Note to Self

When your agent calls you at work during the day, it's because she has something important to tell you. (Definition of "important": something your agent feels warrants more than an email.)

After she has told you what she needs to tell you and you respond appropriately, STFU already! She does not need to hear about the next four books rolling around in your head and your grandiose daydreams about what blockbuster hits they're going to be. She is presently focused on your current book, as she (and you!) should be. She will listen to you and even laugh at your jokes, mainly because she hasn't heard them before. They're funny, but only the first time, so don't go repeating them three times in the same conversation. Yes, you're totally floored by the fact that she likes you (given that your feelings for her are somewhere between awe and adoration) but she really does have other important things to do. In general, she will be too polite to cut you off (though don't push it; I wouldn't put it past her!) but quit blathering on about stuff she does not need to know yet. Write the f-ing books before you start regaling her with them!

Note to others: This is probably good advice in general.

Science I Can Get Behind

Thanks to CrankyProf, for a truly scary glimpse at the future of the race, aka "dumb shit overheard on campus." Then again, I must confess that the last comment resonated with me:

We learned about calories in physics and chemistry today. I figure since calories are really a heat thingy, frozen food doesn’t count!

Excellent point! For those of us on perpetual diets, I'm thrilled to realize that frozen foods, by definition, have no calories. (Kind of like broken cookies; the calories spill out of them.)

The Emporer's Fashion Show

Oh, fer cryin' out loud!

I've resisted weighing in on the latest and greatest [/sarcasm] gift to medical practice, promulgated by my very own AAFP and known as the "Patient Centered Medical Home," because frankly, it's all a crock of shit.

For those readers still blissfully ignorant of what I'm talking about, feel free to click on the above links and the explanatory links within. But beware of terminal boredom and irony overload.

KevinMD and others have discussed this topic ad nauseum. It is the source of endless angst among family doctors in solo and small group practice, because the structure of the PCMH excludes us by definition. The PCMH is advertised to work best in large group practices like Kaiser and the Mayo Clinic. All I can say is "DUH!"

You know what the PCMH really is? Nothing more than this:

IT'S A WAY TO MAKE LARGE GROUP PRACTICES WORK MORE LIKE A SOLO DOC!!!

I am already performing every meaningful function of the PCMH. So is virtually every physician in solo and small group practice. There is absolutely nothing to be gained -- and a significant amount of money to be lost; this thing is expensive! -- by adopting any of this PCMH shit. Somehow that doesn't seem to stop our Academy from tossing us to the wolves by simply ignoring us.

None of the "reforms" currently coming out of Washington have a prayer of actually impacting health care in this country. The enormous sums labelled "down payments" are going to be put to use in exactly the same manner as AIG used their federal trough bailout money. No one who has any direct involvement with patient care will see a penny. Those who are already rich beyond the dreams of avarice will be enriched further, not that any amount of money will fill the hole in their soul that forces them to continue their meaningless accumulation of monetary wealth.

Nothing in this country will change until patients change how they view and use health care, and until doctors reclaim their professionalism and change how they approach the business of medicine.

No idea what I'm talking about? Stay tuned. It's the subject of my next book.

Pneumonia on a Budget

Saw a guy today with no insurance, plus fever, chills and productive cough. His chest sounded clear and his oxygen wasn't too bad (95% sat on room air) but he looked really crappy, so I sent him for a chest x-ray and gave him a prescription for clarithromycin 500 BID for 10 days. As it happened, the x-ray came back positive for pneumonia with a patchy right upper lobe infiltrate, so I told him to be sure to fill and finish the antibiotic.

How much did the day cost him?

I told him I could easily have buffed the chart to justify a level 3 visit ($70) (or even a 4 for $100) but my usual practice for the uninsured is to bump it down a notch.

My charge: $55.00

Instead of sending him to the hospital for the x-ray, I sent him to a new free-standing radiology facility that charges the uninsured only 10% over what Medicare would pay.

Chest x-ray: $62.00

One of the local supermarkets is running a special on free antibiotics. Unfortunately, the one I wrote for isn't on that list, and they wanted $78 for it. He called CVS and their price was $92. He went to Costco instead.

Antibiotics: $17.00

If my math is right, that comes to $134.00 grand total for medical care for today's diagnosis and treatment of pneumonia. What this demonstrates is that there are options for economical medical care with no sacrifice in quality. (Levaquin, another antibiotic commonly prescribed for outpatient pneumonia, is hideously expensive, typically costing $10-$15 per pill. Not only that, but it isn't even the best choice in terms of antimicrobial coverage for community-aquired pneumonia.) That total also comes to a fraction of what a monthly health insurance premium would cost him.

