Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, May 31, 2007

"Aw Shit!": My Reaction to the Flea Debacle

As everyone and his brother now knows, our dear de-blogged Flea suffered a dramatic moment in his malpractice trial: the plaintiff's attorney asked him if he was, in fact, the anonymous blogger known as "Flea." He apparently answered in the affirmative, and then had to settle his case (for a "substantial sum") instead of continuing to fight the case on its merits.

On the Pharm is correct in this:
It saddens me when a case is settled not on the facts of the case, but rather on issues that are only tangentially related to the matter at hand, at best. That said, perhaps Flea was confident in his anonymity, but probably shouldn’t have been...

Unfortunately, hindsight is 20-20, and things that are obvious after the fact are often not so obvious while they are occurring. We’ve all done things that were dumb in hindsight — myself especially — so I will refrain from being an armchair jackassexpert and saying that Flea should have known better.

But ultimately we have a legal outcome wasn’t about the truth. The truth — whatever it happens to be — is apparently irrelevant. Unimportant, even. I think that alone is poor commentary on our legal system.

I, for one, am hopping mad!

WHERE THE HELL WAS HIS DEFENSE ATTORNEY? And why didn't said defense attorney object to the question, on the grounds of relevance?

Flea -- and all of us -- have a right to blog anonymously. This also means we should have the right not to be compelled to renounce that anonymity. Anonymous blogging didn't have anything to do with the medical case at hand. What business did the attorney have bringing it up in court at all? Answer: she didn't. So I repeat, where the HELL was Flea's lawyer when that question was asked?

(Actually, Flea should have had an arrangement with his attorneys so that he could signal when there was something dangerous about a question, letting them know to either object or call for a break. He should have told his defense team about his blog, too, so they would have been alert to the possibility of a question about it.)

That said, this whole thing sucks. It just sucks.

Addendum: I don't disagree that real-time blogging about litigation is foolish. But I still think the "punishment" (settling a defensible suit, necessitating a report to the National Data Bank which will forever tarnish one's reputation) is completely inappropriate.

It's like the line from the closing argument in A Time to Kill, where Matthew McConaughey is apologizing for putting a convicted felon on the stand, but goes on to describe that the felony was statutory rape, the girl was 17 and the witness was 23, and that they later went on to marry and raise a family, and should that affect how the jury views his testimony.

From the point of view of pure justice (which I understand has nothing to do with any of this), how does saying or blogging something now have anything to do with what was or wasn't done at the time of the alleged malpractice?

It still sucks.

Wednesday, May 30, 2007

Nose to Nose

Sometimes you admire someone from afar.

They may have an amazing blog, and as you read you marvel at the sensation of their words transporting you from your comfortable swivel chair in front of your family room computer into another place so different, so strange, so amazing that you couldn't in your wildest imaginings conceive of such a place.

You wonder what it would be like to meet that person in real life. What are the stories behind the stories? Can they possibly be as wonderful and amazing as you imagine them to be? Are you going to have anything to talk about with them?

Then you meet.

And you find the real-life person to be even more incredible than you imagined.

The true magic of the internet is creating the opportunities for those kinds of experiences. What a blessing!

Sunday, May 27, 2007

Solo Dilemma

The other day I got a big, fat envelope in the mail containing my biennial re-credentialing packet from the hospital. I know I have to go through this whole rigamarole on a regular basis. Most insurance companies require it every two or three years, and so does the hospital. But whoever needs it, it's always a pain.

There's the basic information about name, address(es), phone, fax and contact numbers. Then there's a re-hash of all the educational information; no, my medical school and residency graduation dates haven't changed in the last two years. Fortunately many of the forms have this information "pre-populated" (already filled in for me) but I still have to go through and make sure they have it right. This time around there's a new indignity: my medical school doesn't exist anymore, so I am listed as having graduated from the university that was kind enough to take it over when it was threatened with total oblivion. I sigh and decide I don't care enough to go rocking the boat by trying to change it; I figure not sending them money is revenge enough.

Board certification usually comes next. This, too, hasn't changed in the last two years, but because Family Practice board certification expires, they want to know all the dates of cert and re-cert. It's harder than you might think to put my hand on the piece of paper documenting my second re-cert when I'm a year away from my fourth.

Malpractice insurance doesn't change either, but I always have to write it in, as well as include a copy of my face sheet.

There's the standard list of questions about open malpractice claims (ever since the trial three years ago I can finally say "none" once again, thank FSM), whether I've ever been disciplined or committed of a crime (luckily they specify an exception for "minor traffic violations"; lets me off the hook for that parking ticket downtown eight years ago), and if I'm addicted to any kind of substance, legal or illegal, that could impair my ability to practice my profession. I'm going to assume that because I can do my job without chocolate (even though I don't like to) I'm safe checking off "no" on this one too.

