Tuesday, December 30, 2008

Primed and Pimped

(The essential part of rounding with medical students and interns) Pimping is an essential part of medical education that seems to be so often missed in our kinder and more gentle brand of medical education that seems to be the rage these days. Pimping is an art form that is slowly perfected over the years and is passed on as a write of passage. A Crucible of sorts that is very specialty specific and never forgotten by young doctors. Pimping consists of asking the ever studious medical students and half awake interns questions that are essentially unanswerable. Dr. Fred Brancati, M.D. in his immortal work "The Art of Pimping" explains that lawyers often call this Socratic education but really there is so much more. He writes that pimping inoculates the intern with profound and abiding respect for his attending physician while at the same time ridding the intern of needless self-esteem. Eventually, as the interns become residents they learn the art of pimping themselves and how to dodge and bluff the questions and become the pimpers themselves.

Here are some of the great pimp questions:

Where is Meckles Cave? (Fifth cranial nerve bundle prior to ducusation)

What is an Otis Elevator used for? (To go up and down floors)

Why are some organs paired? (Surgical answer is so you can cut one out)

What is a Hasselhoff? ( An emergency patient with bizarre explanation for their injury (David Hasselhoff's had a bizarre shaving accident in which he hit his head on a chandelier; the broken glass severed 4 tendons and an artery in his right arm)

What did Rudolf Valentino die of? (A perforated ulcer, his surgeons thought it was appendicitis when they saw imflamation in the right lower quadrant. The moral is check everything, not just the obvious.)

What is the first thing that you check on an x-ray? (The name of the patient)

What is the sensitivity and specificity of the cryptococcal csf antigen test? (the answer is not important, you just have to look frustrated when they dont answer.)

Do identical twins have identical finger prints? (No.)

What did Dr. Moniz win the Nobel Prize in medicine for? (The prefrontal lobotomy. Often asked when looking at trauma head cts.)

How much spit do we make in a day? (1 litre)

There are a bunch more. I'll try to remember more.

Monday, December 29, 2008

Non Secular Party

The children on our local public schools could not have a Christmas party this year. They could have a "Holiday Party" as long and there was no secular references. The school district stated that they were trying to avoid all the legal hassles that may arise from a "Christmas Party" do to discrimination lawsuits and suits based on the seperation of church and state. The superintendent also stated that he could just see the lawyers salivating hoping that he would allow the Chorale to sing "Silent Night". "The schools budget is tight and their is not room for more frivoulous lawsuits."

I think I know why attorneys are so fierce in their interpetation of the seperation of church and state.The last thing that they want is an outside reference to what is moral. Further, the Bible seems to call “a spade a spade”.

Luke 11:46 King James

“And he said, Woe unto you also, ye lawyers! for ye lade men with burdens grievous to be borne, and ye yourselves touch not the burdens with one of your fingers.”

Luke 11:52 King James

“Woe unto you, lawyers! for ye have taken away the key of knowledge: ye entered not in yourselves, and them that were entering in ye hindered.”

So, what the schools teach is determined by lawsuits, what the children do is regulated by lawsuits and what do the children learn? To file lawsuits.

Thursday, December 25, 2008

Anemic MedMal Insurance

Bad news from the state meeting of the AMA. One of the arguments that our local trial bar has used to fight med mal reform is that the medical liability insurers were flush with cash and that high medmal insurance rates were due to greed and had nothing to do with frivoulous litigation. The insurance companies which are physican owned cooperatives countered that the surplus was do to strongly perfoming investments and that the surplus was needed secondary to the increasing cost of litigation. Well, the bottom has dropped out of the market. As a result, the surplus is projected to be gone. The rate of litigation is also expected to increase. So, guess what? It looks like we are getting an across the board rate increase.

I checked into what I could do to decrease the cost of my medmal. First, I could stop teaching. It seems that educating medical students, interns and residents puts you at higher risk. Oh, big discount if you dont supervise ARNPs or PAs. Stop doing any procedures. Move to purely office based practice and not have to cover an ER. Go to work for the VA fulltime. The last big one was to swith to a different specialty. (or to another career)

Saturday, December 20, 2008

2:1 (JD:MD)

I came across some amazing statistics. Last year the American Bar Association reported that US law schools graduated 40,000 new attorneys. In the same year, the number of graduating physicians from US medical schools remained the same at 16,000. This means for every new doctor there are over 2 new lawyers. 70% percent of the world's attorneys practice in the US but we have only 5% of the worlds population. There are 1,130,000 practicing attorneys in the United States in 2008 and 805,000 MDs, 24% of the MDs are foreign graduates. (The good news is that several new medical schools are opening up and it is hoped that we will be able to increase the number of US med school grads to 20,000/year within the next 8 years. There are over twice as many new law schools opening up!.) 36% of House of Representativess and 53% of the Senate are trial lawyers. 25 presidents were attorneys. Less than 1% of the House and Senate are physicians. Physicians have almost twice the suicide rate of the general population.

Scary stuff!

One Good Deed equals one Good Lawsuit

In California, four coworkers were driving home and ended up in a bad accident. One of the cowokers pulled another from the car fearing that she would be burned when the car exploded. The woman that was saved has paraplegia from the accident but has chosed to sue the person who pulled her from the car. The California Supreme Court is letting the suit go forward. The plaintiff claims that even though she had a broken neck from the accident, it is the person who removed her from the car that caused the paralysis. (I can only imagine the chase for who has the big pockets)

This case is sending waves throughout the medical community and the people in California. There is nothing like the threat of a lawsuit to further push people away from helping in a crisis. In medicine where fear of lawsuits is the norm, there is great confusion about what the "Good Samaritan Laws" actually mean. Most of my collegues are afraid to stop at the scene of an accident and render aid for fear of being sued. The Good Samaritan Law is supposed to prevent this fear of suits but no one seems to believe that it will offer any protection. I have tried to find cases where physicians and nurses have been sued for helping at accidents or sporting events and so far have not found them. Not that they haven't occured. When I ask other physicians, everyone seems to have heard of a doc being sued but nobody has any first hand experience. I personally always try to stop and help and for the most part there is not much that I can do except hold pressure and wait for EMS but I have had to help them intubate and performed CPR.

I think it is sad enough that people would rather go their own way and not help in an emergency without the courts now opening the door to suing those that are trying to save your life.

As Clear as the Colostomy Club's Swimming Pool

(Health Insurance companies pre-certification processes) We had a patient that no matter what we could not get an MRI pre-certified. If this is not done the insurance will not pay and the patient will get the full bill. Trying to stay up on all the latest hoops that the insurance companies want before they will approve a test is almost impossible. We try to get some kind of protocol but of course they will not release it. So, you can only find out by trying. If you do get something in writing from them it is about as clear and the colostomy club's swimming pool. This is usually how it works. If we order a MRI, our team has to call the insurance company, then fax the clinic notes. A person at the insurance company who has no medical training then looks the notes over and checks to see if the right words are there and if there is the correct previous tests and then checks her protocol to see if it can be approved. (the protocol is not to be distributed outside of the insurance company). They then automatically deny the request unless it is 100% within their protocol. This is becuase they make sure the responsibility of getting the test approved is on the physician, not the patient. (If you make it hard to get a test, the office will not order them. Keep the hassle away from the patient so they think they have great insurance.) So, we get the denial and then have to talk to someone else to find out what else they need. They also have no medical training, This goes nowhere becuase you cant explain to them that the test is needed because you think the patient has a brain AVM and might stroke out. All they say is that if we think the patient really needs the test they should get it done and pay out of their pocket or go to the ER. Finally, in the battle you get a manager who will let you talk to the medical person who has authority to approve the test. This will always have to be scheduled at a later date to make it as inconvient as possible. (Another trick to see if yo will just drop it.) This is supposed to be a peer to peer, but the person you talk to usually has no clue what you are talking about. (The classic was a retired OB and I had to talk to him about a tumor of the skull base!) Finally, the insurance company will pre-cert the test. This whole process took one of our office staff three hours and me 30 minutes on the phone. All this for one test!

All I want for Christmas is a Hysterectomy

The hospitals are busting at their seams right now. The insurance companies business model is in full effect. Health insurers know that people will defer getting elective procedures done until their deductable is met. They also make sure that the deductables follow the calander year because most people take time off in December over the holidays and the hospitals and health providers will try to take time off as well so people will have a hard time getting things done. So, what happens? People generally meet their deductable about the end of November and then want all the medical care and procedures they can before the end of the year so that they don't have to pay another deductable. As a result, there is a huge rush at the hospitals. It seems that "all I want for Christmas" is that hysterectomy that I have been putting off, or hernia, or knee replacement, etc. It is amazing. The OR volume from Thanksgiving to New Years doubles! The hospitals are at limited staff because the staff wants to have time off or their elective surgeries as well! One good thing though, the insurace companies give their staff extra time off during this time of year so that all these elective procedures can not get pre-certified and they can still stick the patients with added expenses.

