Why is This Legal?

So I was talking with a lawyer the other night (briefing him about health care, actually) and the topic of "referrals" came up. He mentioned that when he as a lawyer is unable to help a client and makes a referral to another attorney, he gets paid by that attorney; either a flat rate or a percentage of any recovery made in the case. Routinely. It's how they do business. No one thinks twice about it.

Excuse me, but as a doctor we call that a kickback and/or fee-splitting. It's considered illegal, immoral, unethical and grounds for license revocation. Rep. Peter Stark of California has eponymous legislation that has now spawned three separate phases and untold reams of regulation that has drastically impacted the way doctors are legally permitted to do business. I recently read that at this point, even he agrees the entire exercise has been a waste of time and effort. [Thanks to Anon 8:54 for link]

Yet apparently lawyers pay each other for referrals all the time. Excuse me, Tim, but: un-F***ing-believable!

Brown Bag Review

Managing patients' medications is an ongoing struggle. One way to keep track of their pills is to ask them to bring all their bottles in to an office visit. This has been called the "brown bag review," and is something I do frequently. It is often very helpful. Not only do I get the chance to verify what medications are being taken, but I can also confirm doses and refill status. On occasion, I also find it helpful to count the pills that are left in the bottles and compare them with my records; great way to confirm compliance.

The thing is, virtually everyone uses white plastic grocery bags to bring in their bottles. They're bigger, stronger and infinitely more available. They certainly accomplish the stated aim, but now and then I enjoy teasing my patients by complaining that no one follows directions anymore: how can I do a "brown bag" review when I'm continually presented with bags that are white plastic instead of brown paper?

Well just this morning, a lovely older couple who have been in my practice for many years (and to whom I've previously complained about white plastic bags) gently teased me back: they went out of their way to find an actual brown paper bag in which to bring their medications.

Finally! Someone who listens!

Breaking a Rule

I have previously expounded on what I've called Dinosaur's Blogging Rules, and about a month after that I also posted My Personal Blogging Rules. In case you don't feel like reading both of those previous posts for the detailed discussions, here are the actual rules:

Dino's Blogging Rules:

1. Write well.
2. Say something.
3. Mix it up.

My Personal Blogging Rules:

1. No commercials.
2. Comment rarely.
3. Blogging about blogging is boring.
4. It's more about the writing than the readers.

Why am I rehashing this now? Because I'm about to break one of the above rules.

Why?

Why not.

It's Personal Rule #3: I really do think that blogging about blogging is just boring. So far, I think I've done a pretty decent job of refraining from posts like:

Going on vacation. Blogging will be light for a while.

I've just gone and come. I realize some readers probably care about me as a person (amusing, given my persona as a large, extinct reptile) and may become concerned about a prolonged lack of posting. But I would also hope they would get a life, even as they assume that I am doing the same. But now I find myself wanting to explain why blogging may be a little lighter than usual for the next few weeks or months, even though it means breaking one of my own rules.

It's because I've gotten involved in several *paying* writing projects of late, both on the internet and in the Real World(tm). My self-imposed goal is 1000 words per day at least until October, which should put me in good shape to meet contractual deadlines. Although I'm not (yet) at liberty to say more, suffice it to say that there is an extremely exciting announcement in the works.

And oh yeah: Yesterday was my second Blogiversary. Two years of Dino Blogging has been great fun. Who knows what the next two may bring?

Clinical Case: Taste Disturbance, Otitis Externa and Other Symptoms (Part 2)

Part 1 is here.

(Note: This post was written at the same time as the case presentation, so none of the comments are taken into account -- because they didn't exist as I write this.)

The patient's daughter had discovered a condition known as Herpes Zoster Oticus -- also called Ramsay Hunt syndrome. It is basically shingles of the geniculate ganglion, and it explains every single one of the patient's symptoms!

Essentially zoster of the ear, Ramsay Hunt consists of a painful vesicular rash in the external ear canal associated with a facial nerve palsy, vertigo, oral vesicles and taste disturbance. Treatment is with antivirals directed against herpes zoster, which I had already initiated, and steroids. (Actually, I increased the dose of the Valtrex and extended the course another week at the higher dose.)