I have to sign the thing. Over the years, the disclaimer/attestation/whatever that precedes the signature (the part that says I've told them everything, haven't lied, that they can contact anyone they want to verify the information, and that I can't sue them) has grown from a sentence or two, to a paragraph or two, to two single-spaced pages in tiny font.

Nowadays there's actually a way to do this online. This outfit collects all the info, verifies it, and then provides it to whatever insurance companies I authorize to receive it. I only just did this thing, even though I've known about it for a couple of years now, and although it was a PITA to go through it the first time, I can see it being a huge time-saver in the future. So I called someone at the hospital, just to see if they can't contact those folks online and not put me through all the nonsense. They said no.

Of course the hospital packet includes more specific stuff on privileges; am I applying for the same set of core privileges I already hold, or am I asking for any changes? And if so, am I qualified to do what I'm asking to, and can I prove it?

Here's my problem: I haven't admitted a patient to the hospital in seven years. I consider myself an expert on outpatient care, and I'm good at it. I can get things done in the community using resources my hospitalist colleagues have no idea exist. My specialty is keeping patients out of the hospital. If someone needs to be in the hospital, it isn't me they need. At this point, no, I don't feel competent to manage an inpatient [and please, whatever you do, don't tell my residency faculty that I've failed them.] But all the insurance companies that I still have to maintain contracts with require that I have hospital privileges. And so the charade goes on.

But this time around there's something new:
If you have had no clinical activity [at the hospital] in the last two years, you must submit the enclosed Clinical Evaluation, to be completed by a peer or associate.
Enclosed is a two-page questionnaire with a list of qualities and two columns for the respondent to check off for each: "Favorable" or "Unfavorable." Here are some of the things they are asking someone else to certify about me:
  • Medical knowledge
  • Technical skill
  • Patient management
  • Outcomes
  • Quality of charts
  • Patient relationships
  • Involvement in medical staff affairs
  • Relationships with nursing staff
  • etc.
The second page is a re-hash of the "impairment" questions about restriction of privileges, substance use and so forth.


"Solo" means "alone." No other medical professional in the office. No one. How can anyone fill out a form like that meaningfully? Oh, I can probably find a buddy somewhere to sign it and send it in, but this whole episode has got me thinking about several things.

I know I am competent; that I keep up to date; that my charts are wonderful, my patients love me, and my outcomes at least average. At least I think I know this. I believe it, at any rate. But realistically, with no one else in the office (short of an actual observer coming into the office, watching me interact with patients and auditing my charts), how can I prove this? I could be a complete schmuck, and no one would ever know.

I know this because there are other docs I know of who scare me. I've seen their charts when their patients transfer to me; I've talked to them at meetings. They scare the crap out of me and frankly, I wouldn't send my dead dog to them. Yet they somehow manage, year after year, to get re-credentialled by hospitals and insurance plans. Back in the day when HMOs were new in town, they also managed to get themselves into the top "Quality" tier for payments.

(Digression: Dinosaur's Law of HMOs:
The more times the word "Quality" appears in a given document, the more the document is bullshit.)
Then again, I've also known the "good 'ole docs;" the ancient oldsters still using aldomet for hypertension and oral dicloxicillin for impetigo. (Yes, they work, but that's not the point.) The ones who, despite their best efforts to keep up, have held on too long and can't cut it anymore.

How do I know -- in my heart of hearts -- that I'm not one of them?

You might say, "What about CME? If you're doing your 50 hours a year then you're fine." Let me share a dirty little secret: I'm more likely to attend a CME conference about something that interests me than about something that doesn't. (Revelation: yes, there are certain subjects that don't interest certain docs, at least not as much as others.) People -- including me -- tend to stick to the familiar. What this means in the context of continuing medical education is that we tend to be very up to date with some things, without ever realizing how stale our knowledge is in areas we were never very good at to begin with.

So even though I haven't even hit the half-century birthday mark yet, how do I know for sure that my competence hasn't already begun to slip? That the quality of my care isn't really as good as I tell myself it is?

Scarier still: I'll never really know.

Thursday, May 24, 2007

No Need to Lend a Hand

I have a patient who works in a supermarket. She tells me stories of little old ladies slowly going up and down the aisles, leaning on their carts, always needing help with this and that because they don't walk so well anymore.

Except on weekend mornings, when the bus for Atlantic City (and its casinos) comes to the supermarket parking lot. Watch how quickly they clamber aboard -- no help needed at all.

Wednesday, May 23, 2007


  1. Black people are lazy.
  2. Surgeons are assholes.
  3. Doctors have lousy handwriting.
What do those three statements have in common?
  • They are not true.
  • They are offensive.
Attributing a trait or quality indiscriminately to a group of people is prejudice, pure and simple, whatever the trait and whatever the group. Adding a modifier like "many" or "most" does nothing to mitigate the offense, and trying to downgrade it by inserting "some" results in meaningless assertions. "Some" members of any group are just about anything.