Sunday, December 14, 2008

Shocking Situation

An ER doc friend of mine told me this story that happened a few weeks ago. He had a patient come in to the ER complaining that he had one of those "bad pacemakers" that he had heard so much of on those lawyer commercials. In fact he had even called the 1-800 number to report his problem. He had been on the phone for several hours and that was why he didn't come right in. His problem was that every few minutes he was getting a shock. At first the shocks were really strong but now they were relatively weak. He explained that the attorney site said that there was a problem with the wires in the device and he may be able to participate in their lawsuit. I guess telling him to go to the ER was not part of their sales pitch. The patient didn't think that there could be anything wrong with his heart because the commercials all said that the pacemakers were defective so he stayed on the line and gave them all the information he had. Name, address, he even read them the information on his medic ID bracelet and the card that he carried that identified the "Automatic Implanted Defibrillator" that he in his chest, including the company and model number.

The first thing the ER did of course was hook him up to the monitors while he went on an on about what the attorney had said and sure enough his "pacemaker" was shocking him. He was having runs of vtach and the pacer was actually a defibrillator and was keeping him alive! He was so busy talking about his possible lawsuit that he didn't mention that he had been feeling really bad and passing out. He also didn't mention that he had gained some weight and since it must be water had increased his lasix dose. His "defective pacemaker" stopped shocking him when his potassium was corrected.

Somehow, I get the feeling that he will still try to sue.

Saturday, December 6, 2008

Blister pack panic

OSHA and JACHO have conspired again to hinder the care of patients in the name of more bureaucratic meddling. When a trauma patient comes in, the first thing everyone does is put on goves and a gown. As the patient is getting his primary survey at least one large bore IV goes in to help get meds, fluid blood etc. Here is the problem. It was hard enough to get the old IV catheters out of the plastic bubble wrap they were in. They had a little part that you could peel off but with gloves on it was impossible. So you just twisted the whole thing and the catheter would pop out. But that little bit of sabotage was not enough. We now have to use these special pre-bubble wrapped packs that has a latex free touriquet, aseptic swab stick, guaze, and finally the catheter. Not only is the whole thing in blister wrap, but each component is seperately blister wraped. There is no way you can open these things with gloves on. So, now you have to make sure that you tie up a whole person whose sole job is to open the stuff instead of helping the patient. This is in addition to the other person whose sole job is to stand there and document. They are documenting that you used the JACHO and OSHA approved IV start kit of course.

Wednesday, December 3, 2008

Half time = Half trained

The kinder and more gentle days of residency are upon us. Residents are limited to 80 hours a week. This is a big change. The term resident came from the fact that doctors in training resided in the hospital. You litterally ate, breathed and lived medicine. This was the way to cram as much training and experience as possible into the years you spent after medical school. Residencies got longer and longer as there was more to know. In surgery, the saying was that if you were on call every other night, you missed half the cases and had half the experience. This came from the fact that the days were filled with the routine cases but the emergencies that came in while on call prepared you to handle anything. Now we have surgery residents checking out like they work in a factory. "I reached my limit and its time to go!" In many cases the hour limits have decreased the experience by a third to a half.

Here is one of the problems. Is a surgeon who has only 2/3 of the experience handling emergencies as good as one who has done more? Should we increase the length of residencies? Surgery is already 5 to 7 years. Neurosurgery can be 7. This does not count fellowships. All this is after 4 years of college and 4 of medical school.

Was I tired in residency? You bet, I learned to catnap, eat standing and to follow the rules of "The House of God". See a bed, lay in it. See food, eat it. See a chair, sit in it. When I finished residency it was better but I still had the long hours because I was supervising residents.

Here is another thing. Out of residency, you cant have your beeper go off and tell the ER that "no, I cant help with that emergency, I have already worked my hours." "Sorry that the baby has decels and a c-section is needed, Ive reached 80." Residency prepares you for what its like in the real word. There are no work hour restrictions in the real world.

I tried to expain our work ethic to a friend who is an attorney and explained that you go home when the work is done and get called in when there is more work to do. We base things on the job to do. You go home when the patients are stable. He didn't understand, he gets paid by the billable hours, the longer something takes, the more money he makes. It is to his advantage to drag things on as long as possible. He can go home anytime he wants. It not like people are dying!

Monday, December 1, 2008

Acute Thespian Syndrome

(The sudden need to fake an illness.) In medicine we learn to ask questions and to believe the answers. Even when things don't seem to make sense, we error more on believing the patients. The problem are those patients with Acute Thesbian Syndrome. These are those wonderful citizens who are on their way to jail who sudden have chest pain, or mind splitting headaches with neck stiffness, or the classic sudden abdominal pain. My favorite was the women who claimed that she was in premature labor (fat dont make you pregnant). Their goal is that the police will bring them to the hospital, and leave them there instead of pressing charges. The police will often do this so that they dont get stuck with the bill or for minor offenses they just cite the person and hope that they will show up in court. The patients know that there will be tests ordered and as long as they keep complaining the work up will continue until the police lose interest. The "patient" then suddenly gets better and then is discharged or leaves AMA. It is amazing how good patients can fake chest pain after watching "ER"! This weekend was no exception. We had several cases of ATS. The good ones know to complain of severe pain in the hardest areas to evaluate such as deep in the pelvis or abdomen. Several were in with severe kidney pain from stones. We have to have several people watch them pee into a cup to keep them from picking a scab and dripping blood into it. They not only wanted the police to leave them but were hoping for some narcs. One patient with ATS this weekend had severe vomiting. We were lucky that the radilogy tech saw him taking ipecac when he went behind the screen to set up the abdominal film.

Acute Thesbian Syndrome is also a good way to get out of jail or prison for a few days and enjoy cable and the presence of nurses of the opposite sex. The prisoners know that the best way to do this and to help their cause is to fake a psychiatric illness. They parlay this into getting out of jail for a time and then use it as an excuse for their criminal behavior in future parole hearings. We catch them with our "patient safety cameras" in sudden lapses of normality.

I wish we could be like those stores that have signs and lists that say "We do not take checks from these people". Ours could be "We do not take chest pain from these people!"

Sunday, November 30, 2008

Black Friday, Oh, my God Saturday and What the Hell Sunday

(Besides it's association with shopping, the day after Thanksgiving is associated with the most horrendoma's that present to the ER.) I have been trying to figure out if Prozac will fit in the battery compartment of my beeper because I think that my beeper may be suicidal. It went off 34 times on Black Friday, 31 times on Oh, my God! Saturday, and so far on "What the Heck, Sunday 21 times. These have not been the routine, hey "I am going to lie to you in the hopes that you will call me in narcotics over the holiday calls" but the urgent consults that are urgent because people waited to come in. People are driving home after being "pissed" with their family and taking it out on the packed roadways. Sic kids are visiting their grandparents who have COPD who then catch the cold and end up intubated. People are falling off roofs trying to put up their Christmas lights. That pesky indigestion that feels like an elephant on your chest radiating to the arm is getting worse and worse. Its the same thing every year.

The hospital seems more quiet but that is because there is not the elective surgeries or the outpatient diagnositic stuff going on. Instead it is filled with the hustle of the techs moving patients in and out of CT, OR and the cardiology labs. We have most of the senior nurses and techs working because they are the most efficient and we need them in a time like this. A tear was brought to my eye when in a code the charge nurse yelled to another nurse who grabbed a computer terminal to document what was going on, "F***the computer, take care of the GD patient!"

Friday, November 28, 2008

Triage Trolls

I love to hear the latest on how long people have had to wait to be seen in the ER. Most of the time it is because they misunderstood that it is the "Emergency Room" and not the "I have a back ache and cant sleep room" or the "I blew off work and need and excuse room". I had to follow up on a complaint by a local attorney who threatened to sue the hospital and the ER doctor because he had to wait 3 hours to be seen for a 1 cm laceration of his finger that did not require sutures. ( I have no clue what he thought his damages were.) This is what I found out. He had signed in and was seen by the triage nurse. They checked his vitals signs and saw that he was not bleeding and he was then triaged to the list of those who would be seen in order for the "minor" complaints. "Minor complaints" are those that mean you are not at risk of dropping dead that instant from your problems. These are who were seen ahead of him. Two people involved in an auto accident who were intubated in the field, one of which went immediately to surgery. A ruptured AAA. Three possible MI's (2 were positive) a copd patient who needed intubated. A pregnant woman with ecclampsia and seizures. A kid with a ruptured globe. 4 acute fractures. 2 pneumonia patients requiring oxygen, a brain bleed, 2 strokes and a slew of others.

