The Best Way to Break Bad News: It Depends

My father pointed out a recent article in Parade magazine to me the other day. He claimed it was because the woman mentioned is a family friend of my sister, but his motives may be suspect in that he's always on the lookout for things he thinks would help me in my profession. This is amusing, in that most of the time I am either already well aware of whatever it is he sends me, or I could have written the article myself. Thankfully, he has not yet sent me any of the articles I actually have written.

The piece in question was about the do's and don'ts of breaking bad news to patients.

Old news, Pop.

The basics about conveying bad news are pretty basic: do it privately, expeditiously, and compassionately. Beyond that, I would submit that the specific answer to the question about how to deliver specific bad news to a specific patient is pretty much the same as the answer to the vast majority of other questions that get asked in medical practice: it depends.

The woman quoted in the article appreciated the fact that she was given her cancer diagnosis over the phone. It allowed her time to get over the shock privately, so that when she saw the doctor she was emotionally better prepared to deal with the discussion. Fine for her. I commend her physician for taking the time to get to know her well enough to appreciate that this was the right approach for her.

Now if he were to say, "Oh, this is how I always do it," I guarantee that there are patients floating around somewhere permanently scarred by his callousness. "How dare he tell me on the phone! The least he can do is tell me something like that in person!" or similar sentiments, are certainly ringing out somewhere. The trick, as always, is to individualize the breaking of bad news to meet the specific needs of each patient.

I happen to agree that there are systemic factors that contribute to unnecessary delays in the conveyance of information. I don't care what lab or pathologist you're using: biopsy results do not take two weeks. Doctors who are "too busy" to communicate results the same day they receive them are doing their patients a disservice. Without a doubt, there is room to improve the expediency of these critical communications.

Compassion, though, is in the eye of the beholder.

Some patients want the facts and just the facts, thank you. Their version of the best way to receive bad news is straight up. No need to waste time with any of this maudlin emotional stuff. Just give them the information they need to make whatever decisions they need to make. Or, just tell them what they need to do. Even in this era of "shared decision making", there are surprising numbers of patients who don't want to be bothered with that kind of responsibility. I feel very strongly that the new "collaborative" paradigm does not serve these kinds of people well at all. We shouldn't be afraid to make decisions for patients who explicitly request that we do so. Still, there are people whose version of compassion is decidedly NOT of the touchy-feely variety.

Others want their hand held all the way. They want the physician to be there with them while they do their initial crying, because although they are upset, they are comforted by the doctor's presence. The doctor who responds the same way to this patient as he does to the previous ones will be seen as a cold and uncaring automaton who probably doesn't have any feelings of his own.

Doctors have two options: figure out what each patient wants and individualize their approach, or treat everyone the same and hope that they attract only patients who appreciate that particular style. The former is desirable; the latter, I have found, is more often the case in the real world.

There is a push to involve patients in this decision, for example asking (as does a poll in the above link to Parade) how they want to receive bad news. I think this approach is bunk, even though it may sound logical and well-meaning. Here's why: people may have definite ideas about this question, but find their feelings are remarkably different when they find themselves in the actual situation. More important, they may not even realize it. I'm not saying not to ask; just consider taking the answers with a grain of salt, if a skilled physician feels that a different approach would work better than what the patient said they wanted. (Granted this can be a no-win situation, as there would likely be a mixture of responses, all the way from, "Why didn't he do what I said? I know what I want!" to "I'm so glad he did it that way and not the way I said I wanted him to," and everything in between.)

Once again, the answer to the question -- in this case, "What's the best way to break bad news" -- is: It depends! That's why medicine is still an art.

Another Article

Many thanks to Medscape for again featuring an article of mine:

The Emotional Ups and Downs of Solo Practice

Blogging has been light of late because other stuff is driving me stark raving mad. I'm sure I'll get back to it in short order. Really exciting stuff on the horizon. Really.