Now let's look at some of the differences among those three statements. In this day and age, no one but the most obnoxious racist would agree that the first statement has any degree of veracity whatsoever. The problem is that the second two sentiments are considered true by so many people that they are often considered "conventional wisdom."

Why is this so? Why do people feel justified in labeling an entire medical specialty emotionally dysfunctional and an entire profession legibility-impaired? Perhaps people believe that because they have had experiences demonstrating these qualities with multiple members of a group, their observations are therefore applicable to the entire group. Perhaps people may even feel they have never met a member of the group who does not possess the offending quality. Yet despite that reasoning, it is still not legitimate to conclude that all blacks are lazy based on personal experiences with a given number of unmotivated African Americans, or lack of experience with those who are studious and industrious.

There are people of every race and nationality who are lazy. Discussions of motivation need to be addressed to the individuals displaying the behavior instead of inappropriately criticizing a whole group of people. Surgeons who lack interpersonal skills should not be excused because, "That's the way surgeons are." Not only are they not "all" like that by any means, inappropriate behavior does not deserve to be tolerated under any circumstances.

What about handwriting?

First of all, how legible is the handwriting of the average adult in any profession today? Who knows? How much longhand writing does anyone do anymore anyway? Not much. Handwriting fatigues the more you write, so being expected to write the equivalent of up to 15 pages by hand daily (hospital notes and prescriptions, not to mention office notes for those of us without EMRs) might explain some diminished penmanship.

I was a calligrapher before I became a doctor. My handwriting is not just legible; it is lovely. Patients are often in awe of my prescriptions, instructions and Return to Work notes, usually accompanied by some crack about doctors and their handwriting.

I don't disagree that those physicians who do not pay attention to these matters can represent a danger to patients both in and out of the hospital, with illegible orders and prescriptions respectively. Those individuals need to be counseled about their unacceptable performance in this area. But I know for a fact that I am not the only doctor with legible handwriting, and I am sick of listening to assumptions about my penmanship based on the letters MD after my name.

So knock it off about docs and handwriting already, you lazy assholes.

Sunday, May 20, 2007

Identical Boy-Girl Twins

(Inspired by item # 2 of Ambulance Driver's response to the Random Facts About Me meme)

I have fraternal boy-girl twins. (No, they don't beat each other up.) They are about as identical as night and day, and always were.

When they were babies and total morons would ask (after being told they were a boy and a girl) "Are they identical?" here is what I answered, while keeping a straight face for as long as I could:
Well, you can't tell. You have to wait until they grow up and have kids of their own, and then if all their kids have the same blood type, they're identical.
I figure anyone stupid enough to ask deserves whatever I care to dish out.

Thanks, but...

Thanks to one and all for the comments on the previous post. *smiling humbly*

Despite all the praise for my so-called eloquence, it was a commenter (thanks, Someonetc) who summed up the essence of both Panda's position and mine (poetic license taken/switched around a bit):
Medicine is a business. The practice of medicine is a calling.

Friday, May 18, 2007

Is it Worth It? A Response

Panda Bear MD has written a provocative post about the pros and cons of a medical career. After a careful discussion of the economics of medical education (including a terrific didactic discourse on the concept of opportunity cost), the earning potential in the context of the present political climate (including the risks of potential changes in that climate), and an fear-mongering yet anecdotal presentation of the issue of medical malpractice, it would seem very difficult to justify the decision to pursue a career in medicine.

Panda's analysis is flawless. It is also meaningless.

At the risk of being labeled by Panda and others as a creepy fanatic, I assert that it is not about the money. Nor even about the lifestyle, really. At the end of the day, the week, the year, the career, it is about the life lived. Medicine is about a life lived impacting the lives of others. To call it Noble is old-fashioned, out of style and downright hokey. None of that changes the fact that it is true.

In this season of graduations (kvell: younger son garnered FOUR academic awards at the banquet last night) (/kvell) and kids coming home from college wondering what they want to do with their lives (realizing that now is the time to begin making those decisions) this whole process of introspection -- and providing guidance -- is very near to my heart. How does one go about making these kinds of choices?

You can go through (or read) elaborate analyses of the various pros and cons of assorted possible careers, balancing the financial issues with the lifestyle ones. But this approach assumes that the only role of a job in one's life is economic; the option that generates the most possible money in the least unpleasant manner is what will come out on top every time when looked at this way. But what about passion? What about "doing something with one's life"? Life should be about more than just work. Medicine is one among many opportunities to make a difference while making a living.

People wonder why I and my fellow Family Physicians keep on doing what we do. It's because even in the face of all the hassles, bullshit, declining reimbursement and everything else, the deep satisfaction we get from making a difference in the lives of our patients is real, worthwhile and meaningful. We don't talk about it because it's such a part of our soul that among ourselves, it's assumed. Showing a mother something she didn't know about her new baby, even if it's her third; steering an adolescent away from drug or alcohol experimentation; reassuring someone they don't have cancer...and that was just today!