I still believe the right pinna had become secondarily infected with a bacterial pathogen, which also speaks to the question of steroids. By the time the diagnosis was clear, I didn't think we were still within the time window for steroid efficacy, so I elected to omit them. I did offer him narcotic pain relief. No wonder his ear didn't feel better even as the bacterial infection was clearly responding to treatment!

As I said, I never heard of Ramsay Hunt syndrome. I felt certain that all of the symptoms were somehow related, as they were anatomically related to his ear (vertigo from the labyrinth medially; facial nerve passing anteriorly) but I couldn't fit them together until the patient's family did my internet research for me, for which I was grateful. For me, it was a thrill to have a single entity to explain all the symptoms.

Now 'fess up: Who else has never heard of Ramsay Hunt Syndrome until now?

Edited to address comments:

Ok, so apparently it wasn't all that obscure; oh, well. Then again, human nature being what it is, I suspect that there was a significant bias towards those who HAD heard of Ramsay Hunt saying so in the comments and those who hadn't just clicking on to something else.

As far as feeling bad about never having heard of such an "obvious" diagnosis: nope, ain't going there. I believe one of the things that differentiates me from other doctors, and especially other blogging doctors, is my ability to admit to my shortcomings; both to my patients and on my blog. Oh, plenty of people talk the talk about not knowing everything and not being perfect and such; I walk the walk. If I've never heard of something, I admit it, because that's how I learn. I'll thank my patients for finding me the information, and I'll come right out and blog about things that don't necessarily show me in the best light.

In private, dealing with patients, I firmly believe that this approach does a great deal to enhance my credibility when discussing material with which I am familiar. If they know I'll tell them when I don't know something, then when I tell them I am sure of something, they know they can trust me.

In public -- on the blog -- I've grown a thick-enough skin not to care (too much) when people berate or belittle me. Hell, I've had to! Otherwise I'd be cowering under the bed after those last two diabetes posts.

Two feeble points in my defense, though: by the time I first saw his ear, it was already secondarily infected and swollen shut, so there was no way to appreciate any vesicles in the external ear canal. As for the very first symptom, the taste disturbance (dysguesia) alone, drug reaction would be at the top of the differential. I dare anyone to even consider something as far-fetched as Ramsay Hunt when that's the only symptom. (Of course, *now* I will...)

As for sending my patient to a specialist, sure I could have called a neurologist; they would have been happy to see him in October or November. Fat lot of good it would have done him by then. And by the way, his cardiologist (with whom I remained in contact because of the recent stent and what I thought was the role of the Plavix) had never heard of it either.

Lynn: regarding your insertion of my evil twin in Chapter 17: I happen to know that book of yours has only 16 chapters.

Many thanks to all who commented.

Clinical Case: Taste Disturbance, Otitis Externa and Other Symptoms (Part 1)

(Blogged with patient and family permission)

At last! A zebra, of sorts.

70-something-year-old man one week status post coronary stent placement presented with a complaint of two days of severe taste disturbance. He described it as "bitey"; whenever anything touched his tongue -- even water -- he complained of an acid-like, vinegary taste. All food and drink produced this sensation. There was no oral pain nor pain in the tongue. There was no complaint of dry mouth. On exam the tongue had a faint brownish coating, but nothing else; no inflamed papillae or taste buds were noted. The rest of the exam was completely normal.

The patient was on multiple medications, but the only new one was Plavix, begun after his stent placement last week. Perusal of the PDR revealed a single mention of "taste disturbance" in the Post-Marketing section of the entry for Plavix. At this point my working diagnosis was dysgeusia as an adverse drug reaction to Plavix. Unfortunately, we were unable to stop the drug, so I sent the patient out with instructions to experiment with different foods, flavors and textures to see how he might best cope with this distressing symptom.