Impoverished Obituary

I sent a link to the previous post to the author of "The Impoverished Student's Book of Cookery, Drinkery and Housekeepery" with the subject line, "Fan Mail." Today I received this:

Dear Dinosaur,

Thank you so much for your great fan mail message to my father. Sadly, dad passed away from cancer a little more than a year ago. But, as your email proves, his indefatigable wit will continue to amuse and inspire readers of all ages for generations to come.

...Interestingly, you created the post the day after what would have been my father’s 67th birthday. It’s a great gift to those of us who cherish his memory, and I truly appreciate that you took the time to share your musings about his work.

Warm regards,

[his daughter]

Bummer!

Rest in peace, Dr. Rosenberg. As long as there are colleges and beer, your wit and wisdom will truly live forever.

From One Generation of Impoverished Students to Another

Thirty years ago, my mother presented me with an amusing little book she had found. Technically it wasn't even a book; containing all of 48 pages, it qualifies as merely a pamphlet. I'm not sure where she had found it, but she thought it was funny, starting with the "Analytical Index," a table of contents presented in the form of a flow chart. She presented it to me on the occasion of my first (and only, as it happened) year living off-campus in my second year of college. I also found it hilarious, and I enjoyed it immensely.

In addition to discourses about kitchens vs. KITCHENS, spice racks, and assorted recipes, it also held forth on such topics as the correct construction of the venerable brick and board bookcase, and suggestions for shared bookkeeping (toilet paper counts as food; liquor does not count as food.) It became one of my treasured possessions, living to this day alongside the rest of the cookbooks I consult regularly.

It was called The Impoverished Student's Book of Cookery, Drinkery and Housekeepery.

What made it so damn funny? The humor is dryly intellectual in both format and style. Homemade bread is described as:

...one of the few gifts of the gods to man not mediated by a hierarchical priesthood.

Here is what the Table of Contents has to say about Sandwiches:

Wherein the author, assuming the reader to know his own mind, says all he wishes to say on the subject of sandwiches in the compass of one page.

The section on "Budgetry" offers this:

Giving three methods for keeping books in various situations, at least one of which generates a beer fund.

Within its pages are contained recipes I have used many times over the years, primarily for punch (contained within Subsection the Third: NON-BEER-COLD of Section the Third: DRINKERY). One of these, labeled "Highly Spikable Punch" (frozen lemonade prepared with lemon-lime soda instead of water) has the following note:

Into a gallon of Highly Spikable Punch, one can pour with impunity an entire fifth of gin. It will not be noticed. Indeed, it can only be detected by sensitive chemical analysis. Vodka cannot even be detected that way.

I can personally attest to the truth of these statements.

As I say, it became one of my most treasured books. I recently had the occasion to take it down from the shelf and share it with the NinjaBaker, as he prepares to move into an off-campus apartment himself for the coming school year. Because he shares my sense of humor as well as my love of cooking, he too found it highly amusing. When he asked if he could take it with him (I was culling my cookbooks to provide him with some basics) I hesitated. More than twenty years after my mother's death, I have few tangible memories of her; this little pamphlet -- complete with the notation "Price: $2.95" on the cover -- is one of them. I declined.

As I went poking around it, though, imagine my amazement at discovering that this tiny beloved volume was originally penned in 1965, a good fifteen years before my mother discovered it. As a general rule, I have found that humor tends not to age well. That I enjoyed it a half-generation after its composition was cool. That it continues to appeal to my children thirty years later is truly a marvel. It appears that certain elements of college life (the appeal of beer funds, among others) are eternal. That, along with the author's acknowledged rhetorical gifts that obviously transcend generations. This thing reads like something CrankyProf could have written, if she happened to leave her potty mouth in the shop.

Remembering that this is the Age of the Internet, I discovered that my beloved pamphlet was still around (2 available, Used, from $29.90) on Amazon. That seemed a little steep, so I googled the author, one Jay F. Rosenberg.