Medicine is more than a job. It is more than a career. It is a calling. (Perhaps that's what Panda means when he says that fanatics "...hear things that normal people do not.")

Is it worth it? I would answer, is it worth what?

Don't pursue a career in medicine because you think it would be a good idea. Don't do it because you want to. Don't do it because you love it. Do it because you cannot possibly imagine being happy doing anything else.

Thursday, May 17, 2007

One for All You Obstetrics Folks

I enjoy birth stories, and many of my patients are eager to share them. I would say that the bulk of amusing anecdotes stem from the part of the story where the baby is about to appear and the bevy of professionals attending the event stand around commanding the mother:
Don't push.
Telling a woman at the end of the second stage of labor not to push is like telling the sun not to rise yet; you're still tired and you haven't finished your dream yet. Telling a woman with no cervix and a baby on her perineum not to push is like telling the tide not to come in; it's getting your blanket wet. In short, it's the stupidest pair of words ever uttered, yet they continue to be heard day in and day out, in hospitals and birthing rooms around the globe.

There is something I have come to realize.

Among those who actually know what they're doing -- midwives, L&D nurses and really experienced OBs -- the words "Don't push" are merely code. What they are actually saying when they articulate the words "Don't push" is this:
Please just let me get my gloves on.

Monday, May 14, 2007

(More) Stupid People and the Pain They Cause

The message above, unfortunately, does not apply to a distressingly high proportion of the patients who seem to have been seeking me out of late. I continue to amuse my staff by periodically commenting (after the patient is long gone):
I can't imagine how being *that* stupid wouldn't hurt.
I don't know why it's been so bad lately. Perhaps the nicer weather is allowing them to climb out of their caves.

There's the guy with the rash. The one on his leg, and maybe somewhere on his arm; or was it the other arm? It's mostly gone now, but it was really bothering him last week and he wants to know what it was. There's some barely discernible pinkness in a distribution that may or may not have been the rash he's talking about, that may have been a little contact dermatitis, or perhaps even a few hives. There's no way to tell; it's not really bothering him anymore, so there's nothing to do for him. And my head hurts from my brain trying to force its way out through my ears, rushing into the intelligence vacuum created in the room by the guy sitting in front of me.

As it happens, I've basically written this post before; but it was way back in October of last year, which is more than six months ago. Besides, now I have this great picture to share. (Thanks, MIH.) And the stupid people just keep right on coming.

Friday, May 11, 2007

Outcome of "Ethical Dilemma"

First of all, many thanks to all who commented. I was a little surprised by the unanimity of the response, though perhaps I shouldn't have been. Now, of course, either because of Jewish guilt (have to find something to beat up on myself about) or in the name of Continuing Education/Quality Improvement (same thing) I'm wondering why it was so hard for me to come up with that answer. Sometimes things aren't quite so clear on the spur of the moment, with a walk-in standing in front of me and other patients waiting. I'm not sorry about my answer (make an appointment to discuss it) and as it turns out, offering to teach her to self-inject was probably the only thing that made her agree to come back.

I weighed and measured her. Her BMI is 21.5. She doesn't feel she's fat; no depression; no eating disorder; marriage/life is fine; she's perfectly happy. She just wants to lose some of her "storage fat"/"cellulite" (she used both terms.) She gets palpitations when she tries to run, which she is convinced is because of "excess weight." She declined my offer of a cardiac workup, saying she'd already had one and everything was fine. When I tried to explain the status of the treatment as unproven and useless, she wasn't the least bit fazed: she'd done her research (a book written by a DOCTOR; 30 years ago, but still...) and read all about it. She believed it would work, and one way or another she was going to do it. Thanks for your time. No hard feelings.

Verdict: Altie. Allergic to reason and intolerant of science. Oh well.

I did what I could, and that's all I could do.

Once again, thanks to all for opinions.

[*waving @ bean*]

Thursday, May 10, 2007

Help: Ethical Dilemma in Real Time

A lady walked into my office yesterday (established patient, though not seen since 2003) with the following question for my staff: her gynecologist had prescribed a course of treatment involving daily injections for a period of time. She didn't want to travel the longer distance to his office just for a daily injection and she didn't want to do it herself. Would I be willing to provide her with this service?

My staff immediately assumed she was undergoing fertility treatments, so they were certain (and correct) that I'd be fine with it. However what she pulled out was a sheaf of papers describing daily injections of HCG for 40 days (except when having her period) for weight loss.

At this point I came to the front desk and started looking over her materials. (It was a good thing I did, because one look at this tall slender lady who wanted to lose weight made my staff want to slap her silly.) I asked her a few questions: the prescribing doctor was her regular gynecologist, not a "weight loss specialist" or someone I could mentally label an "altie doc." There was a long document in tiny font that appeared to be some kind of release, probably from the third party company that was supplying the drug for injection.