I guess that he felt that people should be seen in the order in which they hit the doors and not by how sick they actually are. It doesn't really matter though. People will only look and say that the average wait was 2 hours, it doesn't matter that they didn't have an "Emergency".

404 Error

(Rounding in the world of electronic medical records). I know that the politicians and all those from the adminostratosphere think that electronic medical records are the best thing in the world but man they are a pain in the neck. It used to be that when I went to round on a patient, I had the chart and in it were the vitals, the drain outputs, pathology reports and lab values. I would talk with the patient, examine them and then go over all the values and answer their questions. Now, you first have to sit down and log in to the computer (If there is one open). Scan all the data, if necessary print out all the information you can and then go see the patient. Of course, a lot of the data is not in the chart because the nurse has not had time to enter it into the computer. You can try to track the nurse down but they are locked away at some other computer trying to catch up on all the other paperwork. So, you go see the patient and they ask you a question that would normally be in the chart. You then try to find an open computer and relog in (you get HIPPA'ed out if the computer is inactive while you examine and talk to the patient) and try to find out the answer to the question.

The tech guys then decided to help with the problem by having these little computer carts that the nurses can push from room to room. Of course when you pull up the patients chart after re-logging in for the 10th time you get 404 Error. You then have to push the cart around the room trying to find the sweet spot that will let it connect only to remember that this is a telemetry floor and the computer is probably setting off the guy in the next rooms AID. (Automatic defibrillator). After considerable wasted time, you find the nurse and ask her for the information you need and the answer is that it is in the EMR!

I think I figured out why people think EMRs will save money and prevent medical mistakes. They first make it hard to see patients, so you see less patients and therefore there will be less spent on medical care. Secondly, you cant make a medical mistake because you cant actually treat patients. (Oh, I am writing this now as they are trying to re-boot the servers that run the EMR system. Go figure!)

Wednesday, November 26, 2008

OB/GYN - GYN = 66%

Wow. I was talking with several of our OB/GYNs in the doctors lounge. One had just decided to stop delivering babies and found out that her medical malpractice premiums would drop by two thirds! She coldn't believe it, when she did all the numbers she would make more by doing less! In fact delivering babies was actually costing her.

I am sorry to see her stop her OB practice. She took care of those with no insurance, those who came in to the ER with no prenatal care, those on Medicaid. It all came down to simple economics, she could not afford to deliver babies and carry insurance.

Sunday, November 23, 2008


I am not the sharpest person in the world, but I know that if my patient is very anemic I can't get him better by taking blood from the right arm and transfusing it into the left. This is why I dont understand this new "job creation plan" that hit the news today. As near as I can figure out, money to the federal government comes from taxes. These are the various income taxes, corporate taxes and tarrifs. Taxes that come from the private sector are what fund the government because government jobs cant fund the government. This is because the government pays the federal employee with tax dollars that it then recollects a smaller portion in the form of income tax. This is like transfusing yourself but letting most of the blood fall on the floor. The more government jobs you create the more money you lose and the more money the government needs in the form of tax dollars from the private sector. This causes the private sector to sink and recess as it has to pay more and more to the Federal Government. The report today stated that the new administration is expecting to create 2.5 million jobs in developing new infrastructure, schools and other government funded areas. This isn't an auto-transfusion, its a hemorrhage.

Saturday, November 22, 2008

Fecal Encephalopathy

(S****for brains) JACHO hit us again. I really wonder if they have any clue on what really goes on in a hospital. We used to be able to keep some medications in the OR because you never know when you will need them. These are things like lidocaine with epi, heparin, thrombin, surgicel, pitocin for the OBS, DDAVP to decrease bleeding, etc. Well JACHO has determined that these need to be kept in the pharmacy or at least somewhere other than where they will be needed. So, when the need arises which is usually out of the blue the circulating nurse has to run out of the room to find it or we have to call someone to go and try to find it instead of just having it. God forbid the nurse actually stays in the room to help care for the patient. This is especially a problem for trauma cases where we are going straight from the ER to the OR. Apparently we can't have a generic pharmaceutical bag or set for each case so at least all the meds could at least be put into the room either.
Why can't JACHO do something that will really improve patient care, like decrease the paperwork so nurses can actually care for patients and help them be more efficient. Oh, nevermind, I forgot, they are self supporting bureaucrats from the high admistratosphere.

INTJ in an ESFJ world

(Myers-Briggs Personality types) I know that many people disregard the Myers-Briggs test but I am amazed by how many others use it. It is used to help determine which jury can be most swayed by emotion rather than facts, who will buy what type of car based on how others will look at them, and how to sway the results of an election by avoiding facts. By researching which personalities tend to group together and act a certain way, the deck can be stacked. This is especially true when you see that of the 16 personality types, 4 make up over 50% of the population. I leaned all this from a friend who is a marketing professor with a Ph.D. is in psycology and has a side job as a consultant for picking jurors!

In medicine, it has been shown that physicians in the same field tend to have a high correlation with the same personality types on the Myers-Briggs test. I dont know if they are that way going into the field or if the field makes them that way. But I can assure you that surgeons have a very different personality compared to pediatricians. The other thing that has been seen is that physicians tend to be in the personality types that are least represented in the general population and in the types that are the least likely to get along. There is also good data that shows which personality types are most likely to sue.

I dont know about politicians. For the Myerss-Briggs to be accurate, it must be filled out by the individual and honestly. Somehow, I get the feeling that politicians would try to fill out the test based on what they want you to think they are rather than what they really are. I cant help but think that the personality type that goes into politics more often than not is not the same one that tends to make the best leaders. Unfortunately, the types that make the best leaders are not the ones that tend to be the most popular.

Friday, November 21, 2008

Benzoin in the mask case

(When wintergreen oil just wont be enough!) Sometimes the odor in the OR is just too much to handle. Wintergreen oil is the first line of defense as you can coat the inside of the mask with it, but for the bad ones, it is good old tincture of benzoin. Not only does it help block the smell, if you use enough of it you can glue your nostrils shut with it. Tincture of Benzoin has got me through many an anosmia wishing case. I dont know which are the worse, the peri-rectal abcesses, diabetic ulcers or forniers gangrene. Sometimes it is the combination of body odor, stool, vomit and old blood mixed with ketones. Anyway, Justice von Liebig is my medical honor role for discovering benzoin.

Thursday, November 20, 2008

Saint Sign (selfless service)

One of my patients has a horrible cancer. He lives alone and has no family. His neighbors have worked together to help him get to his chemotherapy and his radiation treatments, have stayed with him day and night to suction his tracheotomy tube and to ensure that his tube feeds ran. When he could no longer work, they helped with his rent. They did this out of love and caring.

His tumor is not responding and he does not have long to live. He is not rich in money, but he is the richest man I know for I judge a man by his friends and neighbors. He started Hospice today with his neighbors by his side. They will not leave him or let him face death alone. May we all be so rich.

Wednesday, November 19, 2008

Medical Coding and Billing and String Theory

(Things that I dont understand and the more confused I get the more I learn about them.) Of the two, I think String Theory makes the most sense! Well here it goes. For those of you who are unaware, CMS has created alogrithms that physicans must use to determine their charge for each level of service. Further, these things must be documented and thus it has led to the classic concept that you get paid for what you document rather than what you do.

This is the start of the basic algrithm for a simple office follow up visit as deciphered by the American Academy of Family Practice. You dont really have to read it because it is only the tip of the iceberg and does not include all the tables and guides. It is kind of like the tax code, it goes on and on and no one is really sure what it means.

Calculating medical decision making
According to Medicare's Documentation Guidelines for Evaluation and Management Services, a level-3 established patient office visit requires medical decision making of low complexity. Moderate-complexity decision making is required for a level-4 encounter. Before you can distinguish between the two, you must understand that the level of medical decision making in a patient encounter is based on three parameters: the problems addressed, the data reviewed and the level of risk.
The problems and data are evaluated using a system of weighted points depicted in the tables below. These tables were developed by the Centers for Medicare & Medicaid Services and distributed to all Medicare carriers to be used on a voluntary basis; although widely used, they are not part of the official E/M guidelines.
An encounter earns points based on the number and type of problems addressed. For example, an encounter with a patient whose chronic illness is stable would be worth one "problem" point, while an encounter involving a patient with a new problem for which additional work-up is planned would be worth four points. The data table works similarly, with different numbers of points available depending on the type of data and the nature of the review. For example, reviewing or ordering a clinical lab test is worth one point, while reviewing and summarizing old patient records is worth two.

