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.

Saturday, January 30, 2010

One Simple Question

A patient of mine brought her father down to live with her because he was having some problems living alone. She called me in a panic to tell me he was having trouble swallowing, so I rushed over to make a house call (yes, I still make house calls) to see what needed to be done.

It turned out that he'd been having the problem for months. He'd complain (loudly) he couldn't swallow -- yet was able to speak just fine through the episode. Then it would stop as abruptly as it started and he'd be fine, eating and drinking with no problem.

With that history, it was extraordinarily unlikely that there was something seriously wrong organically. Symptoms of an esophageal tumor wouldn't come and go like that. Nothing else really bad came to mind either. Still, it deserved at least a cursory workup, even though the guy was in his 90s. The daughter even told me that she was certain her father had seen the doctor for this problem, although she couldn't remember what testing, if any, he had already had, at his previous doctor's at Geisinger.

As anyone who reads anything about health care economics knows, Geisinger is one of the large multispecialty organizations specifically mentioned as the epitome of efficiency, delivering high quality care with better outcomes at lower costs. These accomplishments are attributed both to the corporate culture of cooperation between specialists and primary care physicians, but also in large measure to the fabulous efficiencies provided by their system-wide electronic medical record system. It should be a fairly simple matter to find out if he had had either a barium swallow and/or an endoscopy to evaluate his swallowing issues. Either of those negative studies would be enough to reassure us that there wasn't anything immediately life-threatening going on.

Piece of cake! The patient signed a release. Three weeks later* I get a half-inch thick sheaf of papers printed out from Geisinger's EMR. I wade through page after page of beautifully documented outpatient visits, complete with nurses notes, medication reconciliation, exam findings; all kinds of crap. Yes, dysphagia (difficulty swallowing) is listed as a diagnosis, but I can't see any record of it having actually been addressed at any visit. I couldn't find any labs, x-rays, other imaging studies, or procedures anywhere in the records.

Hm. Seventy-five pages that didn't say jack.

Then again, there were some notes about a hospitalization. Too bad all it said was, "Hospital follow up visit." Perhaps he had had studies done in the hospital, and those records, although not included in my printout, were easily accessible to someone actually on the system.

So I picked up the phone.

Actually, I had to do it twice. The first time around, my call was dropped somewhere between the voicemail system and any actual liveware. When I called the second time, I tried a different tack. Instead of asking to talk to an actual doctor, I decided to try letting the system do its thing. After all, I just had a very simple question: has this patient had either an upper endoscopy or a barium swallow?

Guess what? She can't tell either. There's nothing written anywhere in Geisinger's much vaunted EMR about the workup of a medical problem this patient has had for the better part of a year.

Riddle me this, boys and girls: what the hell good is a medical record if you can't tell what tests a patient has already had?!? Just by way of comparison, previous studies -- or specific notations about what the patient has NOT had -- are part of my history of present illness (HPI) every time I see a patient for a new problem. Not only that, but because of the way I keep the papers filed in my chart (that's right: still paper), I can put my hands on the report of a barium swallow or endoscopy in about six seconds (and that's only because I have to be careful of sharp paper).

And this is Geisinger; one of the groups identified BY NAME as a model that the rest of us should emulate. Really? When they can't manage to answer one simple question about a patient's care?

I don't think so.

*By comparison, I usually get medical records in the mail the next day; by the end of the week at the latest.

Wednesday, January 27, 2010

Why Bother Blogging?

Why bother ever writing an incendiary blog post ever again?

This says it all.

(The comments are hilarious, too. I actually added one. It's in there, three or four hundred down.)

h/t to Overlawyered

(Edited to add: I swear I posted this before I saw it at Orac's place!)

Monday, January 25, 2010

The Power of Prayer

This is for all those fundamentalist atheists (who are just as intolerant and hateful as all other fundamentalists) who scoff at prayer. Not prayer in lieu of taking actual action; that's just stupid. Demanding logical consistency of religion, an endeavor properly undertaken (and believe me, I quite understand how frequently through the eons religion has been used improperly, to say the least!) to comfort inconsistent humans in times of pain and suffering, is trivial and irrelevant. Yes, it is possible to thank Gd for allowing some to survive, without holding Gd responsible for those who perished, just as I thank DS for taking the trash out without berating him when he forgets. Remember that bit about foolish consistencies and small minds.