It turns out the guy is now a professor of philosophy in North Carolina. His home page has pictures of his 60th birthday party, his daughter's wedding, and a grandchild. He's an aging hippie who looks like someone I know. I can't tell who; I just get the feeling I know him, probably because I know so many people who look like him. It also turns out that that very self-same home page contains the following link:

• Reed College Bookstore (where you can buy my Impoverished Students' Book of Cookery, Drinkery, and Housekeepery!)

Joy!

It turns out that the pamphlet, reissued in 2002, costs $9.95 ($2.00 shipping) when ordered from them. Anything (under $20) for the NinjaBaker! I promptly ordered him his very own copy, pleased once again to be able to pass along something originally from my mother.

Here We Go Again

Via Pharyngula, via Greg Laden, one of my favorite videos evah (see box to the right labeled "Beverage Alerts") now has a sequel:

My Son is a Dick

Phone rings at the office. Wonderful Staffer knocks on the door to interrupt me with a phone call.

My wonderful staff is well aware of the extraordinarily limited circumstances under which they are permitted to interrupt me with phone calls. One of these is when the call is from one of my children.

"It's the Jock," says MWS.

I excuse myself, exit the room and take the call. Here are the first words out of his mouth:

"I just got out of surgery."

I do not have an implantable cardiac defibrillator, so it takes a moment for my heart to resume its regular rate and rhythm as my mind races: Surgery! Accident? Fracture requiring open reduction? Other medical emergency? If he were scheduled for something elective, surely he would have told me.

Finally, after a period just long enough to catch my breath, he continues.

"Yeah. I saw a carpal tunnel surgery, and a knee get scoped, and I got to hold a kid's arm up after they reduced a fracture of his radius and put a cast on it."

As I gently exhale, I recall that the Jock's major is Athletic Training and that part of this semester's activities include shadowing an orthopedic surgeon.

"You know you're a dick," was all I said to him.

I could hear him smiling as he said, "Yeah, I know."

Science and Religion (and Sex)

I have a bone to pick with PZ Myers, professor of biology, lover of cephalopods, and blogger of renown.

Dr. Myers is an atheist, defined as one who believes there is no god. I have no problem with this, although Dr. Myers does share certain traits with some of the more aggressive proselytizers of other religions:

• He is certain that he is right.
• He feels the world would be a better place if others believed as he did, therefore...
• He is actively engaged in activities intended to encourage others to believe as he does.

This is actually beside the point I wish to make, which is this:

There is no conflict between science and religion, because they meet different human needs and serve different functions in human communities. Like exercise and diet, both vital to human well-being yet hardly interchangeable, religion meets emotional needs that are irrelevant to science. Science, on the other hand, admirably meets the intellectual need to understand the world and universe around us, along with providing us the tools (technology) to live longer and more comfortably. When religion and science are used appropriately, there is no conflict.

I will agree that religion appears to be used inappropriately far more often than does science, however in his endless anti-religion rants, Dr. Myers picks on the wrong people: those who misuse and mistake the role of religion. The endless reports of priestly pedophilia, Taliban excesses, and other assorted sociopathic behaviors in the name of higher beings makes it increasingly difficult to notice that there is anything positive about religion (especially if you purposely avoid looking for them because you don't believe they exist.)

An important and appropriate role for religion is to provide emotional comfort in times of pain. For every pedophile priest, there are hundreds of humble souls who spend their days and years counseling and comforting those in distress. It's all well and good for Dr. Myers and his cohorts to sit around swigging beer blithely discussing why there can be no such thing as life after death, but until you have watched a man standing over a coffin containing the second child he's buried in three months, and listened as he told you the only way he can continue to get up and go to work every morning is by knowing that he will see his boys again one day, it takes a lot of nerve to go rudely blathering about a "sky fairy."