I've seen some of the gynecologists in my area doing stuff like this recently; tapping the vast market for weight loss services by purchasing products (usually vitamins and/or "nutraceuticals") and services from third-party companies and then re-selling them to their patients, sometimes along with office visit charges for their services. The first time I saw this I actually called the guy up. I'd known him for a long time and was wondering why he'd gotten into this. All I got was a kind of half-assed, "I dunno; it sounded good, it offers the patients a computerized analysis of their needs based on their personalized profile [right; anything using a computer has to be good]; it doesn't seem to be doing any harm, and the patients like it." I was unimpressed (and lowered my opinion of him slightly) but as long as they keep it in their own offices I don't have much say in the matter. But this is different: a patient is asking me to participate in what I believe is fraud by requesting that I give her injections of a medicaly-unindicated substance.

What do I do? She's standing right there. Yes or no?

Here's what I said: Make an appointment to come back and I will teach you how to do it yourself. She agreed and is coming in tomorrow. Afterwards I realized that there is no difference ethically between giving her the injections and teaching her to do them herself, but it gave me time to think and decide what to do when I see her.

Of course I will begin by calculating her BMI (no way it's over 30; possibly as high as 26, but this lady is NOT overweight) and finding out why she wants (or thinks she needs) to lose weight. I can then (try to) address the body image issues, possibly the mood or relationship issues that are the real problem; at least move away from injections of pregnancy hormone. (That's what HCG is, for all you non-medical readers.) Despite my admittedly formidable powers of persuasion, I don't think I'm going to get very far.

I will then try to explain that the treatment is unproven, not recommended by any competent authorizing body, has no plausible scientific mechanism of action, and like any such therapy has the potential for unforeseen harm. At this point she might ask, "Then why did my doctor prescribe it?"

Now there's a can of worms. "Don't badmouth other doctors" is an important rule in private practice for a variety of excellent reasons. Other docs may know more than I do; patients give different histories to different docs resulting in different treatment recommendations; you don't want them badmouthing you when patients give you different histories, and when you know more than other docs. I can't come out and say, "He's trying to tap into the vast market of desperation and gullibility that typifies women's culturally-induced desire to attain an unreasonable body weight." But I can tap dance around "I don't know" til the cows come home. I may convince her, but I don't think I will.

The most likely outcome of this discussion is that she says, "Thanks for your concern, but I trust my gynecologist ["more than you" is the implication] and I still want the shots." What do I do?

Some other things to factor in:
  1. Money is not an issue. I can charge her for a level 1 (probably even level 2) visit out of pocket every day and she'd likely pay it gladly. I happen to know she is very well-off.
  2. Assume litigation potential is not an issue. Of course "you never know" but I know the patient, and I have assessed the risk as negligible.
Here are the options as I see them:
  1. Refuse to give her the injections, telling her I've thought about it and can't do it in good conscience. Upside: I'm doing the right thing ethically. Downside (potential): she gets pissed and badmouthes me to friends and neighbors. (Patients aren't bound by the "don't badmouth other docs" rule.) Downside (likely): She'll find another way to get the injections, and so will still incur the "harm."
  2. Agree to give them to her, then reiterate to her at each visit the points that she doesn't need to lose weight, the treatment is unproven, etc. Upside: I may eventually convince her and she'll stop, thus lessening the "harm." Downside: She may eventually get annoyed/pissed enough to stop coming, but will probably find a way to get them somewhere else and may still badmouth me.
  3. Teach her to self-inject. Upside (marginal): I am not involved on a daily basis. Also: the patient is pleased with my service. Downside: ethically it's equivalent to giving her the injections without the continued discussions.
All input appreciated.

Her appointment is tomorrow.

Tuesday, May 08, 2007

A Tragic Death

Sunday's Broad Street Run in Philadelphia was marred by a tragedy: the startling, unexplained death of 29-year-old Robert Massaroni, who collapsed and died just moments after finishing the race (10 miles, with a respectable time of 1 hour, 24 minutes, 34 seconds.) (Complete article here.)

I'm going to take a stab at the diagnosis, based on this clue:
He came from a very tight Italian family...
Arrhythmogenic right ventricular dysplasia (ARVD)


Passover, 2002: We've finished our seder and are sitting around the family room with overstuffed bellies watching the video Prince of Egypt, which had been the afikomen prize. The phone rings; the world changes forever.

The Jock's indoor soccer team had played that night, obviously without the Jock, who was home for Seder. The younger brother of one of his best friends -- from a close northern Italian family -- had collapsed on the field after a routine play. As the kids gathered around, one of the moms who was a nurse began CPR. Her son told me later they were standing around crying (15- and 16-year-old boys; when was the last time you saw them cry in public?) saying, "Breathe, Danny! Breathe!" The ambulance came; everything was done; nothing was enough. And a 13-year-old boy lay dead.