What brought this rant thought to mind?

I received an open letter from a surgeon at my community hospital who was on his way back from Haiti after spending a week there, hip-deep in relief efforts. He describes hospital scenes:
Many [patients] had their original dressings on, their wounds filled with dust and debris. Some no dressing at all. Within the next 24 hours there would be 18 rooms labeled Post Op with close to 80 - 100 patients who had had their surgery but were receiving little or no care. External fixation devices everywhere. Amputation stumps with dressing that had gone unchanged. IV sites that were occluded, bottles empty. Some patients crying, some quietly resolute. Occasional screams. Post op orders written on sheets of paper, no charts. Most orders not being carried out. No way to know if someone had gotten pain meds or antibiotics. No blood pressure cuffs. Only your hands and a stethoscope to determine pulse and blood pressure. Very little oxygen, no ambu bags, no suction, no ventilators.
and this:
I can't remember all of their names, but I can see their faces. I can also see the face of the mother who had just delivered whose baby died within her sight as [an ER doc from Miami] and I tried to resuscitate him without a laryngoscope, pediatric endotracheal tube, oxygen or even an ambu bag. Or the patients in Post-op room 18 who watched as we coded a young woman who had had her femoral fracture reduced, had been lying in bed for 3 days without heparin prophylaxis, and upon her likely massive pulmonary embolus, no crash cart, not even an ambu bag and no oxygen. Then they watched as we wheeled out her stretcher, and out in the courtyard, those waiting for triage watched as we put her in a body bag and carried her to the makeshift morgue outside.
But here is his closing paragraph:
Finally, please know that I felt the presence of every single one of you each time I knelt by the side of an injured Haitian patient. Because for strength and prayers, because of the support of all of the organizations, I quickly felt that I was there on behalf of each one of you. I had the privilege of bringing care, comfort and hopefully some healing directly to these people, but in truth I was acting through you. You have touched many, many Haitians' lives. Patients and families. So please do not feel helpless. You have already done so much.
This is what prayer accomplishes. Strength and support for those who are actually doing the painfully difficult work of helping. Relief from the helplessness that comes with being able to do nothing more than write checks. Validation that caring matters.

Could he have done it without "all that sky fairy nattering"? I'm sure you atheists will point out that of course he could, since those prayers weren't actually "doing anything". Maybe; but maybe not. Who knows what heights of human endurance can be enhanced by the knowledge that others are keeping you in their hearts and minds?

I was deeply touched by the letter, only brief snippets of which I've posted.

That is the true power of prayer.

Sunday, January 24, 2010

American Health Care; Vew from Afar

I received the following email from an expat friend of mine from college who now lives in Israel:
I thought of you when I read this, and would be interested to hear your take on it. (I'm one of those pessimistic types that think that America's health care problems will only begin to be cured when a majority of the public realize that their "insurers" are truly robber barons. Guillotining comes to mind as an option. But that's just me.) Trying to sound rational I usually say that it's high time the US took a look around at countries that have dealt successfully with providing health care (Denmark springs to mind) -- but I doubt the American political system or the American voter are ready for that.
My response:

Yeah, don't get me started on all that "Patient Centered Medical Home" shit. Basically, it's a way to get large impersonal multispecialty practices to work like me, from the patient's perspective (ie, everything they say they want to accomplish is precisely what I'm already doing).

As for systems in other countries, forget it. You know what the main problem is with American health care? Americans. If you could magically impose any other country's health care system on the US, I guarantee it would crash and burn in 6 months. Mostly because of the unparalleled litigiousness found here, but also because of patients' generally unreasonable expectations of medical care, coupled with an appalling refusal to take responsibility for modifiable lifestyle factors.