The risk table below is identical to the one in the E/M guidelines. It only takes one element from any of the three categories listed in the table (presenting problems, diagnostic procedures and selected management options) to qualify for a particular level of risk. The documentation guidelines explicitly state that the physician should use the highest level of risk present when determining the complexity of the medical decision making. For example, an encounter with a patient who presents with one stable chronic illness would amount to a low level of risk. However, if the physician actively manages prescription drug therapy during the encounter, the risk level for the visit qualifies as moderate, because prescription drug management is associated with moderate risk.
After you determine the problem points, the data points and the level of risk, you can determine the complexity of the medical decision making. The table
below (see "Medical decision making") shows how the categories work together. The highest two of three elements determine the overall level of medical decision making.

Long and short of it, you look at tables and count up points to see what level of visit you can charge for. But you can only charge for what you document. This is why many feel that they get paid to write notes and not see patients. The average note is now a 500 word essay!

I often think that we should be like other professionals and just charge by the hour. Especially since we do not get paid for phone calls, especially those that come in at 4:00am. Our attorney charges us by the hour and for each phone call, so does the architect that designed the building only to have it not meet code which meant we had to call our attorney who then charged us for more hours.

F = μkN (MD/EMR)

F = μkN (The Coefficient of friction as it relates to Doctors accepting Electronic Medical Records) Both McCain and Obama stouted that electronic medical records are a way to improve medical care and to decrease costs. Well we are in the middle of disproving this in our office.
Normally, when I meet a new patient, I go though the forms that they have filled out that describe their problem and their past medial history and then interview them about what is going on, examine them and then talk to them about what may be going on and what tests, medications or surgeries may be beneficial. I then step out of the room, write a brief short note and dictate the main note.

Now here is the EMR. The patient still fills out the forms but now the front desk person has to enter all the information into the system. (Takes 5 to 10 minutes and we need at least one extra persion) The nurse then puts the patient in the room and pulls them up in the computer and enters more stuff in. When I see the patient I have 2 choices, I can do the same thing as I used to do and then step out of the room and fill out the computer note which then sends the scripts and orders the tests, but it takes 5 to 10 minutes just to do the note. This means see fewer patients or spend less time with each patient. The other option is to do what the office manager wants and that is to do the note while you see the patient. This means that you are looking and trying to type while talking to the patient which so far has really ticked them off and spend less time actuall doing the doctoring. I guess we could always hire someone else to type the note while we see the patient. So far, the EMR has cost us extra money, allowed us to see fewer patients and in general, generate notes that no one can decipher.

The main benefit of the EMR has been that it automatically generates the pages of BS that are required by HIPPA, CMS and the insurance companies as well as other pages of drivel that are there for medical legal reasons.

What a great way to reform healthcare.

Sunday, November 16, 2008

Double barreled refrigerated proctoscope sign

(Increased rectal tone that occurs suddenly if you are about to have a rectal exam with al doube barreled refrigerated proctoscope or if you get both your latest managed care contract quotes on the same day your get the quotes for you and your employees health insurance). Our health insurance plan for our employees is coming up for renewal. To keep the plan the same, with a $35 deductable for office visits, $2500/5000 individual/family max out of pocket and 80/20 coverage we will have to pay an increase of 27%. If you look at our utilization, no one in our practice has even used up to their max out of pocket. The only way we can keep it the same $562/month per employee is to have the employees pay the difference and then we go up to $5000/$9000 max out of pocket and no script card. We can try for HSAs but up till now non have wanted it.

On top of this, all our managed care carriers are quoting us on the average of 20 to 30% less on their fee scales. Most are take it or leave it. It is hard to negotiate with them because Pete Stark made it illegal for us to talk to other physicans and groups to come to some solidarity. At least CMS (Medicare) threw us a bone. A 2% increase if we E-precribe. This is like adding the discount KY for the double barreled proctoscope.


I was between cases last night while on call, your mind tends to wander to: where is the patient? Have they left the ER yet?; Is the blood ready? and what would happen if the Federal Government imposed all its regulations that exist in medicine on the NFL? Oh, SportsCenter was on in the background.

I think it would be something like this. First, if there is a stadium, anyone could come in and stay as long as they like regardless of their ability to pay. The home team must then feed, clothe and maintain all the fans needs until they leave or a place can be found for them. The team must all be legally responsible for the fans until such time as they leave. The fans shall have a "Bill of Rights" that must be strickly adhered to by the stadium. The fans will not be able to watch the game unless everyone in the game has added them to their HIPPA release form. Prior to entering the stadium, all fans must fill out 12 pages of forms and sign all the necessary federal, state and legal documents as mandated.

As to the actual team, it can not discrimate based on sex, age, race, handicap, etc. Infact, the retained attorneys want the team to be made of people from all races, sexual orientations, size, and to be sure to have at least one disabled running back. Comissioner Pete Stark wants to be sure that in no way can players endorse products, receive products or pass the ball to any other player withwhom the player may have a financial interest. So passing is strickly prohibited. The ball can be handed off, but only to a higher level of running so as to avoid EMTLA laws.

While on the field, there will need to be extra players, because there will be one to run the ball and three to document that he did infact run the ball and then others to document blocking. This is after the manditory pre and post touching the ball documentation was done. Each play must be sent to legal prior to going to the huddle to look at its legal ramifications and only after has it cleared this can it be sent to the tax attorneys to be sure that it does not effect the tax layouts. A detailed consent form must them be filled out to describe the play and all the potential complications before the play can start.

There will be no tackling, instead each player will sign an intent of running including a consent to run the ball form the after which each will retain counsel. The defense will then weight the risks of actually stopping the runner vs letting him just run. A cost and benefit analysis will then ensue. If the runner does run and is tacked, professional experts will then be hired to debate if he is injured or discriminated against and then how far he might have run the ball instead of how far he actually did. A jury of those that no nothing of football will then decide what might have happened and award yards based on their emotions as well as adding punitive yards. (This is why you have disabled running backs.)

There will be no television or taping of games as this violates the HIPPA provisions. Players names will not be on their jerseys for the same reason as each player will now have a pin code to ensure that their privacy is protected. A new HIPPA form must be filled out by each player prior to the start of the play.

All payers will be paid strickly on the basis of a CMS relative value scale which will include a yearly decrease. Payment will be based strickly on documentation, not on performance or decree of difficulty. Any plays that result in what CMS considers a preventable error will not be paid. Players will be paid equally so as to avoid discrimination. Attorneys however may charge and collect as much as they can.

All players are subject to a determination of a Standard of Football and any deviation from this may result in million dollar lawsuits. This determination will be determined by attorneys who have a finacial interest in making as much money from suing the players as possible.

Oh, patient is in the room, got to go.

Thursday, November 13, 2008


(Telling it the way it is) This is an email that was sent to me from a friend who is an internist, who wonders if it was written by one of his patients.

I admit I'm thankful that the gov't sends me a check every month for my disability based on "nerves" and back pain, and I'm grateful for the food stamps that are in credit card form; that lessens the stigma in line at the Fresh Market.I'm happy for the double coverage of Medicaid and Medicare which I enjoy. Going to the doctor is a nice little out-of-the-house experience. And the EMTs in the ambulance are so nice when I call (see I'd have to pay for a taxi, the ambulance is free).I'm please with my section 8 housing allowance that allows me to live in a nice neighborhood rather than a tenement. A lot of folks are unaware that these vouchers can be used for some pretty up-scale apartments. Shhhh, don't tell!... :)I'm glad I get the supplemental income because my children act up in class and have been diagnosed with attention deficit disorder.We call it "the crazy money" LOL!Although the paperwork was lengthy this new motorized scooter makes it much easier for me to go to the mailbox. I have been putting on a little weight lately.I'm not a complainer, I just like to get the benefits to which I'm entitled, that's all.But...I just find it tiresome to actually have to breathe for myself.I strongly hope that our new administration will help pass legislation, with the help of the good folks in congress to make more widely available portable ventilators so i don't have to spend the next 4 years using energy to inhale.I have to do it hundreds, maybe thousands of times a day and it just is TOO MUCH.It's only humane .

Sunday, October 19, 2008

Unfunded mandate = unfunded liability

A physican was recent sued and had to pay $400,000 because a patient claimed that because the physician did not hire an interpeter they did not understand the risks of the medication that they were prescribed. In this case the patient was deaf and the risks were printed on the information they received from the pharmacy. Even so, they sued the doc because Medicare mandates that a translator be available at all times. Of course Medicare does not pay for the translator. If you do get a translator, the translator will of course state that they are not responsible if the patient misunderstands the instructions and your hospital attorney will tell you that you are ultimately responsible. So here you go, a pateint comes into the ER, you have to see them by law regardless if they can pay, you then have to pay out of your own pocket what ever it costs to have an interpeter and even then, they can still sue claiming that they didn't understand the instructions. Then of course you must see them in follow up so you do not get sued for abandonment and must hire the interpeter every time they come to the office. (Because, even then it is your not the patient's responsibility to have an interpeter.) Something tells me that they will always be able to find an attorney as attorneys by law dont have to hire an interpeter.