It just goes to show that even in this day and age of "broken" health care, there are bargains available for the savvy doctors and patients who know where to find them.

I Called It: The Ozone May Not Be Falling, but Something is About to Hit the Fan

It's been more than two years since I posted my screed about CFC-free inhalers under what I thought was the pretty cool title of The Ozone is Falling, The Ozone is Falling. To briefly recap, rescue inhalers for asthma deliver the drug albuterol. The CFC propellant used by the generic inhalers was deemed too dangerous for the environment, and so they were banned. The problem is that the new hydrofluoroalkane (HFA) propellant doesn't seem to work as well, and NOT just because patients aren't used to the weaker "whoosh."

I take a great deal of care explaining metered dose inhaler technique to patients, emphasizing the need to inhale the medicine slowly. As it happens, the lighter "blow" of the HFA inhaler makes this easier. Still, in spite of this, I too am hearing complaints about efficacy.

Now (two years later, but who's counting) KevinMD deigns to weigh in. *Sigh* None of this should come as any surprise. The only thing we're waiting for now is the first reports of deaths from ineffective HFA rescue inhalers. Scary times.

Proud Parent Alert

"Maslow's Heirarchy of Needs"
by DinoDaughter

What can I say? I love the colors.

(Link)

This is True

I've had it this week.

Defining Terms

New patient for a well-child visit; taking a routine history:


Me: Have you ever been operated on for anything?

Kid: Yeah, I had stitches once.

Mom: No, dear. The doctor is asking about surgery; you know, that you go to sleep for.

Kid: I did! I fell asleep while they were putting them in, remember?


I guess that one, unlike this, was definitely anesthetized.

He Asked

From time to time, I still get taken in. From the comments:

Dear Dinosaur #1,

I always get a chuckle out of your blog. From where I stand, you have your finger on the pulse of what’s happening in the practice of medicine. Please forgive my unorthodox communiqué. Although I have never left a message on a blog before, I do hope this one reaches you.

I’m an ophthalmologist and I would like to ask you for a favor. My wife is also an M.D. She and I have put together a report describing 8 ways physicians in private practice can ethically and professionally make their practice more profitable. I would be most indebted if you would be kind enough to read our report and let me know your thoughts.

With appreciation,
Robert

Followed by contact info, including phone numbers and website.

So like someone with nothing better to do, I went over and checked out the site. Sure enough, it's nothing but marketing mumbo-jumbo purporting to provide all kinds of help to physicians to increase their practice income...and for only $6,700 for their "Guided Practice-Building System(tm)" [yes, apparently it's actually trademarked] which includes both pre-recorded audio consultation and 10 hours of one-on-one telephone consultation, plus unlimited fax and email questions during the "consultation period."

Or, if you want more, you can have their Two-Day, On-Site, Practice-Building Assessment & Consultation, which also includes staff coaching, patient satisfaction evaluation and a 30 day period of unlimited email and fax communication to assist in implementing recommendations along with 4 more fifteen minute phone consultations. That's only $15,900.

Seems to me like the best way to make money is no longer actually practicing medicine, but rather selling practice management and consulting services to other suckers doctors.

There was a contact page where I could address my response in private, but it had a 1000 character limit. So, in response to the direct request for my thoughts, here they are:

Dear Dr. Karlsberg;

Thanks for your comment on my blog. I perused your website, downloaded and read your "7 Barriers" report. Here is my assessment:

You may very well be an ophthalmologist, but what you and your MD wife are now doing is providing highly priced marketing services to gullible physicians that appears aimed primarily at positioning them to go to a cash-only and/or concierge model practice. Your slick website (which really is lovely) and extensive use of marketing jargon -- most of which is meaninglessly generic -- seems intended to intimidate potential doctor-clients into thinking you are offering something of value.

Bottom line: thanks, but no thanks. Personally, I feel I have a good handle on my practice's financial issues, and in fact I am moving towards a cash-only model in the next few years. As for other docs, mainly struggling FPs, I would discourage them from spending the kind of money you are charging for what appears, in my opinion, to be a very marginal benefit and extremely unlikely to produce any significant return on the investment.

Best,
#1 Dinosaur

Hey, he asked.

Bernie Madoff's Real Crime

As anyone who doesn't live in a hole must know by now, financier and crook Bernard Madoff was taken into custody yesterday for bilking thousands of investors of billions of dollars by way of a giant Ponzi scheme. Obviously the "A" list of victims is replete with folks rending their clothes and screaming for blood. Two of them apparently committed suicide. Here's my take on Bernie's real crime.

