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 .