So yeah, if everyone recognized that the "insurance companies" are basically robber barons, and made rational decisions in their own financial best interests (which would involve paying cash for quite inexpensive primary care, true insurance for catastrophic illness, and programmed savings for end-of-life care (a la retirement)) then sure, we'd be fine. Just remember that this is a country of Limbaugh dittoheads who think Sarah Palin has more than two functional neurons in addition to a hyperfunctional uterus [edited to add] and left-wing nanny-staters who think it's their civic duty to wipe everyone's ass from cradle to grave. Believe me, there are times when guillotining sounds downright sensible to me too.

Tuesday, January 19, 2010

RIP Marvel Battle Van

Also known as a 1999 Plymouth Voyager, with over 100,000 miles (not bad for a Chrysler product with the original engine and transmission), the Marvel Battle Van owes us nothing. For seven years it served me well; the remaining four years of its driveway tenure were in service to the Jock, who found it "convenient" (large and red enough to find in any parking lot; plenty of room for a team and its gear). It had begun sucking down money over the last few years, accelerating at a greater rate than it ever did on the highway -- which is saying something. For anyone who hasn't ridden a Voyager on the highway, that puppy can move!

The quest for new wheels is on, as the Jock and I bid a fond farewell to the last automotive vestiges of adolescence. To the Marvel Battle Van, we say Adieu; safe journeys to that great parking lot in the sky (or wherever Purple Heart takes it).

Thursday, January 14, 2010

I Didn't Know You Could Get Them That Small

True story:

Healthy five-year-old boy in for an annual checkup:

Dad: Tell the doctor why you wear boxers.

Kid: I like the way it feels when it flops around.

Wednesday, January 13, 2010

Consult Codes: Goodbye and Good Riddance

Consult codes have just gone the way of the dinosaur! And none too soon, I might add.

For all you non-medicos with no idea what I'm talking about, allow me to enlighten you:

Medical care comes in two flavors. The first kind, so-called cognitive services, involves the doctor talking to you, examining you, perhaps ordering some blood tests or imaging studies, figuring out what's wrong with you and what to do about it. The other variety, "procedural services," is when the doctor does something to you, like cutting something off of you or out of you. There's plenty of overlap, of course. The most important part of any procedure is deciding whether or not it needs to be done (which usually involves thinking), and procedures of some kind are required to establish many diagnoses. The problem is that procedures pay far more than cognitive services.

It began about 25 years ago, some Harvard economists came up with the idea of quantifying the amount of "work" in a medical encounter. This allowed them to calculate a Relative Value Scale of everything a doctor does (cognitive and procedural). Add some geographic fudge factors (to make it "resource-based") and a "conversion factor" (a dollar amount) to turn it into a fee and you have the Resource-Based Relative Value Scale, the infamous RBRVS. Leaving aside the subsequent actions of the specialist (read: those who do procedures)-heavy RBRVS Update Committee (RUC) that have made procedures more and more lucrative than cognitive services, I have a problem with the idea that the amount of "work" can be quantified for any given medical procedure, cognitive or procedural.

Take the so-called Level 3 (of 5) Office Visit. This has an actual definition:
Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and coodination of care with other providers or agenies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.
Here's my take on that: NOT ALL LEVEL 3 VISITS ARE CREATED EQUAL. Believe me, 15 minutes reviewing three chronic problems, performing a brief physical, and renewing ten prescriptions for a pleasant, informed, cooperative patient is a very different 15 minutes from those spent with a cranky, demanding, loudmouth who has no idea what meds he's taking, much less whether any of them need refilling, and who insists that I order an MRI because he had a headache last night. In fact, that I can manage to accomplish what each of these patients need (not counting a swift kick to the behind in the case of the second patient, but I have a bum foot) in only 15 minutes is a testament to my skill, tact, and efficiency. Nevertheless, I still believe that for cognitive services -- the so-called Evaluation and Management, or E/M services -- the most logical and equitable proxy for "work" is TIME. By and large, the 20 minute visit is generally twice the work of the 10 minute one.

But I digress.

It turns out that specialists have another mechanism to increase their take set of codes they can use for what are essentially E/M services: Consultations.