The community gathered, sharing tears, memories and casseroles. All the soccer kids and their families came to the house. The moms shared tears and kleenex in the kitchen; the kids all clustered together playing hackey-sack; heading a soccer ball around in a small circle; shooting hoops. All activities that kept them in very close physical proximity, yet still involved movement and activity that looked competetive, but really wasn't.

The funeral was awful. His grandparents came over from Italy, and one of the priests did a eulogy in Italian. The idea of burying not just a child but a grandchild ripped my guts out.

The deepest wound was not knowing why. Eventually the word came down, and it was ARVD. The family was tested: the father has it, the mother and brother do not. They tried to get all the cousins checked, too. I don't know their status, as I'm not professionally involved. I'm just one of the parents struggling to hold back tears whenever I think about the fact that Danny would have graduated this year, along with my younger son. Whether I'm right or wrong about Robert Massaroni, I ache for his family. Too young; gone too soon.

Monday, May 07, 2007

That's One Way to Teach the Lesson

As I was drawing blood from a lovely older lady today, I noticed that she had a bit of lipstick on one of her front teeth. She was on her way to work at an upscale jewelry store, so I quietly mentioned it to her. She thanked me as she wiped it off, and told me the following story:

When babysitting her grandchildren, her oldest granddaughter likes to try getting away without brushing her teeth. One evening Grandma mentioned that she had partial dentures, one upper and one lower. Granddaughter asked to see them, curious about what Grandma looked like without them, so my patient removed them and let the children inspect them, and her visage without them.

The little girl ran upstairs to brush her teeth very well, and has never forgotten since.

(Blogged with permission)

Sunday, May 06, 2007

P4P in Real Life: What Would You Do?

One of the two 600-pound insurance company gorillas in my area has a P4P plan they've been running for several years now. Towards the end of each year they send me lists of patients who haven't received certain preventive health care services, according to their records. I have a chance to go over those lists and either fill in the information for patients who have indeed gotten the pap, mammogram, colorectal cancer screening or diabetic care the plan doesn't have records of. But I am also told that I have the opportunity to make sure these patients receive those services before the end of the year, so they will "count."

Because this has been going on for several years now (and because I'm pretty damn good at talking people into getting preventive services when I happen to see them in the office for other things) I'm down to my hard-core folks who continue to refuse these things year after year. I confess there have been times I've called patients -- usually people I know well, so I know I can get away with this -- and said, "Please get your mammogram [etc.] before December 31st so your insurance company won't take money away from me."

There's another group of people, though, and these are the ones I'm asking about.

Because this is an HMO -- a capitated plan -- there are people on this list who have never called for an appointment, who I've never seen in the office; indeed, I've never met them face to face, nor had any contact with them at all. Apparently the insurance company is trying to take the position that merely choosing me from a list is enough to make someone my patient, so they now feel justified in holding me responsible financially for these patients' lack of preventive health care.

I don't know if this has ever been litigated, but my position is that a doctor-patient relationship cannot possibly be established in the complete absence of actual contact between the doctor and said patient. I am aware of case law that describes calling for an appointment as the point where the doctor's responsibility begins (the Friday afternoon call to the OBG's office by a patient with vaginal bleeding, given an appointment Monday but who dies of a ruptured ectopic pregnancy over the weekend) but I hold that there still has to be some kind of direct contact, and that that contact must be from the patient.

My monthly capitation list gives only name, age, ID number, plan and amount of capitation paid for each "member." (To me, they're patients, and I'm a doctor. To the insurance company, they're "members" and I'm a "provider.") No address, phone number or any other contact information. Even if I wanted to (or thought it appropriate) there's no way I could contact new patients who pop up on my list. Interestingly, the annual P4P review sheets do include this information. Apparently, I am supposed to call up complete strangers and say, "Hey, you signed up as my patient. How about coming in so we can get to know each other. I can give you a checkup and make sure you get all these vital preventive health services that would certainly be a good idea for you but would also put a little more money in my pocket."

Even with all the talk about "patient responsibility," we doctors are expected to do a lot of the heavy lifting: making sure patients go for labs, studies and other doctors we recommend; following up on no-show follow-up appointments; rewriting all twelve of their prescriptions three times a year (two of each: a 30-day supply to fill at the pharmacy and a 90-day supply to mail away) when they change insurance plans; stuff like that. I draw the line at calling a non-patient -- also known as "a stranger" -- to try and get him to come into the office. The very least the poor slob should be expected to do is to pick up the damn phone in the first place.

What do you think?

Friday, May 04, 2007

Cool Dads

Fun visit today with a four-year-old girl and her four-month-old brother. Eight shots. Fun.

The dad has the same dry sense of humor I do, so I was lucky to have gotten in the last word not just once, but twice.

Going through the "tell me what he's doing" part (aka developmental history) for the four-month-old, the mom recites the usual; holds up his head, sits with help, bears weight on legs, laughs, vocalizes, grasps toys; all normal. Then dad chimes in, "And he likes to read trashy romance novels."