Saturday, October 18, 2008


(*67 = Verizon's way to block your cell phone number) It is another week on call and I can not help venting on the crazy calls that come in. When you call the office it immediately states that if there is an emergency to call 911 and then goes on to state that prescriptions will not be refilled after hours and only after prompting that there is a problem with surgery or an urgent medical condition will the call be passed on to us. The answering service sends the message to us to call via a text message. The patients usually tell the service something other than why they are really calling. It doesn't matter though, the service does not want any liability so they patch everything through. We call them back *67 which lets us call the patient without the patient having our home number or when we can we connect through the service who can record the call. Again for legal reasons. So, here are some of the urgent medical conditions that have resulted in calls this week between midnight and 6 am. "I have a MRI next tuesday and wanted to see if it could be rescheduled?., "I can't sleep.", 19 calls from people who all claim to have just had surgery and run out of their pain medications. (I have copies of the last month's surgery lists), "My breath is really bad and I was hoping that you could call in some antibiotics.", "I need some Viagra". "What time is my appointment next week?" Oh, wait here come another one.

Friday, October 17, 2008

Null Hypothesis

I recieved this email from a friend who is finishing a detailed research project that shows common sense can not be applied to the practice of medicine. He gives the example of several of his patients who seem to prove the Null hypothesis.

A patient who has low self esteem, who was always yelled at as a child and gets very anxious when talking to others just got a job as a telemarketer.
A patient who tells me they can't afford to buy medication even for just 4 dollars always has a cell phone and smokes 2 packs of cigarettes a day.
A patient who has social anxiety and panic disorder who tells me they stay in their bedroom all the time at home and go nowhere except to come to my appointment can manage going somewhere to score some pot.
A patient who dropped out of school in the ninth grade and gets angry with everyone especially when it is a job where a boss tells them what to do wants a job where he makes all the decisions.
A patient with 15 piercings states that he is afraid of needles and has a low pain tolerance.
A patient who is disabled due to low back pain currently has a 3 handicap in golf.

Thursday, October 16, 2008


(Sensitive Compartmented Clearance) The surgeons lounge is often a free for all of discussions that are often fueled by the pressure of the days surgeries, delays and overall stress of operating. This leads to many ways to vent, with the most common being politics. Today, several of us that have been or still are military got into the subject of our security clearances. If you have never been through a clearance investigation, it is something that you would not believe. For a SCI they talked to everyone from my gradeschool teachers, neighbors, classmates, college friends and former lovers. In fact they gave me some extra credit for lovers that I never had! They whole process took over a year. One thing that amazed me was all my credit card receipts. Anyway, they knew the lot. We got to talking, if a politician is elected, what happens if they fail their clearance? I mean, what if a terrorist is elected or for that matter a spy? I mean, can they tell a Senator he cant be part of a discussion or a vote because it is above his clearance? I had to ask a friend of mine who is with the FBI, he gave me the sobering answer. The clearance comes with the job, meanining, if you get elected you get the clearance. They don't even bother to investigate.

Tuesday, October 14, 2008


(The immediate immature Defensive mechanism prefered by children and politicians) I know that it is human nature to hide one's own culpability by immediately blaming others. It is kind of like, "he who smelt it, delt it". This economic crisis though takes the cake. There is the frontal assualt by those whose job was to oversee Freddy and Fannie Mae who want to point the finger at the President, others in Congress who want to blame only Wall Street instead of the laws that were enacted and the former President who wants the blame to be shared by all except himself.

It is like watching children try to explain how a tennis racquet ended up through the front living room window. No one seems to know what exactly happened but they all are sure that it is the other guys fault. One thing that I think you can always count on, when push comes to shove, politicians act like children without mindful parents.

Wednesday, October 8, 2008

Roe'd right up the river by the courts

A recent court case got me just fuming. In Oceanside, California, a court ruled that a doctor can not refuse to do a procedure based on religious objection. The specific case involved a lesbian couple who went to a fertility doctor for artificial insemination. When he refused based on his religious background they sued stating that he discriminated against them. This is on top of a case where a transexual sued because a hospital would not approve them to have breast augmentation in their religious charity hospital.

I cant but wonder how long it will be before people sue Catholic Hospitals because they wont do tubals or some patient comes into the ER in labor and demands that the ER doc or OB perform an abortion and sues the religiosly objecting doctor. I guess in America, there is freedom of religion unless you are a doctor.

Health Insurance Flatline

I was wondering, with all the recent financial problems in the market and insurance companies failing, how soon will it be before health insurance companies begin to feel the heat? An old patient of mine said that "don't buy insurance, buy stock in insurance companies!" Insurance companies make their money off the interest they can get by investing in the market the money that they take in from premiums. When the market does bad, they do bad. How do they keep their bottom line? They stall on payments and pre-certifications.

I have asked our office if the have noted any changes. The big thing that they have seen is a new middle man. A firm that is contracted by the insurance providers to control pre-certifications. Working with them is next to impossible. In fact they even have hours that don't correspond to when doctor's offices are open just to decrease the number of cases that they have to approve. Every case seems to need a peer-to-peer review just to add to the burden of the whole process.

I can't help to think that perhaps the CEO's of the health insurance companies will have to take a pay cut this year. Then again, if it is only half, they will still get millions!

Monday, October 6, 2008

M4A3 Election

One of the great things about my job is that I get to meet all kinds of people who do all kinds of things. After the medical stuff is done there is sometimes time for a little personal chat. As I was removing sutures (I used 6-0, and no one else in the office would remove them) I asked my patient what he thought of the up comming election. He was elated and said that it was fantastic for bussiness. I could not help but as what kind of business he was in. He owns a local gunstore! He said that he can hardly keep up with demand and that there is a huge run on M4s (the carbine version of the M16) and handguns. (Oh, the Bersa 380 was the big seller there). I asked if this happens every election and he said not really. Sales stayed the same for Bush/Kerry and Bush/Gore. He did see a big run for each of the Clinton elections.

I wonder what other types of business are booming because of the election?

Tuesday, September 30, 2008

Professional Posers

One of the first things that I learned in my career, is that if you want to know who is the best surgeon for yourself, family and your patients, find out who has operated on the most people in the OR and the hospital. These are generally the people who have the best knowledge base and have worked closely with the surgeon and pick that person to do their surgery above all others. It is a womderful compliment of trust when the head OR nurse asks you to do thier childs surgery. I find it interesting then that a local surgeon spends much of his time acting as a professional expert in medmal cases. When I asked about him, the head nurse of the OR said, "Oh, he is a big poser!" I asked her what she meant, and she explained "He looks the look and talks the talk but I wouldn't let him touch a dead cat." "He is a soap opera doctor". After hearing this, I had to agree. He is at all the staff meetings and surgical committee meetings but I have never seen him in the OR. When I asked her about this, this said that he has to be at all them as a strong offense is the best defense. As to being a Medmal expert she said "he out to be good, as he is good at malpractice".

I could not help but wonder about more posers that I see, especially with all recent political unpleasentness.

Friday, September 26, 2008

Trauma score of 21

I just recently had one of those cases that just tears at your heart. Sometimes it hurts so bad that being cynical almost becomes a defense mechanism. I can't help but refer to one of the great tomes of Surgery, "A Chance to Cut is a Chance to Cure". From its chapters is the trauma scale. This is the trauma scoring system as related and handing down through Rip Pfeiffer M.D. and the veterans of Parkland with a few of my own added in. By calculating the total points received per patient the following guidelines were established in determining the patient's chance of surviving a major trauma. This system explains the reason why one chances of survival are inversely proportional to ones value to society. In other words why the minister dies and the gangbanger lives.