Demanding scientific proof of the existence of god is inappropriate. The scientific method is vital to understanding how the physical universe works, but that does not mean it is the only method that should be employed in all forms of inquiry. For example, it is irrelevant in discussing literature. Scientists demand, correctly, that religion (in the form of creationism and intelligent design) be kept out of the science classroom. Dr. Myers should not be so hypocritical as to invade Theology class. Faith isn't open to debate. In fact, in this context, the word "debate" is misused. "Debate" implies openness to persuasion. Dr. Myers has made it quite clear that no one is going to be able to change his mind in such a debate, with which I have no quarrel. Why, though, does he expect that he will be able to persuade others of equally deep faith, if all are coming to the "debate" with their minds already made up?

So what's my beef with Dr. Myers? It's not his atheism, but his expressions of anti-religionism that are deeply offensive. Even as he demands tolerance for his views, he contantly and vociferously proclaims his own lack thereof. Make no mistake: ridicule is an especially pernicious form of intolerance.

One strategy he uses is to cherry-pick news items showing religion -- specifically, evil or ignorant people misusing religious principles -- in a bad light. Then he expresses the presumption that this is representative of religion in general. His reporting of the recent violence in Afghanistan, as well as the routine annual redux of stories about orthodox Jews stoning cars to punish their occupants for driving on Yom Kippur fall into this category.

Another gambit is to goad the faithful with actions he knows will be painful to them. ie, CrackerGate. Ridiculing those who respond is like shooting fish in a barrel. (Regarding the whole cracker thing, by the way: it's a SYMBOL, for crying out loud. How would you feel if someone came along, ripped your diploma off the wall, and shredded it publicly while crying, "It's just a piece of paper!" and "Are you stupider without this hanging on the wall?" and the like.)

Why should you care about any of this, Dr. Myers?

Because you are alienating potential allies. There are people of many faiths who are just as disgusted and distressed as you are over this mis-use of religion, the creeping destruction of science curricula, and the evil done in their names. Although they would stand shoulder to shoulder with you at school board meetings and the like, they don't appreciate the ridicule you heap upon them so freely. When they believe you speak for all atheists, they avoid associating with others of your faith who may actually be more tolerant than you. In short, your anti-religionism is giving atheists a bad name.

You are like an emotionally stunted adolescent who never manages to have a satisfying sexual relationship, who decides to champion celibacy. You point out all the problems with sex like STDs, promiscuity, and adultery to justify your rejection of sex. Then you go making fun of the expressions people make during orgasm.

Those in rewarding, stable sexual relationships will never be able to convince you that you're wrong. The smart ones won't even try. They also won't want to have anything to do with you because of your ridicule, even though they share your dismay over the STDs, promiscuity and other problems. You do not have to renounce something completely to credibly address its shortcomings.

(Note to Pharynguloid Hordes: I am well aware that Dr. Myers is married and has spawned. This is called an analogy. Look it up.)

So why am I writing this if I'm so offended by Pharyngula's rabid anti-religionism? It is because I credit Dr. Myers with enough intellectual honesty to understand the point I am trying to make. It is my hope that my rational explanation will help him understand that some of his more virulent comments may be counterproductive to his very legitimate causes.

(Disclaimer: No one understands better than I the phenomenon of a "blog persona" and the fun of posting somewhat more outrageously than one really feels, just to enjoy the response. I do not know Dr. Myers in person, and I am fully aware of the possibility that he is much more tolerant in Real Life(tm) than in his writings on Pharyngula.)

Outta Here

Harry Kalas died today:

Harry Kalas, the Phillies' Hall of Fame announcer, died at 1:20 p.m. today, the Phillies announced.

Mr. Kalas was 73.

He collapsed in the press box at Nationals Stadium in Washington at about 12:30 p.m. and was rushed to George Washington University Medial Center.

The cause of the death was not announced. Today's game against the Nationals will be played, but the team will not visit the White House tomorrow.

"We lost Harry today," David Montgomery, the team president, said. "We lost our voice."

But not our soul.

Rest in peace, Harry. Rest in peace.

Another Take on Hypertension for Lawyers

A more literary and poetic response to this guy on the same topic (explaining hypertension to a non-physician):

"You, the patient, are King George of England prior to the American revolution.

"Your disease (hypertension in its broadest sense) is the unrest fomenting in the colonies.