Me: "Cool. Does he have any favorite authors?"

Dad: "Uh..."

Me: 1 Dad: 0

Both visits went fine. Both kids are doing great. They even tolerated the shots -- better than mom, at any rate. The four-year-old girl didn't really cry; she just made this unhappy creaking kind of noise, so as they were getting ready to leave I mentioned to the dad:

Me: "You know how she was creaking just now? If you have any DW-40, that would help a lot.

Dad: "All I have is lithium grease."

Me: "Great. That will help stabilize her moods too."

Me: 2 Dad: 0

(I swear these two exchanges actually happened. I even got the dad's permission to blog it.)

Wednesday, May 02, 2007

"How Doctors Think": A Disappointment

After all the hullaballoo on line and elsewhere, I felt compelled to read Jerold Groopman's How Doctors Think. So I did, and in contrast to the glowing reviews elsewhere in the blogosphere, I have to report that I was disappointed.

I'm not sure what I expected; some new insights into medical decision-making and how to improve my diagnostic acumen. What I found was a well-written compilation of material I already knew. Granted, according to the author, the target audience was patients; still, I do not think it met the needs of that population either.

A couple of things jumped out at me, starting in the Introduction. At first, the line in a footnote:
I quickly realized that trying to assess how psychiatrists think was beyond my abilities.
struck me as hilarious; the snide kind of quip we've all lobbed at our mental health colleagues. Later, though, I came to realize that the elimination of this vital medical specialty from a discussion of diagnosis was short-sighted at best and ridiculous at worst. More on that in a moment.

A major issue was the entire disregard of my specialty: Family Practice isn't mentioned anywhere in the entire book. Primary Care is specifically defined as "...pediatricians for children and internists for adults." Later on, simple problems are mentioned as cared for by "general practitioners or internists." I'm not sure if this was an intentional slight, or, more likely, the simple lack of awareness that we exist as a distinct specialty, and what our capabilities are. For example, during our training we are continuously asked questions like "What else could it be?", "Is there anything that doesn't fit?", and "Is it possible the patient has more than one problem?" not by our patients but by our preceptors to whom we present our cases. (And in the first year of residency, we present every patient we see.)

Although we may not use the cognitive terminology of affective error, anchoring, search satisfaction and so on, we certainly learn the concepts from our very first day on the job. Listening to patients, bonding with them (but not so much so that clinical judgement is impaired) is emphasized at all times. Remembering that not all patients have equal literacy skills is drilled into us early and often. I try to keep these habits of thought as fresh as possible in my day-to-day practice all these many years later, to minimize the problems with diagnosis and other misadventures described by Groopman. I'm not saying I don't make cognitive errors in diagnosis, but I am already familiar with and try to utilize the strategies he discusses to avoid them.

As I read through the book, though, I realized that the omission of psychiatry and the discussion of the proper role of psychiatric diagnosis in medicine (as opposed to the misdiagnosis with which he opens the book) renders many of his comments irrelevant to the day-to-day practice of medicine in the community. By "community" I specifically refer to the non-Harvard, non-Massachusetts General, non-assorted-other-institutional-names dropped in the name of prestige. Out here in the real world, psychiatrists think just like the rest of us. They care for diseases that are primarily mental in origin. These diseases have criteria for diagnosis, treatment protocols, risk factors and prognoses. Making these diagnoses is often straightforward -- and sometimes less so. Treatment succeeds or fails, or stops working, at which point it often helps to change the treatment or re-visit the diagnosis. Sounds a lot like medicine, because it IS medicine. Contrary to Dr. Groopman's formulation, psychiatric diagnoses are NOT diagnoses of exclusion, as he implies:
This conclusion, of course, [that what is wrong is psychological, not physical] should only be reached after a serious and prolonged search for a physical cause for the patient's complaint.
As an example, say I consult with a woman in her 40s for fatigue. Tell me about your problem, I say. Listening without interruption, she describes fatigue that has been going on for about a year. She falls asleep ok but wakes at 2:00 am every morning and cannot go back to sleep. Her appetite is increased and she has gained some weight, but she just doesn't feel like exercising. In fact, she doesn't feel like doing anything. She can't concentrate; nothing gives her pleasure; her sex drive is nil. She doesn't want to kill herself, but she wouldn't mind if she didn't wake up one morning. She cries easily, but doesn't understand why she feels so sad all the time, because her job is fine and her husband and kids are great. (That's what spills out before I say a word.) I elicit the further information that she has no heat or cold intolerance, no changes in her skin or hair, no particularly heavy periods nor signs worrisome for blood loss from her gut. There is no family history of cancer, thyroid or other endocrine disease, but she has two sisters who take antidepressants and her grandfather was an alcoholic.