Chances of Survival

0-5 points.............................30%
5-12 points...........................60%
Greater than 12 points.......95%

Etoh level
100-299 2 points
300 or more 4 points
Injured while riding motorcycle
with helmet 1 point
without helmet 2 points
Arrives wearing biker T shirt 1 point
Patient comes from or going to jain 4 points
Spouse in jain 1 point
Arrives by helecopter between 1 and 5 am 1 point
Known by at least 5 people in the ER 1 point
Tatoo (1 point each, maximun of 5 unless homemade then add one additional point)
Tatoos/teeth greater than 1 1 point
Mis-spelled tatoo 1 point
Tatoo on face 2 points
Warrants for arrest (2 points for each, total 6points)
Emergency contacts listed on triage form (1 point for an attorney, 3 for bail bondsman)
Last bath more than 2 weeks ago 1 point
Has two children with same name 1 point
Previously shot or stabbed (2 points each episode, maximum 6)
Knows where the best veins are 1 point
Arrives with iv already in 1 point
Allergic to Kwell 1 point
Smokes more than one carton/day 1 point
Drinks a case/beer/day 1 point
Seeking disability 1 point
Allergic to Talwin, Codeine, Toradol 1 point
Covered in vomit (1 point if their own, 2 if from someone else)

Sunday, September 21, 2008

Stark Reciprocity

Pete Stark is a Congressman that seems to go way out his way to regulate the practice of medicine and every 6 months or so, he seems to turn yet another screw. This makes the practice of medicine more regulated than the practice of running a nuclear power plant. A friend of mine emailed me this. These are the Pete Starks laws applied to Congress. Mind you these are only a few of the Stark laws.

1. Every 6 months each member of Congress shall disclose to his or her constituents by first class mail delivered to the constituent's place of residence:
a. The amounts of each PAC or other political donation from each lobbyist or interest group b. The individual(s), businesses, or special interest group that donated the money c. Any personal consideration received from a lobbyist e.g., meals, trips, use of planes or other transportation, etc, and the identity of the donating party d. How the member voted on bills affecting each party listed in (b) and (c).

2. A member of Congress may not accept gifts or other consideration in excess of $100. This includes political campaign donations and PAC money.

3. Since a member of Congress is in a position to vote for legislation that could enhance the value of their own investments, no member of Congress shall own any investments of any type of kind, active or passive, except for a blind trust. a. Each member of Congress shall be allowed to own ONE piece of real estate property in addition to their primary residence. b. If a given legislative issue affects the value of property owned by a member of Congress, that member shall recuse him/herself from any votes that affect said legislation.

4. Compensation for members of Congress shall be determined by the American Medical Association and annual raises shall be less than the rate of inflation.

5. Health insurance for members of Congress shall be equivalent to the HMO benefits offered by Aetna for a typical medium-sized corporation.
a. All preauthorizations will be denied on the first request b. All treatment rendered will be considered experimental and therefore not covered by the policy c. No member of Congress shall be allowed to stay in the hospital more than 4 days.

6. If a member of Congress has a dispute with their health plan, they may only seek recourse through a federal lawsuit.

7. If a member of Congress (1) votes for something that turns out to be extremely stupid and ill-considered, and that (2) results in harm to the citizens of the United States, then (3) they may be sued for everything they are worth.

8. Every office for every member of Congress shall be inspected annually by JCAHO, CLIA, and OSHA. Any infraction shall be punishable by a f$10,000 per occurrence and loss of voting priviileges for 6 months.

9. Each Congressional office shall be given a 300 page manual concerning citizen privacy rights and shall be in compliance with each and every regulation

10. Any person, at any time, may file an anonymous complaint about a member of Congress a. The member of Congress shall be apprised of the ftact that a complaint has been filed. b. The member of Congress shall have no right to know what the complaint is about until the day of the hearing c. The member of Congress shall have no right to present evidence or testimony in their defense d. The member of Congress shall have no right to a fair and impartial hearing e. The member of Congress shall have no ability to appeal adverse decisions.

11. Never events a. No member of Congress shall become intoxicated b. No member of Congrehss shall have sexual relations with anyone other than their spouse or significant other c. No member of Congress shall add non-germane amend nments (riders) to any proposed legislation d. No member of Congress shal l have any local transportation paid for by the federal government (in other words, no limousines). They can drive to work or take public transportation like everyone else. e. No member of Congress shall fly other than coach unless the difference is paid for personally f. No member of Congress shall vote for anything that turns out to be the wrong thing to do g. If any of the above "never" events occur, the member of Congress shall not receive any pay for the year in which the infraction occurred

Munchausens' by Attorney

When a new patient comes to the office, we are required by insurnace and CMS to get all kinds of information from them. This is all the family history and past medical history stuff that takes so long. We just had a patient that came in the past medical history was seven pages long. It was filled with a list of things like irritable bowel, interstitial cystitis, fibromyalgia, chronic pain, depression, etc. All the things that are in the medical neverland that can not be proven to be real or non-real. When I looked at the form, I was amazed as she included in her Review of Symptoms, those that would support her diagnosis except that they were listed in alphabetical order and not the way they were listed above on the form. (we ask the patients to actually list their symptoms rather than just checking boxes because people would otherwise check everything. None of the symptoms related to why we were seeing her.

I couldn't resist so I ask our Front desk receptionist. She is really the one who runs the practice, she sees all and knows all, and in fact does it all. She told me that this patient had one of those handouts from an attorney that tells them what to list and how to list it so that later the medical records can be requested used for disability or for whatever they have planned. I was shocked, I asked her how often this happens, and her answer was that it was all the time, she said she did not want to tell me for fear I would spend too much time in the office banging my head into the wall. Then she goes, "here, you might like this!". When the patient was filling out the forms, she asked if she could photocopy it, and sure enough, I now had the attorney's handout in my hands. It was a cut and paste breakdowm of each of the "questionable diagnosis" and list of symptoms and where to put them on the forms. There was no attorney's name on the form however.

Three days later, the requests for the medical records came, it was of course from a local disability attorney. I made sure that the photocopy of the attorney's handout was included in the records.

Thursday, September 4, 2008

5 finger CO-Pay

Saddly, medicine is a business and we have to spend much of our time with concerns other than medicine. One thing that we do is monthly review our supplies and how much of what to order. It is amazing how many small suture scissors, pick-ups, guaze, gloves, tongue depressors and thermometers we go through. It is not that we use that many, it is that so many are stolen! We try not to put anything of value in the patient rooms anymore as everything gets stolen. We were losing small suture scissors at a rate of 11/week.

I try not to think about it as having your patient steal from you is not a good thing for a doctor-patient relationship. It is worse though when you catch the patient redhanded. I had patient say, "oh, I though they were disposable" even though they were not used and were not needed for the reason that they were there. From what we can tell, there does not seem to be any demographic difference between who steals from us and who does not.

The latest is that a patient was caught trying to steal the blood pressure machine, the problem was that it was bolted to the wall. She had three of the bolts out when I walked in.

Wednesday, September 3, 2008

Thwarted Darwinism

Traveling by air can be such a hassle but I have to admit that I am a people watcher and some of the best people watching occurs at the airport while waiting for a flight. I had a lot of time to kill and was wandering around the concourses when one of those things that sums up our society occured right in front of me. I was on one of those moving sidewalks where the signs say "stand right, walk left". I was walking behind a lady when she came across another lady who had piled her bag on the stand side and was standing in the walk side leaning on the handrail. The lady I was following said excuse me only to get a foul look from the other who was blocking the whole sidewalk. When she finally moved she said b*****. The lady that was walking turned to her and asked if she could see the signs. When she had gone the lady that was blocking the whole thing turned to another lady who was beside of her and said, "why didn't you tell me not to stand there?" All I could think of was this was our society. She could have said "my bad" or "sorry" but instead of owning the mistake turned and blamed someone else. I guess it should not have stuck me so bad, except that she was traveling with 5 school children as a chaperone.

There was slight justice, she was so busy yelling at others for her mistake that she missed the end of the moving sidewalk and went flat into the floor. Darwin was thrwarted though, only a slight bruise.

Sunday, August 17, 2008

Hereditary Entitlementiasis

I had one of those episodes in the office that sums up the entitlementiasis that seems so epidemic these days. I had grandma who was 42 and on disability for "fibromyalgia" and daughter who was 22 and on disability for "bipolar" who were requesting that I fill out forms for grandaugher to have full disability for her now resolved skin infection. Both had knowledge of the whole disabilty process that would make most attorneys jealous. I gave them my usual answer, that is , I said "I am not a disabilty doctor and I really dont think you would like me to fill out those forms."

Right after they left I had another patient who is on full disabilty. He is not impaired in anyway that I could determine, in fact I had seen him climb out of his jacked up moster 4X4 truck with a 4 wheeler in the back. Turns out he was on full disability for his back. I wonder if he got it after loading his ATV in the back of the truck.

I dont understand diability, the disabled patients all drive themselves to their appointments, why cant they get jobs as drivers? I guess I haven't caught entitlementiasis yet, it must be all that alcohol had cleanser that we use.