"The 'high blood pressure readings' are the vocal and printed speeches and pamphlets being circulated in the Colonies advocating revolution.

"A possible treatment for the political disease affecting King George could be the prescription (proscription) that all political speech and press in the colonies be banned. This would hamper the ability to coordinate opposition to England and delay, if not prevent, the onset of the revolutionary war.

"Note, however, that while the observable signs of dissent may be controlled (normal BP readings), the unrest and dissatisfaction among the colonists remains. In the long run, the damage may still be done.

"A better treatment for the disease would be diet and lifestyle changes before prescriptions. If King George had repealed unfair taxes and given the colonists a greater political voice, we Americans may have remained subjects of the British crown to this day."

Many thanks to RFS MD of NH.

Hypertension for Lawyers

I got an email the other day from this crotchety guy in his 80's who I've known for years. His current beef is that he resents being labeled "hypertensive" even though his blood pressure has been well-controlled on medication for many years. As so many others do, he quotes his Wikipedia professor from the university of Google:

Hypertension, also referred to as high blood pressure, HTN or HPN, is a medical condition in which the blood pressure is chronically elevated. In current usage, the word "hypertension" without a qualifier normally refers to systemic, arterial hypertension.

The article continues:

Hypertension can be classified either essential (primary) or secondary. Essential hypertension indicates that no specific medical cause can be found to explain a patient's condition. About 95% of hypertension is essential hypertension. Secondary hypertension indicates that the high blood pressure is a result of (i.e., secondary to) another condition, such as kidney disease or tumours (pheochromocytoma and paraganglioma). Persistent hypertension is one of the risk factors for strokes, heart attacks, heart failure and arterial aneurysm, and is a leading cause of chronic renal failure.

He asks for my response.

Sigh.

The problem here is entirely semantic. Then again, the guy is a lawyer, so he tortures words for a living.

For starters, in medicine the terms "hypertension" and "high blood pressure" are not technically synonymous, although they are often sloppily used as such. Not every patient whose blood pressure measures above the normal range has the disease "hypertension", and not every "hypertensive patient" has measurably high blood pressure.

The main problem is that I take issue with the description of "essential hypertension" as "no specific medical cause can be found to explain a patient's condition." I prefer to define essential hypertension as follows:

A complex multi-system disorder in which the body's assorted regulatory mechanisms interact in such a way as to keep the blood pressure too high.

The body has many ways to regulate blood pressure: how fast the heart beats; how hard it beats; total blood volume, regulated by total body sodium content as controlled by the kidneys; caliber of arterioles as controlled by smooth muscle in the blood vessel walls. Different antihypertensive medications work on each of these and other parts of the varying control mechanisms, which is why moderate doses of meds in different classes often work better than maxing out a single drug.

The problem is that even though the blood pressure itself may be kept within the normal range, the condition apparently has other effects not directly related to the actual blood pressure. This is probably why people with this condition are at a higher risk for heart attack and stroke, even when the BP is optimally controlled. For example, there seems to be a relationship with elevated serum cholesterol levels, another known risk factor for cardiovascular disease (and also modifyable with medication.)

By analogy, a father is defined as a man who has children, even when they are not physically with him. In a group of unaccompanied men, it may not be possible to discern which ones are fathers and which are not, just as simply measuring blood pressure cannot differentiate between non-hypertensives and patients with controlled hypertension.

Therefore just because your blood pressure is controlled does not mean you no longer have the disease "essential hypertension."

Hope that clears things up.

The Third Leg

I am sick and tired of hearing about health care reform from people like "health care economists" and the like, who don't even realize that they have no idea about what is actually involved in the delivery of health care in the United States today. Every now and then, though, a breath of fresh air breaks through. Maggie Mahar had a guest post from a retired physician about the nuts and bolts of health care reform. His comments are spot on, but only as far as he goes.