So many savvy investors taken in by outrageously favorable returns on their money over ridiculous periods of time; so many multi-millionaires who were so blinded by the opportunity for more-more-more that they arrogantly chose to believe that the old truism, "If it looks too good to be true, it probably is," did not apply to them; all I can say is this:

Bernie's biggest crime was being more greedy than they were.

Horse-Zebra Hybrid

When you hear hoofbeats, think horses, not zebras.

This old medical expression is the way we doctors express the truism that common things are common. It is also true that, on occasion, we see rare diseases or conditions and this is why we call them "zebra" diagnoses. Another version of this is a "zebra" presentation: a common condition presenting in an atypical or unusual way. Then there's the in-between version, like a case I had a few weeks back: a relatively common condition presenting in a common way, but with a statistically uncommon cause.

I saw an 85-year-old man with weakness and fatigue. Before you go generating hundred-page-long lists of differential diagnoses (not hard to do, I know) let me add that this was relatively recent in onset. Up until about three weeks ago, he was just fine. Mentally intact; living alone and caring for himself unassisted, although he no longer drives. About the same time this began, he'd been started on a new drug by another doctor, but because of the fatigue he'd stopped it after only three days and hadn't gotten better. Now, three weeks later, he was getting worse.

[I'm not presenting this as a full-blown clinical puzzle, in which case I'd rattle off his med list (three blood pressure meds, one cholesterol pill, and an aspirin and a diuretic) and the findings on physical exam (BP 110/50; 30 pound intentional weight loss over the last two years; otherwise nothing) now, but none of that applies to the point I'm trying to make.]

His workup revealed a calcium level of 12.4 (normal range 8.6 - 10.2)

This is a condition called hypercalcemia, and causes muscle weakness, fatigue and depression, among other things (usually kidney stones and inflammation of the pancreas.) If the level gets very high, it can cause coma and cardiac arrest. It was clearly the source of his symptoms.

What causes hypercalcemia?

The two major causes are malignancies (classically multiple myeloma and prostate cancer; basically any cancer that metastasizes to bone, which is where the calcium comes from) and an over-production of parathyroid hormone. This hormone, which increases calcium levels, is produced in the parathyroid glands. These are four little niblets of tissue nestled in the back of the thyriod gland in the neck. Sometimes one of them can grow a tumor that produces PTH regardless of serum calcium levels, which are normally held within a narrow range by multiple regulatory mechanisms.

Multiple myeloma and other cancers are more common the older you get. Prostate cancer in particular is incredibly common in men over eighty.

Parathyroid tumors are most common in women over sixty.

If you took one hundred 85-year-old men with hypercalcemia, ninety-five of them would have prostate cancer as the etiology of the condition; four of them would have multiple myeloma or another cancer.

Surprise:

This patient had just seen the urologists for a relatively slight increase in PSA (actually, it was his PSA velocity that prompted the consult) that turned out not to be cancer. Tests for multiple myeloma and other cancers were also negative. But his PTH level was elevated almost four-fold.

A true zebra-like presentation of a condition that isn't all that rare. If you went with the odds, though, you'd never come up with it. The correct diagnosis in this case came from my being thorough and ordering a test, the PTH, that I really thought was going to be normal.

I consulted with a surgeon and put the guy through a mega-workup of imaging, trying to locate a single parathyroid adenoma which could be removed. As it happened, we didn't find one and the surgeon didn't want to operate. So I sent him for an infusion of Zometa, which knocked his calcium down beautifully. I'm following him once a month, and whenever it climbs back above 10.5 -- or he gets symptoms again, now that he knows what they're from -- I'll send him for more Zometa. Three, four times a year; whatever it takes. He's 85, after all. He and his family are fine with this as a management plan, as they weren't crazy about the idea of surgery either.

So there you have it: a true hybrid between a horse and a zebra.

Alice in Pre-Cert Land

The wild and wacky world of drug pre-certification has become downright surreal of late.

Case 1:

Patient who has tried three of the four available nasal steroid sprays with inadequate response to each. I suggest trying the last one (which happens, in my personal perennially allergic opinion to be the most efficacious) and write the prescription. Not unexpectedly, I get a request for a prior authorization. I get the first sense of foreboding upon perusing the form: there is one -- and only one -- question:

Has the patient had an adverse reaction to [the preferred medications]?

Well, no, but they didn't work. I write this extra information in around the single question on the sheet and fax it back. Surprise (not): the only acceptable criteria for coverage of the requested medication is an adverse reaction to the preferred ones.

What they're saying is that they will only cover medications that don't work for this patient.