Here's the way the system is supposed to work: everyone sees their family doctors for all their concerns. Family doctors are perfectly able to take care of 90% or more of the problems they see. The remaining 10% are either too complex or severe for our skill set. Those we refer to the specialists, who, by virtue of their longer and more detailed training, are better equipped to deal with this small proportion of the general public. For this (a specific request from another physician who was unable to handle the problem) it is generally accepted that specialists deserve greater compensation. The purpose of Consultation codes was originally to identify this specific service, to distinguish it from any old garden-variety E/M visit. Logical; fair; economical.

Two things are necessary for this system to work as designed, though:
  1. Everyone has to go to their primaries first, and
  2. There have to be more primaries than specialists.
Instead of having the accepted ratio of 70/30 specialist to primary care, this country has exactly the opposite. This is only part of the reason why people don't go to their primaries first; in too many cases, the too-few doctors are too busy. Then again, Americans are notorious for demanding "the BEST." In the case of medical care, this usually means the specialists. (The really sad thing about this situation is that for the unselected, self-referred patient, the specialist's approach is much more expensive than it needs to be, and subjects the patient to all kinds of inappropriate interventions.)

So when you have 70% of physicians using codes intended for 30% of them, to care for medical conditions that do not require their full expertise, you're going to be spending far more money than necessary.

This is why the Centers for Medicare Services (CMS, ie, "Medicare") decided to stop paying for Consultations. Weep bitter tears for the poor specialists who are now stuck with the same paltry selection of E/M codes as we Primaries. If nothing else, maybe it will help them work together with us to increase compensation for cognitive services.

h/t to my good friend TBTAM, with whose post on this topic I respectfully disagree.

Saturday, January 09, 2010

What You Can Do with Your Pink Ribbon

For those who may not be aware of the goings-on at that massive time waster known as Facebook, there was a bit of a tizzy over there the other day. Simply put, women were encouraged to post the color of their bra in order to "raise awareness of breast cancer."

Note to those whose opinion of me is inversely proportional to the amount of time I waste spend on Facebook and other internet frivolities: I did not find out about this online. Rather, the patient I was seeing apologized for the fact that her phone kept buzzing. Apparently, she had it set to alert her when anyone updated their Facebook status, so it buzzed constantly as all her friends played along.

By today, there was commentary galore, both pro and con, throughout the blogosphere. For the record, here was my response:
Lucy doesn't care what color your bra is. If it contains two healthy breasts, consider yourself blessed.
As DenverDaughter puts it, all the pink ribbons in the world won't bring her mother (or mine; or anyone else's) back again.

(Apologies to my Facebook friends for the redundancy.)

So True

If you don't read Indexed, you should.

Thursday, January 07, 2010

Fun on the Radio

Whenever I am in my car I listen to WOGL. It's a nice oldies station (kind of sad that "music of the 70s, 80s, and 90s" -- my music -- is considered "oldies") with an affable morning crew. In addition to music, news, weather, and so on they have assorted games that people can call in to play. One of them is called "Buck-a-Bark," and (no surprise, I would hope) requires that the caller have a dog. The goal is to get your dog to bark as many times as you can in 15 seconds, and they then send you the corresponding dollar amount.

What fun. I listen to it regularly on Thursday mornings. Usually the dog barks like crazy before the timer starts, then won't make a sound for the critical 15 seconds. Other times it won't bark at all. Occasionally, the dog goes on at the right time. The most I've ever heard was a Pomeranian who got in 44 barks.

The best part is watching the Rolling Peke react to the dog barking on the radio. Since she adores d-o-g-g-i-e-s (I have to spell it out; just hearing the word sets her off) she goes nuts during the feature. I have to stroke her and tell her that there really aren't any d-o-g-g-i-e-s out there, and she should shut up already.

Ever since her surgery almost five years ago, RP has come to the office with me. For a small dog, she is unusually quiet. Most patients and visitors to the office are amazed that there's a dog there at all. Most of the time, that is.

For some truly unfathomable reason, there are certain people who drive her crazy. She barks like crazy at them from the instant they walk in the door until the moment they finally leave. Sometimes she sits at the door after they've left and barks a few more times, as if to say, "And STAY out!" These people have nothing in common. For a while, I thought it might just be old people; but not always. Or smokers; nope. Dog-haters? Not at all. Dog-lovers? Sometimes yes, sometimes no. It's random! But once you're on her "bark" list, you stay there.