Friday, August 15, 2008


(two MDs consulting on a case) I wish everything in medicine was cut and dried like it is on TV. Sometimes though, you have to scratch your head and take a SWAG. (scientific wild ass guess). To help figure it out you call on partners, collegues and whoever you can get. The problem usually is that they are guessing too. It is one thing to sit back and guess from the sidelines, but having to act on the guess is a totally different thing because it is not you who will pay the price if you are wrong. Just recently we had a case where there is really not a good answer that has been determined for what to do with this type of cancer. My partner and I each had different opinions, two docs with a paradox. We tried to explain the diffent options and then the patient looked at me and said, do what you think is best. Luckily, they did well.

The Innocent Pay.

Our legal system always amazes me. We have the criminal system where one is innocent until proven guilty and the tort system where one is guilty no matter what it just depends on how much you want to pay. Well here is yet another example. I have a patient who was shot in a drive by shooting. As he is ready to leave the hospital he will need some supplies and equipment for his trach and tube feedings. He has to pay for these out of his own pocket as he does not have insurance. He will also be responsible for his other medical bills. There is a slight possibility he may get some money refunded from the victims fund. The guy who shot him however crashed his car and is in custody. His full medical expenses are covered. The victim can not work and may well be paralysed. The guy who shot him has a free court lawyer already working at getting him off on a technicality not to mention trying to get him disability.

Saturday, August 9, 2008

Pertinent Findings

Our medical students and new residents are awesome but sometimes I have to cut off their patient presentations. They want to describe and report all the normal stuff like blood pressure, HR, number of toes and rectal tone. I have to try to get them to go to the pertinent findings like blood in the abdomen or a C6 fracture. I wish we could do the same with the news! Today the headlines were John Edwards affair, Caylee missing in Orlando, the Olympics and Starbucks closing a few shops and offering a refill on a double latte. Oh, by the way, if you looked for the pertinent stuff, Russia has just invaded Georgia, it looks like Iran already has enough fissable uranium for bombs and oil is plummenting as speculators are worried that we might drill. This stuff is at the end of the hour and almost not even mentioned.

I know our news is all about the ratings, but isn't it also how we get info to decide on who and how to vote for? I know that facts tend to not be sexy, but then again, they are facts and they tend to be good things to know. I sometimes wonder if our national politics and congress are part of a big soap opera that is scripted by the media. I had a wonderful opportunity to live overseas where the news was just people reading what happened that day. There was no editorials, there was no fancy commentary. It was just what happened. They did have a comedy segment, it was usually about US politics.

Sunday, August 3, 2008


(Airway, Breathing, Circulation). I was going through the new ATLS (Advanced Trauma Life Support) texts and then my mind began to wonder. In any trauma we always want to ensure that the airway is open, that we are breathing and that there is circulation. I couldn't help but have the TV on in the background as it eases my ADD and of course if was all about the election. I began to wonder what would be the ABCs that I would want in politics as the result of this November. In fact the question was so bothering to me that I even brought it up in the surgeons lounge the next day. The discussion was worthy of our founding fathers! While everyone was debating, one of our older urologists happened to walk in and said three things that shut us all up. He said, "term limits, The Fair Tax, and line item veto".

We were amazed, he then added "its easy, I want the things that every career politician fears!"

Thursday, July 31, 2008


I am often asked how much we get paid for an office visit. So I really tried to find out the answers. Here they are:

For an established patient following up, relatively straight forward Medicaid pays: $24.74, Medicare pays $35.36.
New patient expanded visit is $34.42 from Medicaid or $60.08 from Medicare.
Telephone consultations or calls $0.00
Initial hospitalization (admit to hospital) Medicaid $55.71, Mediare $117
Critical care, first hour $95.19 then $46.42 for each additional 30 minutes
Intubation for respiratory failure $90.13

I think that it is interesting that attorneys get $200/hour or more while we get $95.19/hour for critical care.

Monday, July 28, 2008

Plastic wrap annoyance

Call is finally over, now to do all the things that I did not have time to do like take out the trash. One of the bags is overflowing so I did the foot smash to compact it and looked in. It was kind of eye opening. Almost all the garbage was some kind of plastic wrap or paper plastic combination! There was blister wrap from batteries, burrito wrapers, the plastic that comes over everything. I looked in the pantry, everything seems to be covered in plastic.

I started to wonder, where does all this plastic come from, of course it is from oil. What do we do with all this stuff, why throw it away of course. So here is the idea, instead of getting everything wrapped in plastic could I just get it and take the oil in the form of gasoline? At least that way I am getting some use of it instead of just trying to find a way to rip it off of what I really want and then throwing it away?

Ya get what you pay for (sort of)

One of the things that I love about my job is I get to take care of anybody regardless of their ability to pay. I can't help but wonder though what that effect is on society as a whole. For example, right now about 20% of the patients in the trauma unit are illeagals. Their care is being paid for by funds from citizens with insurance and from the hospital with a portion of federal funds. So, in a sense we are all paying for their care. I know that in the large scheme of things that this money has to come from somewhere and that we all are in some way paying the bill. It is easier to just do the medicine and not worry about the bigger picture!

Saturday, July 26, 2008

Up one, down two

July is almost over, so far the new interns are doing well. We have had a few moments but overall they are learning. Going on rounds looks like Mama duck with all her little ducks winding from one room to another. You can tell how far along someone is in residency by how little is in their pockets. The interns all have lab coats stuffed to the brims with Wash manuals and poket pharmapedias. The senior residents are in scrubs with a sweatshirt. All have coffee or diet colas.

As we round we try to teach the residents the important things, like you take the stairs to go up one flight or down two. Keep your wallet in the inside pocket of your scrubs. Wounds heal side to side, not end to end. Dyspareunia is better than no pareunia. You can always find hemeacult cards but never the reagent. Surgical caps hide bad hair days. There are always bullion cubes and crackers to eat. Never try to drink Jevity. Ward clerks save you butt, charge nurses are there to make you miserable. Crying and complaining mean that the patient is oxygenating. Patients bleed whole blood not packed red cells. Patients dont die of pain, they die of too much pain medication. If you decide to send the stool specimen to the lab through the tube system, make sure the lid is screwed on really, really good! Patients with no arms or legs can still pull out their feeding tubes.

There are many more, but its a 5 to 6 year residency.

Wednesday, July 23, 2008

Bug light

I was on my way to the OR late at night for an urgent case. On my way, I have to walk up a long hall. There is the red line before the surgical area that represents where surgical scrubs are needed. The OR suites are positive pressure so that there is always a breeze coming down the hall when the doors are open. I looked up and there was a moth, flying upstream as hard as it could to get into the OR area. He was focused on the bug lights that are just beyond the door. Try as hard as he could, he just could get there. The doors would shut and he would fly around and bump into the windows of the door. The door would then open and there would be a whoosh and he would beat his wings as hard as he could to try to get in. Finally, with an incredible effort he makes it! Only to fly right into the bug light and get zapped in a flash of bright light and smoke.

You know, when I am on call, I feel like that moth!

Friday, July 18, 2008


I don't know how they do it, but they are amazing!!! These are the case managers who somehow find placement for patients. We are losing nursing homes like crazy as they can't afford to stay open on what little re-embursement comes their way, not to mention skilled facilities or even rehab centers. You can get the patient through the ruptured spleen and the liver lac but the closed head is going to take a while to clear. The case managers step in and try to do their magic. They work in these little closed rooms trying to find somewhere that will accept the patient who is uninsured has both a trache and a g tube.

We had two facilities here in town but both are being sued and already are in the process of shutting their doors. Both of the suits involve patients having decubes and thus the family who doesn't and didn't care before has sued. It doesn't matter that both patients are in air beds and moved constantly, or that their hypotension from their injuries cause the sores. All that matters is the money.

I don't know who is going to accept these patients in the future.

PDR Quagmire!

It seems that almost every day in clinic I have a patient who stops their medications when they look at the PDR or the volumes of legalese side effects that are listed by the pharmacy paperwork. The most recent was a patient who stopped her diabetes medication because she saw a statement that it might increase her risk of heart attack. Apparently she did not realize that it was her diabetes that increased her risk of heart attack and her sugar went over 400 and she came in dehydrated and confused and tried to die in the ER.

I try to explain that these side effects lists are written becuase of lawyers. What happens is that when a drug is tested any possible thing that the test patients experience is listed. This is why you see that every drug seems to cause ringing of the ears, colds, bronchitis, abdominal pain, etc. You are giving the drug to thousands of patients and so if they get a cold, it is on the list. If there ears ring anyway, it goes on the list. The PDR and the other lawyer sources dont say that the incidence of these things is the same as the placebo group because that doesn't help you in a lawsuit!

Oh, my other one this week was a patient with afib on coumadin who did not want to go in the hospital and be on a heparin drip before her valve surgery. She had heard on TV that heparin can cause headaches and other problems. Oh, it was an attorney advertisement. When I explained that she could not be on coumadin for surgery because she would bleed to death, and that if we just stopped heparin she would throw a clot and die, suddenly she though heparin was a good idea.