Suffice it to say that the differential diagnosis for fatigue is enormous. However any physician worth his salt who doesn't come up with Major Depression in one of the top three positions on the list of possible diagnoses for this patient probably shouldn't be trusted with a medical license. Once you've ruled out anemia and hypothyroidism (maybe diabetes and a few other things with routine screening blood work), it would be pretty irresponsible to continue on a "serious and prolonged search for a physical cause" of this condition instead of proceeding to at least a trial of treatment for depression (be it prescribed or referred, medication or talk therapy, or some combination.) Sure, it could turn out to be something else, but the fact remains that common things really are common. Out here in the real world, "zebra hunting" by specialists (exhaustive workups for rare entities) is far more prevalent than Groopman's "zebra retreat," despite the fact that he comes back again and again to the Celiac patient misdiagnosed as having an eating disorder.

While on the subject of that patient, although he does eventually say:
Once believed to be rare, the malady, also called celiac sprue, is now recognized more frequently thanks to sophisticated diagnostic tests.
the fact remains that fifteen years ago, when this poor lady began her medical misadventures, anyone who even thought of celiac disease would have been -- correctly -- laughed out of the conference room. I'll bet even the great GI doctor from Boston's Beth Israel Deaconess Medical Center who finally made the correct diagnosis wouldn't have been able to do so when the patient first presented, not in the least because those "sophisticated diagnostic tests" didn't exist at the time.

Which brings me to my next point; one that Groopman doesn't address, although he could have. Although pathology doesn't actually change, our understanding of it undergoes tectonic shifts. Not nearly as often or as dramatically as the popular press would have our patients believe, but still with sufficient frequency that it behooves us not only to keep up with new developments in medicine, but to keep an open mind in applying new information to our "old" patients; those who carry diagnoses yet who do not seem to be responding to our treatment. What if the physician of that celiac patient had gone to a lecture titled, "New Perspectives on Celiac Sprue: No Longer a Zebra." Would the doctor have been able to recognize that this new pattern fit her patient, and cause her to go back and re-think the diagnosis?

I have experienced this phenomenon. A patient of mine almost from the day I hung out my shingle kept having great difficulty with depressive symptoms and anger issues. Antidepressants didn't really help, nor did counseling. About two years ago I attended a seminar on Bipolar Disorder, including the fact that it's far more prevalent than previously recognized, and that it's much more than just classic manic-depressive symptoms. One of the talking points was that on average, patients waited seventeen years before being correctly diagnosed. After that, I brought tools from the seminar into my practice. I didn't go around diagnosing everyone with bipolar, but I did begin recognizing it more than I had. The first time after the seminar I saw the lady I mentioned, I listened to her telling me once more about her symptoms; her anger, her explosiveness. Whoa, I thought. I whipped out the Mood Disorders Questionnaire from the seminar to confirm my impression. Sure enough, now that I had become familiar with a diagnosis with criteria different from what I had learned, I was able to see her in a new light. I treated her with mood stabilizers, and she responded beautifully; very grateful that "something finally worked!" I looked back over her chart. Ironically, it had taken seventeen years to make the diagnosis.

I would have appreciated a discussion of the incorporation of new information into medical decision making. At what point should new information be acted on? With recent evidence-based information coming out on things like coronary stenting (only helpful acutely), chest CTs for early lung cancer screening (doesn't help) and computer-aided mammography diagnosis (increases false positives without a corresponding increase in cancer diagnosis), this is a timely topic.

Much of the time I found the book depressing. Primary Care is described as blurry vision from watching a train rushing by. Even if a patient were able to take the advice given and ask the recommended questions to help his or her physician make the correct diagnosis, what chance would they have against the neurology group in cahoots with the lawyers (Chapter 9: Marketing, Money and Medical Decisions.) If Dr. Groopman himself couldn't get a correct diagnosis of his hand problem without seeing four orthopods with different opinions and treatment recommendations, what chance does an ordinary patient have when confronted with a surgeon telling him he needs his spine operated on?

Which brings me to my final point: a lesson that jumped out at me, but is either unnoticed or unacknowledged by Groopman. "Prestigious" does not always correlate with "quality." The third orthopedist consulted by Groopman for his hand was, despite his waiting room papered with plaques declaring him "Best of" this and that, a jerk. I don't care how many papers you've written or how in demand you are as a speaker worldwide; if you can't be bothered to take the time to explain your diagnosis and treatment to a patient, you are not only not "The Best"; you aren't even very good. The guy didn't even come up with the right diagnosis.

I understand the Dr. Groopman lives in the rarified world of Boston academe, and that he has access to many people with very prestigious qualifications. I enjoyed "meeting" several of them, reading along as he describes his conversations with them, and they sound like nice enough people. But the implication that those with top-tier training make better-thinking doctors is elitist and wrong.

I do not believe this book would be particularly helpful to patients, and I find myself wondering if those physicians who enjoyed the book (not noticing the absence of Family Practice or the omission of psychiatry) share Groopman's unspoken bias of the prestige-quality connection. The bottom line is that I was disappointed with How Doctors Think.