A few weeks back, a patient of mine was burned in an awkward location on his back. He lives alone and was having some trouble changing his bandage. Because I've known him such a long time, I started having him come in every morning right before the first patient so I could dress the wound for him. (It's healing beautifully, by the way.) As it happens, he's one of those people who drives the dog nuts. Every morning. All I have to do as I pull into the parking lot is say to her, "He's here!" She sits up and starts the little huffing noises dogs make before they burst into full-throated barking. She runs after him, barking her fool head off. She follows us into the exam room where she finally shuts up. Then as he's leaving, she chases him out. It's hilarious.

So this morning, they invited folks to call in for Buck-a-Bark just as I was heading out to work. It occurred to me that if I called in, I'd end up arriving at the office just as they'd be getting us on air. Assuming my patient was there (he's only failed to beat me in once), my 15 seconds of fame could very well coincide with the RP's giving him a very vocal piece of her mind.

So I did it.

And it worked!!

I'm bummed beyond all words that I can't find a way to podcast the piece, but the Rolling Peke let loose right when they started the timer. She barked like a champ as the mean, nasty man my patient goaded her.

The official Counter of the Barks, Mr. Bill Zimpfer, declared that the RP had barked 19 times. Frank Lewis (the weird guy) rounded it up to 22 (I said he was weird), and I had the time of my life chatting with Ross Brittain and Valerie Knight.

Thanks for making my day, WOGL's Breakfast Club!

Yet Another Reason Why Assumptions are a Bad Idea

Because of various insurance requirements, I am forced to use a certain lab (call them "Mission" Laboratories) for almost all my patients. For us dinosaur offices, the lab still provides us with a large doorstop of a book that contains all the information about how to order the various tests they offer. Although we have lab forms pre-printed with the vast majority of things we frequently order, there are times when I still have to go to the book to look up a specific test. Which I did the other day. And got a phone call from the lab:

"What test do you want?"

"I wrote the name and the number from your book," I answer, reciting the name and number back to them.

"That's an obsolete test number. It's not in use anymore. How old is your book?"


"Please call Client Supplies and have them send you a new one."

So we did, and they did. All was fine (so I thought) until today, when I get another call about a test ordered yesterday:

"What test do you want?"

"Test number @#$%. I wrote it on the slip, and I got it from the new book I just got. It's right there on page 186."

"I'm looking at page 186, Doctor, and there's no such test on that page."


Finally, DinoStaffer "D" notices that the book, while announcing "2009" in large friendly numbers at the top of the cover, says "New York/New Jersey" in smaller letters further down.

Epic WTF?

Why on earth would "Mission" Laboratories send a New York/New Jersey reference book to a Pennsylvania office?? The DinoStaff came up with a thought.

DinoStaffer "B" is a lovely person, but her native origins are clear the instant she opens her mouth. Our suspicion is that upon hearing her heavy New Yawk accent, "Mission" Lab immediately assumed that they knew her location...and sent us the wrong fricking book.

We have requested a replacement. This time, DinoStaffer "D" made the call. She is Pennsylvania born and bred.

We shall see.

Wednesday, January 06, 2010

Stupid is as Stupid Does

If you're planning to leave your wife of thirty years,
and if you wait until just after Christmas to tell her about it,
and if you already have plans for New Years with your new girlfriend...

What kind of idiot are you to put it all on Facebook, where your kids can see everything you're doing (and therefore find it all the more difficult to believe you when you deny everything)?

How stupid can you get?

Tuesday, January 05, 2010

Thank You, Westboro Baptist Church

For those of you stuck off in an underground bunker with the great good fortune never to have heard of them, the Westboro Baptist "Church" (no link) is a family-run cult that specializes in disrupting military funerals and staging protests at schools, churches, and municipal institutions that dare to show any kind of tolerance and acceptance of anything their two neurons can conceive as having anything to do with homosexuality. One of the deeper ironies of the universe is that their founder is a lawyer who began his career with great success in civil rights litigation. He has since been disbarred and has begun a new phase of his life as founder and leader of the Westboro Baptist cult "Church".