Thursday, July 17, 2008


(on a scale from 1-10). This adding pain as a vital sign has really got me worried. It seems that every patient I see in the ER describes their pain as 11 on the 1-10 scale. It doesn't seem to matter what is wrong with them. I go and look at their medications and of course they are on lortab and oxycontin for chronic pain so their receptors are totally screwed up and the little bump that they sustained from falling has interrupted their narcotic induced altered state of existance. One friend of mine put it to me clearly. He said, "look, they think normal is how they feel when they are on their narcs so just being normal causes them to think they are in pain!" I don't know when people began to just write prescriptions for chronic lortab or percocet but I sure would like them to have to see what has happened to their patients. Personally, I have an occaisional sore back that vioxx and bextra helped and I wonder how many of these people did well on these meds before they went off the market. Now, they can't get relief and some poor "good intentioned sod" started them on narcotics making them total addicts.

Of course there are the chronic drug seekers. You can spot them pretty easily because their pain is always a 11 and secondly they cant describe the pain. You ask them is it a stabbing or aching pain, burning or throbbing and all they will say is that it hurts. You ask them where it hurts and they will be vague about it as well, not to mention they can't precisely tell you when it started. The guy with the rib fracture will tell you the millisecond it happened, that it throbs when he takes a deep breath and will point right to it. (His pain was a 4) Drug seekers are always allergic to NSAIDS, have anaphalaxis from toradol, hives from Ultram and the only thing that seems to help there pain soulds like laudid. People in real pain just look at you and say, "I don't care what it is, just make it not hurt so much!".

I got a fax from a group of doctors that it trying to see if a vioxx or bextra can come back to the market. It was a petition, I signed it.

I can't wait for the next JACHO vital signs like anxiety, mood, appetitie, sexual eagerness, and favorite color. It is a good thing that I am not in charge because I would add vital signs like intellegence, probability of following medical advise and body odor listed.

Thursday, July 3, 2008

Otis Nirvana

Elevators are one of the greatest benefits of a large teaching hospital. While on the floor or in the OR the beeper goes off constantly. It never goes off for something good, it only goes off when there is something else for you to do. Each time it goes off, you try to find a phone and although it was important enough to page you for, the person who paged never answers the phone. So while you wait for them to get that person, your beeper goes off again. (cell phones are not to be used in hospitals because of problems with telemetry). After what seems like the 10th page, you get in the elevator. It is paradise! You cant answer a page and if you are lucky it will stop at every floor on the way to where you were going. Often, the pager doesn't even work in the elevators. A good 10 to 12 floors might mean 10 minutes of respite. I hate to admit that even when I am alone in the elevator, I push extra floor buttons.

Tuesday, July 1, 2008


05:30 am the first wave of new surgical interns hit the beaches, some were immediately hit by scut fire while other rose only to get taken down by a barrage of pimping from senior residents. Those that made it to the trenches hunker down waiting for the attendings while they hope that they don't commit any friendly fire accidents while running the gauntlet from the surgical wards to the OR.

July 1st is the day that all the new interns start and the residents move up in rank. It is generally a good day to not be sick in the hospital. Besides residents, new nursing students, case managers an RNs are also starting so that everyone is learning the ropes. The older folks are extra vigillant as they try to catch errors and keep the teaching hospital running. Choas has its own intertia.

The new interns look so young that it hard to believe that we were that age or even that we once had ironed white coats. Their coats are full of books and stethescopes as opposed to ours that are filled with muliple little pieces of paper and a few partially eaten "snickers". The new interns have the look of terror and excitement in their eyes. Excitement wears off though, terror grows. It won't be long before they are all addicted to coffee and will have learned to sleep standing up and be tempted to drink some have used enteral feeding.

So begins the trial by fire. Some interns will do great, other will fail. It is time to sort them out.

Thursday, June 26, 2008

Suit Sign

Anyone walking the halls of the hospital in a suit is either an attorney, mortician or an administrator. Either way, the outcome will not be good.

We just got back from our reality check in Guatamala and I really hope that we were able to help make some peoples days a little bit better. I was so saddened though when we saw that so many of the children in the orphanage had adoptive parents waiting for them but that the whole process was marred by attorneys our for their own good. We saw famlies waiting for 5 to 6 years because each step was met by another attorney needing $5000 for this and then that, stringing them along while another just comes out and says "give me $60,000 and I will see that all the paperwork is expeditied". The lawyers have turned orphans into their own little cash cows and they are milking them for all they can.

Friday, June 13, 2008


Never let a doctor start an IV!!!! To help pay for school I was an orderly and then an IV tech. I used to be able to start and IV on a turnip, but wait. We now have these special catheters that have been redesigned to prevent needle sticks by making them almost impossible to use. On top of that, they are 5 times more expensive! To start an IV we first would put in a tourniquet, look for a vein, prep it with alcohol and then stick the needle into the vein and advance the catheter over the needle. One it was in, you pulled out the needle and hooked it up. But wait, now we have to use a prepacked, disposable special preping swab and then use this thing that is spring loaded so that once the needle hits the vein you are supposed to press this little button that may or may not work that retracts the needle into the hub. In reality it sticks and you cant get the catheter off the thing, the patient bleeds and you blow the vein and have to start again on the other arm. Isn't it great! I wonder if the OSHA and JACHO guys are working for the company that makes these thing. It seems we have to use a lot more of the catheters becuase they just suck. The good thing is that I found a stash of the old IV catheters. Dont tell the JACHO Nazis.

Retrospective studies

I hate to say it but sometimes the overall process of medicine can just get me down. I mean all the hassles and paperwork, the politics and the economics. A reality check is sometimes needed. For us these reality checks are in the form of mission trips. It is amazing to see people walk for two days just to have their children seen for diseases that are rare here secondary to vaccinations and sanitation. You don't know how good you have it until you see a child with polio or see an infant suffocate from whooping cough. We do our best with the medications that we can backpack in. There are no forms, no insurance companies, only people trying to help. We try to vaccinate, give vitmains are kill parasites. There are no MRIs or CTs. Bleach is our best medication as it can make water safe. Clean water is life.

There you try to do the best with what you have and you pray that it is enough.

On the trip back the first thing we see as we get back to the States, a big sign for trial attorneys trying to drum up business to sue for malpractice and nursing homes. We had doctors and nurses, builders and engineers, teachers and postal workers, homemakers and accountants on our last mission trip. We had no attorneys, health insurance claim adjustors or JACHO auditors.

Monday, June 9, 2008

MAP Packs

(Mission Aid Packs) I know that the drug companies are the target of all the scorn the media can launch but I wonder how much the drugs would cost if we could get them straight from them instead of having to pay the wholesaler and then the retail chain? For our mission trips to Guatemala we call the drug companies and they supply us with MAP packs. These are awsesome and contain a whole formulary of medications. These things are amazing! There is everything from cephalosporins to antivirals, blood pressure meds to inhalers. They rock! If you try to get anything from CVS or Walgreens, they look at you like you are nuts! I wonder who really deserves the scorn!

Thursday, June 5, 2008

Goody's and a RC Cola

(breakfast of champions!) More musings while I await the CT results. Usually I hang out in the scanner control room but we are three deep and the alcoholic who fell and hit his head is first. There is the usual aroma of ketones, stale beer, vomit, urine and burnt popcorn wafting through the hall. He is giving a running discourse on how he is spending his "stimulus check" and how bad his head hurts and want's to know why we don't give him a Goody's and a RC. The CT tech is trying to guess how much he weighs and if he will fit in the scanner. (It is only good to 400 pounds). I can not tell but I think they had to use 2 backboards for him.

Nuts, the popcorn nuked in the microwave again. Howcome there is always that one mutant bag of popcorn that undergoes meltdown? Oh well, there might be a few good kernals in there somewhere. Coffee is burnt too. I think the guy in CT is right, a Goody's and a RC would be good right now.

Thursday, May 22, 2008

Appy Dogma

(Tis better to operate on a patient who doesn't need it than to not operate on a patient who needed it!) Some people are able to make decisions, others want somebody else to make the choice. Many times it is the pain in the RLQ that seperates one group from the other. I often think that you can teach anyone how to do an operation. In fact, the operation is the easy part. The hard part is knowing when to operate. In the classic trip to the operating room to rule out appendicitis, a pretty good average was to be right 90% of the time. The main idea is that you would rather go in and find out that it was a swollen lymph node or something else rather than miss the peritonitis of a missed appy. In this world where 2/3 of the attorneys on this planet are in the U.S., I wonder how long it will be before any negative appy is a lawsuit.