Much has been ballyhooed written about the government's role in health care, while the role of doctors (regional variations in care, end of life issues, etc.) has been given short shrift. Nothing will be accomplished by imposing government changes on physicians unwilling or unable to incorporate them. Still, doctors and government between them are only two of the three elements necessary for meaningful change. No one is talking about the third and most vital of these legs of the stool:

Patients. In this case, Americans.

The American health care system has arisen because it cares for Americans, who have different needs and wants than Canadians, New Zealanders, the Germans, the French or the English.

Everything written about the roles of doctors and government is absolutely correct, but no one is talking about the third leg of the stool: the role played by patients and their expectations. As long as Americans insist on only "the best" medical care, perceived to include instant MRIs and stents, backed up by the threat of litigation for any suboptimal outcome, we're not going to get anywhere.

As I say, I'm sick and tired of hearing people who know nothing go on and on about all kinds of changes that are not only no different, but are only going to make things exponentially worse by perpetuating systemic flaws. I suppose I have no choice.

I'm going to have to write a book.

A New Definition of "Small"

(Boring background information: Lyme disease is carried by the deer tick. It's really small.)

Evaluating the possibility of Lyme disease over the phone:

"How big was the tick that bit you?"

"Small."

"How small?"

"Really small."

"Smaller than the group number on an Aetna ID card?"

"About that size."

"Ah. Please come right in for a blood test."

Moral of the story: Could they possibly print the group numbers on an Aetna ID card *any* smaller!?!

The Story of Passover, as Told on Twitter

Saw this hilarious Twitter-style re-telling of the Odyssey here (h/t Janet Reid) which got me thinking (always dangerous) about other classic tales that could be recast in the new format. In honor of tonight's festivities, here is my version of the Passover Story, as told on Twitter:

Yo, Bro, you wrecked my fancy threads; who's this Egyptian dude?

This slavery shit really sux. Maybe I can fake out Pharaoh and get some better grub.

Anyone can read dreams. Multiples of seven, that's the trick.

It's good to be the king; or at least his right hand; same difference.

Look who's back in town!

Fruitfulness and multiplication; ah, that's the life.

Hey, who's the new guy with the Pharaoh shtick?

I need a new city; yo, circumcised guys!

I can't stand that constant wailing. Drown all the baby boys.

Yocheved, you don't really need that laundry basket.

OMG, it's the Princess!

I shall call him "Moshe."

Luke Moshe, I am your father mother.

Stop beating that slave? Who's gonna make me?

Shit; my goose is really cooked if anyone finds out about this. Where's Midian on the GPS?

That's one hell of a shrubbery. Most. Whacked. Out. BBQ of all!

Back to Egypt again? I've got a bad feeling about this.

Let your people go? NFW

Mud AND straw? You don't need no stinkin' straw.

Holy shit! When you say "or else" you really mean it; times ten!! Get outta here already.

I don't care if it hasn't risen yet; just grab it and lets boogie.

Changed my mind. After them!

Excuse me, wasn't there a sea here a moment ago?

Chariots don't float. Who knew?

Miriam and the Ladies, one night only, at The Shore.

Happy Passover

Real Chinese Medicine

I saw an interesting little article in the newspaper today about health care reform in China. (Original source article here.) Here are their goals:

By 2020, China will have a basic health-care system that can provide "safe, effective, convenient and affordable" health services to urban and rural residents...

What is it they want to do?:

The government will improve the public health network for disease prevention and control, health education, mother and infant health care, mental health and first aid service...

Sounds good to me. Anyone notice what's not mentioned anywhere?

• Acupuncture
• Herbal medicine
• "Traditional Chinese Medicine"

Gee, why could that be? China rejecting its own "traditions"? Perhaps because once you have access to medicine that actually does something, you no longer have any use for magical-life-force-based placebos.

In China, acupuncture and herbal medicine are for those who are poor and do not have adequate access to real medical care. In this country, they are for people who are too stupid to know any better, or to appreciate what they have (ie, medicine that works!)