Two days later (on a Saturday night) he called complaining of severe right ear pain. He was camping and felt he might have been bitten by some kind of insect, but now the ear was swollen, painful and draining. I met him at the office and discovered that his right pinna was markedly swollen, hot and red. The external canal was swollen shut, therefore I was unable to visualize the tympanic membrane. There was some serous drainage that seemed to be coming from several areas on the antihelix and other parts of the pinna itself. The ear was very tender to touch.

I also noted a small patch of white vesicles on the right side of his soft palate, and perhaps some slight flattening of the right nasolabial fold. The tongue appeared unchanged.

At this point I diagnosed a bacterial otitis externa, probably secondary to a possible insect bite or sting, though I thought it could also have started as a contact dermatitis. I prescribed Augmentin and hot soaks. The lesions on the palate were consistent with Herpes Simplex virus. The patient did have a history of cold sores in the past; frankly I wasn't quite certain why he now had intra-oral lesions, but I treated him with Valtrex nevertheless.

When I saw him back two days later, the ear was much less red, hot and swollen, though he stated that the pain had not decreased. There was still some serous drainage from areas on the pinna, but I could now see into the external ear canal; it was clear and the eardrum was normal. However he now had a definite right facial nerve palsy: he couldn't fully close his right eye; the right side of his mouth drooped and there was decreased forehead furrowing on the right. He was also complaining of dizziness, confirmed to be vertigo with careful questioning. In terms of treating the facial weakness (often caused by Lyme disease or a herpes virus) I had already begun Valtrex. I didn't want to give him steroids with the active bacterial infection in his right ear. I did review eye care, including the use of patching at night and artificial tears during the day. With the evidence of herpes, I did not feel it necessary to rule out Lyme disease.

I saw him again later in the week, and not much had changed. The right pinna, now normal in size and color, was still draining. The Augmentin knocked him for a loop, not unexpectedly, and he had lost a few pounds. The vesicles were now gone from his soft palate. Interestingly, the taste disturbance seemed to be subsiding. I suggested he continue hot compresses and complete the course of Augmentin, as his ear was clearly better, and that he finish the Valtrex.

A few days later, the patient's daughter called and described a discovery she had made on the internet.

Have at it! (Answer to be posted Monday.)

PLEASE NOTE: Obviously googling the symptoms is cheating, as the diagnosis is easily found. I had never heard of the eponymous condition my patient had and I'm curious about who else has and hasn't.

When Sauce for the Goose isn't Gravy for the Gander

So even though the insurance company (I won't say which one, but it's named after a color and a shape) requires that we submit claims within six months of the date of service (a "timely manner") they go ahead and recoup payments "in error" made in -- get this -- 2005!

Nothing we can do about it either. It's just deducted from a check that includes payments for multiple claims, leaving us high and dry, bending over and taking it up the rear yet again.

I really need to go to a cash-only practice.

Whose Patient is it Anyway?

For some reason I've had a recent run on breast cancer patients. From abnormal mammograms to masses I've found on exam to lumps the patient has found herself -- all have ended up with positive biopsies and surgical referrals. All have proceeded to oncology and radiology evaluations and are receiving appropriate treatment.

I know it's petty, but here's my beef:

All subsequent cancer correspondence on these patients is addressed to the surgeon, while I'm reduced to a name on a cc list. I suppose I should be grateful that I'm getting any information on them at all, but I find it a little galling that although I'm the one who found the initial lesion, I am now considered peripheral to the patient's care. (I'm not even going to start in on the fact that the surgeon is choosing the oncologist without asking my preference first. As it happens, there are two excellent groups in town, though I do have a distinct preference. Unfortunately they've been sending them to the "other" one.")

Part of the problem is that when the surgeon passes the patient on to the oncologist himself, pieces of the longer-term history often get lost. I have a much more productive relationship with the oncologists when I'm the one referring to them directly. If nothing else, the letters are addressed to me. I find they get better care this way (or at least they tell me they're more satisfied with it, which is generally considered a functional proxy for quality of care.)

Perhaps it's the logical extension of the old surgical maxim, "You cut it, you own it." No wonder surgeons may be more prone to a Gd-complex than other docs: they "own" people. Well news flash! You may be the primary surgeon, but you're not the primary physician. That's me, and I'd appreciate you keeping that in mind.