That was the red pill. Ready for the blue one?

Case 2:

I see a patient who, I fear, has a peptic ulcer. I prescribe generic omeprazole 40 mg. (I am aware this is available over the counter, but in the quantities he needs it can get pricey. He pays for prescription coverage, so I figure I'll try writing it for him. And don't go telling me I should just write for Nexium. The response is the same for any PPI.) I receive a phone call from the pharmacy that the medication requires prior authorization, despite the fact that it's a generic. My staffer spends an outrageous amount of time on the phone being told she needs to call no fewer than three different 1-800 numbers. The final verdict:

The prescription will only be covered if the patient fails the OTC version.

Okay, let me see if I've got this straight: they will pay for the prescription, but only if it doesn't work.

I'm sorry, but "WTF" just seems so inadequate. My mind hurts trying to twist its way around this nonsense. I need drugs. No, wait: they'll probably need pre-certification. I'll just have to settle for alcohol.

Large, Metal Germs

Encounter with a new patient, aged 7:

Me: Do you have any pets?

Kid: We had a cat, but it died. It had a germ.

Kid's father: No, it was hit by a car.

Yes indeed; a great big metal germ.

Birthday Addendum

Thanks to the United States Preventive Services Task Force, the occasion of one's fiftieth birthday has come to include good-natured ribbing regarding one's newly acquired eligibility for colon cancer screening. I'm a doctor. I know this. I tell patients this all the time. So what did I do on the occasion of my fiftieth birthday?

Nothing.

I figured I would get around to scheduling one eventually. There was really no rush.

I had a regular day. I went to the office. I saw patients. I dealt with paperwork, including the mail. One item left on my desk was a short, stubby envelope from the local gastroenterology group. I opened it and removed an embossed card containing text in a font and format that looked like an invitation or announcement. I looked it over, expecting to see something like an announcement of a new associate. You know, something like,

"We are pleased to announce that Dr. Sigmoid Cecum has joined us in the practice of gastroenterology. Dr. Cecum has special expertise in the diagnosis and treatement of diseases of the sphincter of Oddi, and is now accepting appointments. We look forward to providing continued service to you and your patients."

No.

It was an invitation to a special Saturday morning session for screening colonoscopies "for Physicians and Spouses Only," embossed card, fancy font and all.

That's right: I actually got an engraved invitation to schedule a colonoscopy on my fiftieth birthday.

What else could I do but schedule it? And for you sick individuals anyone who suggests either live-blogging or Twittering the procedure, all I can say is don't hold your breath. You are likely to rapidly turn an exceptionally unhealthy shade of blue.

Fifty Years

I was born fifty years ago today.

I don't look any different (than yesterday.) I don't feel any different. Today does not represent some huge existential crisis for me. I don't mind turning fifty. Why should I? I have a successful career and am on the threshold of another. I have a Darling Spouse and healthy grown children. I have a roof over my head and food (sometimes too much) on my table. I have my health. So what's the big deal about "the big five-oh"?

A day isn't very long. Nor is a week, or even a month, and now even the years seem shorter. The divisions of time as we measure it may be arbitrary, but as I look back I suddenly realize that fifty years is a long time.

The 60s were the years of my childhood, memories faded into sepia even as Kodachrome was coming into vogue.

The 70's, an era now ridiculed for shaggy hair and bad music, were my coming-of-age.

The 80's were my training. Dominated by medical school and residency, I still managed to get married, buy a house, have three children and grieve the loss of my mother.

The 90's were supposed to be the building years of my thirties. I built my practice, but the marriage failed and I found myself flung into the chaos of adult singlehood.

The Aught's (or whatever we're calling this zero decade) have been my forties. It's been a time of great change that frankly I could never have predicted. Finding Darling Spouse was one of the kindest blessings the universe could ever have offered. My kids are great; not fully grown, but fun, wonderful people well on their way to making it on their own in the world. Ten years ago I had a cat; now I have four, not to mention a tiny, paraplegic dog. And now the chance for a new career as an author when it is only in this decade that I began calling myself a writer.

The world has changed in so many ways. Far be it from me to launch into a history of all the political and scientific changes over fifty years, but however you look at it, fifty years is a long time.

If I live to be 100, then I am entering the second half of my life; if not, then I have already had more than half my allotted time on the planet. None of that feels important. Whatever I do today is what matters. Whatever tomorrow brings, I will face it then.

Still, just this once, I look back and treat myself to the thought that fifty years is a long time.

I confess that I've always loved birthdays and enjoy making a big deal out of them. In our culture, though, it is unseemly for adults to do so -- except for birthdays that end in zero and some that end in five. Therefore I am looking forward to having an excuse for making a big deal.