Creative Consulting

One of the least logical aspects of our dysfunctional payment system for medical care is that I get paid more if another doctor asks me to see you than if you come to see me of your own accord. In the latter case, the visit is considered an "Evaluation and Management" service, but if another doctors asks -- in writing -- for my opinion and if I convey that opinion back to him -- in writing -- then the encounter is considered a "Consultation." What's the difference? Benjamins.

This is one of the major mechanisms used by specialists to enhance their income. Whenever they ask who your primary physician is, they use the information to compose a letter that begins,

I saw Mrs. Munchausen in consultation at your request.

even if I never asked Mrs. Munchausen to see them and in fact wouldn't trust them to care for my dead dog. Technically, because my "request" isn't in writing, they are supposed to be billing for an E/M service instead of a consult, but because oversight of this technicality is sparse to say the least, they continue to do it with impunity.

On the flip side, surgeons not infrequently request my opinion about the medical conditions of our mutual patients prior to subjecting them to whatever interventions their little surgical minds can dream up. They call this "Medical Clearance" and, when the patient has an actual medical condition, it is legitimate. The ritual pre-operative History and Physical, interestingly, is not the same. Surgeons also went to medical school, where I know for a fact they all learned how to do H&Ps. Additionally, they are being paid for them as part of the global fee for the surgery. I have blogged about this before.

Still, there are certain surgeons and hospitals who continue to insist that I complete certain forms pre-operatively. To assure that I am within the letter of the law for billing the visit as a consultation, I have developed a form that I fax to the referring surgeon prior to the patient's visit to me. Here is what it says:

Dear Dr. Halstead,

Please confirm that you have requested a medical pre-operative evaluation of the above named patient by completing the following information within 48 hours to avoid delay in preparing our patient for surgery.

The form then has spaces to fill in the proposed surgery and diagnosis. Then there is a line that states:

Specific medical reason (UNRELATED TO THE SURGERY) for medical clearance:

I can't imagine being more explicit than that. The form closes with spaces for the surgeon to request pre-operative blood work and other studies, if he wants me to do them. There is also a place for the referring provider's NPI, which I need for billing.

You would be amazed at what appears on that line for "specific medical reason":

• Hypertension (anyone who has checked off "blood pressure" on their two-page review of systems form)
  
• Diabetes (ditto)
  
• Heart disease (includes anyone who has ever had a heart attack, thought they had a heart attack, or seen a cardiologist)

Many of those are valid, and I am happy to confirm for the surgeon that the stated medical conditions are stable (even though the information is easily and quickly available from the patient.)

• Anxiety
• Depression
• Bipolar

Um, excuse me but what does this have to do with surgery? Everyone is anxious about going under the knife, and the reason they need to do so is often something pretty depressing. Yes, people with major psychiatric illnesses sometimes require surgery, but the mental illness rarely has anything to do with the surgical issues.

• Arthritis (for joint replacements)
• Gall stones (for removal of the gallbladder)
• Hernia (for repair of the hernia)

Hello? What part of the (capitalized) statement "NOT RELATED TO THE SURGERY" didn't

But far and away the most frequent are the most useless:

• Cosmetic
• [blank]

What's a poor Dino to do?

Why I Love My Staff

The phone rings:

My Wonderful Staffer: Good morning, Dr. Dino's office. How can I help you?"

Deceptive Patient: Is the doctor there?

MWS: Can I help you with something?

Note: It took awhile, but I finally taught a good Catholic the Jewish trick of answering a question with another question.

DP: Well, my leg has been hurting for a while now, and I've been seeing another doctor for it. He ordered an MRI, so I need Dr. Dino to write me a note for it.

MWS: If the other doctor ordered it then he's the one who needs to write you the note [left unspoken: "and get the damnable pre-authorization too!"]

DP: [hemming and hawing] Actually, the doctor isn't ordering it. Some of my friends told me that's what I need for my leg.

MWS: I'm sorry, but Dr. Dino won't write a note for a test without seeing you first to evaluate the problem.

No appointment scheduled, but no note written either.

Jeez!