and Dork come up with.) (Edited: But you don't have to provide it unless/until you win.)
  

Example: (Adapted from a letter written by my father, originally in a non-medical industry)

Wrong way:

What kind of fucked up place are you running? Everything went wrong with my hospital stay last week!

Right way:

I am well aware that your hospital provides flawless care to thousands of patients each year. Unfortunately, this was not the case during my recent admission.

Note: Including a "Wrong way" version is optional, and does not count toward the 250 word limit.

(No, Dad, you may not enter because:

1. I snarfed your favorite example.
2. You already have my book.
3. You know who I am.

Then again, if you want to come up with something new, I guess that's ok. You won't get another copy of the book, though.)

Memo to Obnoxious Lawyer Bitch Girl*

(*A fun nickname originated by her; no offense intended, and I trust none taken.)

From an email exchange with Medblog Addict:

If I feel like writing "fuck you" I should be able to ... I guess it's that old "don't want to disappoint anyone" rearing its ugly head.

Look at it this way: in anonymous blogging, you have found unconditional acceptance, and an audience who really likes the authentic "you". I think you'll find the more you let loose, the more your blog will be enjoyed (by me, anyway, and I know by others), the more positive feedback you'll get, and the better you'll feel. You have a place to let "Obnoxious Lawyer Bitch Girl" safely out to play, and who knows: you'll probably reap the benefits in Real Life (tm) of having aired out your negativity, and probably glean some interesting ideas from your new blogging friends and commenters about ways to handle some of your RL situations.

I've got news for you: just as you are captivated by this medical world of ours, the legal world of letters and lawsuits, depositions and litigation is just as intimidating and fascinating to us. We, too, feel like outsiders. In fact, the feelings are closer than you might think: you know more than we do, and you can use your knowledge to hurt us if we aren't careful. We try to stay far away from you, even though calling you early (and paying you inordinate sums of money that we don't feel we can spare) can minimize or even alleviate considerable pain down the road. Doesn't that sound a whole lot like a guy in his fifties making excuses not to see the doctor?

So bring on the work stories; the nasty clients; the snarky letters; all of it. The idea that lawyers are really people after all is a revelation. Even though you're not in med-mal (especially because you're not in med-mal) we are fascinated by your work, and are thrilled with any little glimpse you are willing to provide into your world.

As I have been (Not) Saying...

I would like to extend my sincere appreciation to my better-late-than-never colleagues' recognition of the hoopla (or should I say "woo-pla") of all of the assorted blogging "awards" (to which I am intentionally not linking) that have recently occluded the flow of spontaneous blogging.

For what it's worth, I would like to point out that way back on December 18th I wrote this:

• It's more about the writing than the readers.

This is the real reason for this post. I don't want the kind folks who nominated me (and may vote for me) for Best New Medical Weblog to think I don't appreciate their esteem. I am truly flattered. But I'm not doing this for the awards. The acclaim and recognition are very nice, but I know myself well enough to be aware that the quest for these things could easily overwhelm my original blogging intentions. And I don't think I'd like myself very much if that happened to me. I write/blog because I want to. I'm thrilled to have my opinions respected -- even when they're disagreed with -- but just getting my words out there has to be enough for me. I'm content with my small circle of readers. If it expands, wonderful. If not, fine. It's very important to me not to get all caught up in my blogging wonderfulness.

Granted it was buried at the very end of "My Personal Blogging Rules," but the whole point of my post was the same as what Dr. Dork and Dr. Flea are now coming to see.

So again, thanks to all who enjoy my blog. But don't expect to see any animated yellow-and-blue icons flashing around here anytime soon.

Updates

1. The lady with the locally advanced breast cancer welcomed her fifth grandchild on New Year's Eve. February will be the second anniversary of her diagnosis.

2. Rad Rage: The guy with asbestosis (ridiculously abnormal chest x-ray with new pneumonia) got the CT of his chest, which was negative for anything really scary (ie, cancer.) There was bibasilar consolidation read as "either acute or chronic" that was probably what was read as the original infiltrate. But...it also showed left hydronephrosis*.

So...I had to call him back in to tell him about it; get a CT of abdomen and pelvis and refer him to urology. I steeled myself as I walked in the room. He was worried too. (We've known each other a long time; he can tell when I have something to tell him.) As soon as I said "Kidney" he said, "The left one? I was wondering if that stent was still working." Turns out he had stones (all my chart said was "nephrostomy 1978") twenty years before I met him. We still have to go work it up, but he's not the least bit worried; and he totally made my day!!