Today I am fifty. What am I going to do now?

I'm going to Disney World.

The More Things Change...

Weighing in (along with such as Orac, PalMD, Val Jones, and Tufted Titmouse) on the anti-scientific debacle that is Senator Tom Harkin's disappointment that the NCCAM hasn't "validated" more alternative medicine therapies, it occurs to me that we've heard this kind of thing before, albeit from the Republicans. Quoting Harkin:

One of the purposes of this center was to investigate and validate alternative approaches. Quite frankly, I must say publicly that it has fallen short. It think quite frankly that in this center and in the office previously before it, most of its focus has been on disproving things rather than seeking out and approving.

Doesn't that sound exactly like George W. Bush complaining that the UN inspectors failed to find weapons of mass destruction in Iraq? He *knew* they were there, therefore the inspectors' failure to find them couldn't possibly have meant that they weren't.

Plus ça change, plus c'est la meme chose.

En Route; A Paramedic's Stories of Life, Death and Everything In Between

Who here likes to read?

Okay, silly question for a blog.

How about this: Who here likes to read kick-ass writing that grabs you by the throat and by brute force alone refuses to let you turn away?

Lots of hands; great.

Who here has ever read a blog written by a dude who goes by the nom-de-blog Ambulance Driver whose real name is Kelly Grayson and whose kick-ass writing grabs you by the throat and by brute force alone refuses to let you turn away?

Okay, anyone who didn't raise their hands needs to make with the clicky. Suffice it to say, you don't know what you're missing.

Next question: Who here has ever had the desperate need to move away from the computer for one reason or another but has found themselves grabbed by the throat by the brute force of AD's writing, refusing to let you turn away?

For you, I have wonderful news.

Now available everywhere is AD's book, En Route; A Paramedic's Stories of Life, Death and Everything In Between. What this means is that you can read a combination of the most gripping stories ever to appear on AD's blog, mixed in with new stuff that's just as kick-ass gripping that you've never read before -- and not be stuck in front of your computer! This is an actual book -- paper and everything -- that you can carry with you and read anywhere. In the airport; on a plane; in the john (my preferred locale); anywhere you want to sit, lie, recline. No longer are you tied to a screen and keyboard. You are free.

But you have to buy the book.

I dare you to read Kelly's re-telling of a ten-year-old case as he sits outside the house remembering, without choking up. That holds true even if you've read it before. A tiny sample:

When you're a father as well as a cop or EMT, your particular curse is that you see your child's face in every tragedy. You see your teenager in the bloody, broken face you pull from the wreckage of his graduation present. You see your wife's face when you knock on a stranger's door at three-thirty AM to tell her that her daugher has died. And you see your infant's face somewhere in that purple, mottled face of a baby wearing fuzzy yellow pajamas, and you start CPR even though your rational mind reports that you are far too late in coming.

There's more. In case I haven't already made it abundantly clear, this is kick-ass writing that grabs you by the throat and by brute force alone refuses to let you turn away. It's the best of AD, his highs and his lows, and not to be missed. All I can say is, Kelly: you rock.

Thank Goodness for Case Management

I have no idea what Case Management is, but it's something that big insurance companies pay nurses (who can't or won't hack real nursing jobs anymore) with some of the money they aren't paying me.

Two weeks ago, I got a call from a Case Manager about an elderly, demented patient I hadn't seen in about a year. She had fallen, been admitted to the hospital despite having no fractures, and then transferred to a rehab facility. Her son had called me about all of this. Apparently she wasn't doing well at rehab, so they were supposed to send her back home. Her son had called to let me know this, too.

When I got the call from the Case Manager, I was trying to handle calls on two other lines at the same time, so I asked what she wanted.

Case Management RN: "I just want to give you my name and phone number."

Me: "Okay. Why?"

CMRN: "Because her insurance company offers case management services as part of her coverage."

Me: "Okay. But what do you want me to do?"

CMRN: "I'm going to fax you a form."

Me? "What for?"

CMRN: "Giving you my name and number."

Me: "Fine." click (I was really frazzled at that particular instant.)


I wrote down her name and number, and got a faxed form with her name and number, and a request for all kinds of information that I couldn't possibly provide, given that I hadn't seen the patient in about a year, so I stuffed it all into the patient's chart and ignored it.

Last week, the patient's son called to let us know his mother had died peacefully and to thank us for all we had done for her.

This week, I got a call from the Case Manager. She wanted to let me know the patient had died.

What on earth would I have done without her? [/sarcasm]