To The Nestling, With Love

Calculus humor:



Hat tip: Pure Pedantry

Can You Say "Oops"?

Sent a patient with a long-standing shoulder problem to the orthopedist. After trying a course of conservative care, the decision was made to operate.

So the patient shows up at the hospital on the assigned date. (Gets a ride from his wife, because of course he isn't going to be able to drive himself home afterwards.) Gets all set in the pre-op area. Gets his IV (after several sticks; not sure why; his veins are fine.) Waits for the surgeon.

And waits.

And waits some more.

Overhears his surgeon rushing to get another patient into the OR. Figures there might be an emergency, but no one comes to tell him anything.

He waits.

And waits.

And waits some more.

Finally...three hours after his scheduled OR time (1:00 pm)...someone sticks a head around his curtain and says, "You still here?"

"Uh, yeah. Waiting."

And waiting.

Finally they come. Tell him it will be awhile; does he want to continue waiting? (It's now 5:00 pm.)

"No."

"Can you come back on Thursday?" they ask.

"No."

So they pull his IV that's been infusing for however many hours he spent waiting and sent him home.

He called to ask me for another orthopedist. I complied.

How do you completely forget about a patient ready and waiting for surgery? Sheesh!

The Last Word on Diabetes

My, my, my, but didn't my little rant start a pissing contest!

Many thanks to all who commented. Obviously I appreciated those who agreed with me, but to those who didn't (specifically those who questioned my treatment of diabetes) let me say this about the disease in question:

Diabetes is the ultimate lifestyle disease. Despite the terminology of doctors "treating" or "managing" it, diabetes is a condition truly managed by the patient. Sure, doctors can prescribe and suggest (and cajole and persuade) but in the final analysis, diabetes control is pretty much completely in the patient's hands. (Which is why P4P measurements aimed at physicians are so unfair; but I digress.)

I have patients maxed out on three oral medications plus insulin who still run A1c's in the 8's, 9's and 10's. Every single visit includes treatises on the virtues of diet and exercise, along with the dangers, perils and hazards of non-compliance/uncontrolled diabetes. Sometimes it works, but -- NEWS FLASH! -- sometimes it doesn't.

I know how to teach patients to manage their own diabetes. How well they do it is up to them. It's just like a little secret I learned years ago: despite all the medical talk about "managing" pregnancy, women manage their own pregnancies. They listen to the doctors, then basically do what they want. (Don't get me wrong! I deplore it when they then refuse to take responsibility for their actions and blame the docs for anything they think went wrong.) Contrary to what the lawyers have everyone fooled into believing, medical "management" of most conditions doesn't amount to more than just a bunch of suggestions. Patients then do whatever they want.

(And yes, I'm quite aware that the title of this post is an oxymoron.)

How Not to Treat Diabetes

THUMP. THUMP. THUMP. THUMP.

This is the sound of a very angry dinosaur approaching.


Very nice 60-something patient with coronary disease, hypertension, hyperLDL, gout (the usual) and relatively mild diabetes. A1c's over the last two years ranged from 7.3 to 7.8%; ie, not perfect, but not horrible, MANAGED WITH DIET AND EXERCISE*. Already taking eight different meds for coronary disease, hypertension, hyperLDL, gout (the usual), so I was emphasizing exercise, diet and lifestyle management. Certainly considering adding some metformin at the next office visit.

So this patient is admitted for some chest pain (after going to the ER without calling me first) which was presumably found to be non-cardiac. (I wouldn't know; I never got any info from the hospital.) While there the blood sugar was found to be over 300. (I don't know if they checked an A1c; I never got any info from the hospital. ) I saw the patient in follow-up the other day, only to find out...(wait for it:)

They had added three (3) diabetes medicines:

1. metformin 500 mg BID (not just once a day, but twice!!)
2. glyburide 5 mg BID (not just once a day, but twice!!)
3. Januvia 100 mg.

Three new meds; all at once. Not one pill; not two pills; but five more pills a day were added to the medication regimen, when the A1C isn't even over 8%.