3. I haven't heard back yet from Urology about the guy with gross hematuria, but I tried asking about him when I called about the hydronephrosis guy I'm sending. I was told, "He doesn't work Fridays." Nice work if you can get it.


*Swollen kidney and ureter, presumably from obstruction. Possible stone, bladder or ureteral tumor, or something else. Plan: "punt."

More Hard Conversations

Having garnered considerable praise for my handling of these cancer conversations (thank you) I would now like to go out on a limb and describe another, more recent, interaction for which I make no apologies, but which may very well evoke more criticism than praise.

I got a phone call last week from a guy in his 50s: "I'm peeing blood." I told him to come right over and sure enough, the specimen cup contained pure merlot instead of nice clear ale.

Here's the thing: gross hematuria (blood in the urine; lots of blood in the urine) although also caused by kidney stones or really bad bladder infections, has to be considered cancer until proven otherwise. Kidney cancer and bladder cancer, which can both present this way, are the "drop dead" diagnoses for gross hematuria and have to be ruled out definitively.

So in addition to a history, exam and urine culture, this guy was going to need a CT scan of his abdomen and pelvis, and a cystoscopy by a urologist. I was not going to stop until I was certain he didsn't have cancer. (Maybe someday I'll tell you about the last patient who peed blood whose initial CT was read as negative.)

To my way of thinking, I have to tell him this up front. Look at it this way: which is more alarming? Being told from the git go that I'm looking for cancer, or being sent all over kingdom come for rests and referrals and more tests without being told why? I trust my ability to tell the truth while remaining supportive, and so I opt for full disclosure.

I sat down with him (known him for over ten years) and his fiancee (whom I'd just met) and laid it out. It could be just a bad bladder infection (less likely in a male, though) or kidney stones (even though he didn't have any renal colic or kidney stone-type pain) but I was worried because cancer can cause that kind of blood in the urine, and we needed to rule it out.

He got a little teary but the fiancee was a tower of strength. I called the urology office and got him an appointment in less than a week, and pulled strings at CT to get him in the day after next (including getting a pre-cert all by myself; no staff that week.)

But here's what happened:

On exam, his temp was 100.1. He had no CVA tenderness and a benign abdominal exam, but a giant, non-tender prostate on rectal exam. I had actually documented it (huge; asymptomatic; normal PSA of 1.7) a few months back on a routine physical. He had to run to the bathroom four times during the visit, meaning he had what would be called "significant lower tract symptoms." The urine was filled with blood, to the naked eye as well as on dipstick and microscopic (meaning there was no way to tell if there were excess white cells with all those red ones, which would point to infection.)

I gave him generic trimethoprim-sulfa (cheap; great bacterial coverage and tissue penetration for both kidney and prostate; all infectious bases covered pretty well) and by the next day his fever was gone, the bleeding had stopped and he was feeling "100% better." His PSA was still less than 2 (low likelihood for prostate cancer) and his renal function and blood count were fine. The kicker was that his urine culture grew out a pan-sensitive E. Coli. Yesterday I got the CT report: no renal masses. I haven't yet heard from Urology, but I'm optimistic (1. That they did a cysto; 2. That it was normal; 3. That I will hear from them.) So the whole thing is looking more like a hemorrhagic cystitis with or without a superimposed prostatitis, probably all secondary to subclinical urinary retention from his enormous prostate, with no cancer at all.

Here's the question: Did I do the right thing by trotting out the C-word at the start?

It's a real one, and I don't know the answer yet. I will be talking to the patient in the next few days, and (assuming everything is fine) I shall ask him how he felt about it. I'll report back here, and we can all compare notes.

Whaddya think?

From the Department of "You Can't Make This Stuff Up"

Overheard in the doctors' lounge: a colleague had received this letter from a patient:

I understand that Lipitor has pancreatitis as a potential side effect. As you know, I was taking Lipitor at the time of my hospitalization for pancreatitis a few months ago. Would you please review my records and see whether it was the Lipitor and not my heavy drinking that may have been responsible for my pancreatitis?

The sad thing is that the Department of Risk Management is now expecting him to review this patient's two inch thick hospital record, and come up with an actual answer.