I know what you're thinking: why on earth would I be expressing thanks to one of the most disgustingly vile hate groups masquerading as "Christians" in this country today? Here's why: yesterday, they held an early morning protest outside my niece's high school.

Still don't get it?

The community's response of peacefully gathering and ignoring the protesters, while providing a buffer between the hate-filled rhetoric and the students, was a source of deep pride to my niece and her family. I called her last night, and she told me that the incident sparked a great deal of discussion in school, both in formal classroom settings and among friends. All told, it sounded like the incident generated a fair amount of positivity (including this).

Although the world would certainly be a better place without all the hate spewed by WBC and its ilk, if it has to exist -- and if it absolutely has to invade the loving and tolerant world my family is trying to provide for our children -- the very least it can do is generate the warmth and community spirit as was found in New England yesterday.

I love you all, RFS et al.

Saturday, January 02, 2010

Worth the Hype

I am generally pretty cynical when it comes to movie reviews. In fact, I find that my impression of a film is inversely proportional to how many stars it receives in the paper. The less everyone else thinks of it, the more I like it, and vice versa.

Today was the exception that proves the rule.


The IMAX was sold out, but the regular theater with the 3D glasses was good enough.

It has everything: a functional if predictable plot; engaging acting; an appropriately dramatic soundtrack that managed to stop short of inducing cephalgia; and of course, knock-you-out-of-your-seat visuals. Despite its length (two hours and forty-two minutes) I was never bored or fidgety. (I've been known to fall asleep in movies. As an adult.) Not this time. Every moment captured my attention. The opportunity to be immersed so fully in such a well-realized and executed world/alternate reality was nothing short of exhilarating!

Go and see it if you get the chance. You won't regret it.

Friday, January 01, 2010

Ten Years Ago

Ten years ago, my children were in Middle school. We were planning a joint Bar and Bat Mitzvah for the Jock and DinoDaughter. I was so proud of how grown-up they were.

Today, all my kids have traversed the High School graduation milestone with ease, navigated the bulk of their college years, and are now actively planning for life beyond schooling. I believe this is called "adulthood."

Ten years ago, this crotchety old guy I've known for years was taken off a cruise ship with ruptured diverticulitis and flown to Miami for emergency surgery -- including a colostomy -- in the middle of the night. I flew down to be with him for several days, and to spell his wife, who was caught in the middle of the rioting over Elian Gonzalez (remember him?) When the COG wrote a poem about his colostomy, we knew he was going to be fine.

Today, we're all still basking in the warm glow of last year's trip to Bermuda to celebrate his 80th birthday. His colostomy is history (when the doctor closed it, all the guy wanted to hear was, "Mr. COG, you have your asshole back." Instead, the doctor told the wife, "Mrs. COG, you have your asshole back.") although his abdominal wall is a scarred battlefield of assorted repaired ventral herniae. His mind is as sharp as it ever was, though.

Ten years ago, I was single, dating frequently, and hating every moment of it.

Today, I pinch myself every morning as I wake up next to the most Darling Spouse anyone could ever wish for. (I have another kid, too.)

Ten years ago, an orange cat was pissing off his original owners so thoroughly that they brought him back to the shelter where they got him.

Today, nine years after attaching himself to Darling Spouse and DenverDaughter when they went to select a cat at the behest of DS's late wife ("so he wouldn't have to come home to an empty house"), the Mighty Hunter lounges in the sunshine between presenting us with small former rodents and getting shot up with NSAIDs.

Ten years ago, everyone was getting their panties in a wad worrying about the ramifications of the Y2K bug, which turned out to be a whole lot of hot air over nothing much.

Today, everyone is all in a tizzy over health care reform, which I predict will, in retrospect, have exactly the same impact as did Y2K.

Ten years ago, I was busy berating the arithmetically challenged hordes insisting that a new decade was dawning today, instead of a year from today.

Some things don't change, even after ten years.

Happy New Year, everyone!