Ok, all you cardiologists, (and endocrinologists; according to the patient one of them came by also) since you obviously weren't paying attention on the second day of your third-year Medicine clerkship back in medical school; does this sound familiar:

Start low; go slow.

Hello!!! That means starting only ONE new drug at a time and WAITING to see how the patient does on it. MONITORING patients over "time" (that means not all at once.) You're not going to fix the patient's diabetes in 48 hours by loading up on meds in the hospital.

Ok; this isn't working very well (since my hands are still quivering with rage) so I'm just going to have to try channeling the poor man's CrankyProf:

You ignorant idiot fucktards! Bacteria in the bovine stomach fermenting grass into bullshit do their jobs more intelligently than you. It's a wonder you figured out which end of the pencil to take your Medicine Boards with, especially since it was probably stuck up your ass to begin with. Scarier still is that ignorant innocent patients entrust their lives to you. Morons like you make me want to beat you over the head with a 2 x 4, just to try and knock some sense into you. Here's the only problem with that: Why ruin a perfectly good 2 x 4?

Still hopping mad; this approach is simply not working. I'll just leave it at this, then maybe go punch something:

Ignorant assholes posing as docs piss me off.


(*References: Exercise, diet and lifestyle management is the cornerstone of diabetes management.)

My Mother

Things my mother loved:

• Cooking
• Baking
• Viennese cooking and baking
• Especially Linzer Torte
  

Tricks my mother taught me:

• Keeping a cannister of vanilla sugar in the pantry by cutting up a vanilla bean into one inch pieces and putting them into a cannister of sugar. (You'll never have to use artificial vanilla flavoring if you use this sugar for baking.)
• How to make the special lattice top for Linzer Torte

Things my mother would have loved if she were still alive today:

• Costco
• Large bags of almonds available at Costco
• Hand-held Braun electric grinders, sold for grinding coffee beans but can be used for grinding just about anything

Tricks my mother probably would have figured out on her own if she were still alive today, but that she would have been proud of me for coming up with on my own:

• Grinding up (in my hand-held Braun electric grinder) my own almonds (from Costco) and keeping them in a cannister in the pantry for making Linzer Torte, instead of paying exorbitant supermarket prices for ground almonds

Reasons I wish my mother were still alive today:

• To taste my really great Linzer Torte with the lattice top that looks just like hers
  

The Latest Craziness

Old man in atrial fibrillation orders his Coumadin from a mail-order pharmacy benefit manager. (I tried to send him to Walmart, or even Tar-jay, where they have even better deals, but he doesn't drive.) His INRs, measured monthly, range between 2.4 and 2.6 (ie, perfect.) Early last month we faxed refills for the Coumadin and his ToprolXL to the mail-order PBM, per his request. For some unknown reason, they ship his ToprolXL but not the Coumadin.

He called us. We faxed it again two weeks later. We also called in a thirty-day supply to his local pharmacy to hold him until it arrived.

Today he calls again: still no Coumadin in the mail. So we call the PBM. Four departments and six idiots later, we hear this about his prescribed dosage of 3 mg/day, except for 4.5 mg on Sundays:

That's considered high for his age.

See the gouges in the desktop from my saurian claws of outrage as I reply through clenched teeth:

His INRs are therapeutic and monitored regularly.

Aren't you proud of me for sucking back the words, "You ignorant fucktard!"

Another Example of Why I Can't Win

Patient A: Will you write me something for my vertigo, Doc?

Me: You can get meclizine over the counter without a prescription.

Patient A: Yeah, but it costs $10 and my prescription co-pay is only $5.

Me: Ok.

Patient B: Hey Doc; that script you wrote me for meclizine will cost me a $30 co-pay. Isn't there anything cheaper?

Me: You can get it over the counter for $10.

Patient B: So why did you write the prescription?

Me: (muttering) Because I can't win.

I'm All Over the Place

Thanks to Pure Pedantry for a lovely edition of Grand Rounds today; especially thanks for including my post.


Also: appearing today in Medscape's Business of Medicine:

Solo Practice -- Making It on Your Own

by yours truly.