Sunday, January 31, 2010

Oz scintillation retinopathy

(When you cant see the man behind the curtain.) I was watching the news and one of our Congressman was going off on how the drug companies are behind the high cost of medications and how they are so much cheaper overseas. (Part of the Progressives view that all corporations are bad!) Anyway, I thought about it and did a little checking. When we go on our medical missions we stock up on meds. I can get 1000 Cipro tabs for $24 from a medical wholesaler. I then got on the phone to Walgreens and they told me 20 would be $16. I then ran a bunch of common meds, propranolol, amoxicillin, predni sone. It was all the same, the mark-up at the pharmacy was enormous! I tried some brand names that were not generic, and guess what, it was the same!

I found out the only reason I could buy the meds from the wholesaler was my medical license but I could not be a distributing pharmacy. You see here in the US, a patient can only get medications from a distributing pharmacy which can mark up the price as much as the market can bear. The big pharmacy chains can be their own wholesalers and also negotiate with each insurance company a cost for each medication. As a a result of this their proffit goes through the roof.

There is a reason why there are pharmacies on every corner and why drugs cost so much. It isnt so much the drug companies but the pharmacies. (When you get meds from Canada you get them from wholesalers). So, ignore the man behind the screen at the pharmacy because he is robbing you blind.

Friday, January 29, 2010

MAR de Debarquement Syndrome

(When you get dizzy discharging the patient from the hospital). Whenever we go to discharge a patient from the hosital we have to fill out this form that shows all the meds they were on while in the hospital and we have to decide if we want the patient to continue them. The problem is that often we are not the ones who put them on the meds to begin with and further, the list has the meds the patients say they were on before they came in to the hosital. I love it how all the older men always say they are on Viagra and need a script before they go home. I have had anabolic steroids on the list and of course the ever present, I wont be able to go to the pain clinic for a while so I need my Oxy and Percs. I tell the residents the only scripts patients get from us are for the meds that we put them on, none other. When the ever present JACHO form nurse asks about the other meds, I write on the form that "other meds are at the discretion of the original prescribing physician and patient can not be discharged until these medications have been reconciled". I know that by doing this I am "ticking off" alot of the long white coat clipboard carrying administrative types, but it sure does get them moving in a frenzy to check on all the patients medications and make sure that they have someone accountable. Everytime they come back to me and ask me to be the one to approve some of these medications, I explain that I am here to fix the trauma, no be responsible for their their pre-existing narcotic dependence or erectile dysfunction and they can find someone else to admit these patients and I will just consult!


Got this in the email this morning! I't looks like I am not the only one!

OK, HUGE annoyance that just won't go away! You see a patient for a sprain/strain (not work comp) and then at some undefined time in the future you get a request from the patient for a return to work note. Ummmm never had you OFF work to start with, so I probably don't need to say it's ok for you to go back (you weren't supposed to be gone from work!).
Better yet, you didn't even see the patient (they were referred because you were the schmuck on call for the ER). And 3 weeks later they call you to request a return to work note. Ummm still NO.
Even better (and today's scenario), the patient went to the ER, you see the patient after for free follow up (medicaid or no insurance) and 3 weeks later you get a call from them saying they want you to send a note for return to work to their "turn the book over" Lawyer! Good God! NO you can't have a RTW note if I didn't take you OFF work to start with. And yes, I know that puts your job in jeopardy, and yes you might lose your job (while you are obviously trying to win some settlement for your terrible fictitious injury). But I'd be happy to send your lawyer a note (for a charge) stating that I never took you off work to begin with!
What is with people???

Wednesday, January 27, 2010

Umbilical Abortion

I just recieved an article from a friend that shows that in Rustberg, Virgina a woman gave birth and then suffocated the child to death. She was not charged with murder because the umbilical cord was still attached and she had not delivered the placenta. I wonder then where the abortion rights folks think murder begins?

Saturday, January 23, 2010

Déjà pensé and Magical Thinking

I was trying to hold back my excitement with Scott Browns elections the other day. My excitement was that hopefully there might be some meaningful discussion about the good and bad of our medical system and a true attempt to tweat it to make it better. In medicine we straddle both the consumer and producer fence of healthcare. As a small businessman, I have to negotiate health insurance contracts for my employees and try hard to pay for it. As a deliverer of healthcare, I have to negotiate contracts with insurance companies to hopefully get paid for what we do. The biggest problem is that there is no competition, both are take it and leave it. There are only two insurance companies that will write small business health insurnace in our area of the state. The difference in price is minimal between the two for the same policies. Interestingly, one if for proffit and the other isn't but that is another discussion. As to how much we get paid, guess what. There is the government which has a set fee schedule, and then the same two insurance companies.

I was hoping that the Massachusetts election might make Congress look at different ideas and consider getting away from the laws that presently make it so that there are only really two insurance companies and do things like allow out of state competition. Why cant we have GEICO, ALLSTATE, PROGRESSIVE, STATE FARM all fighting it out for our health insurance dollars?

I was thinking of this and had my fingers crossed when I sam Obama being interviewed as well as Pelosi and Harry Reid. They just seemed to ignore and come up with a new idea (one that they had before) and just think that if they blame Bush and increase taxes it will all just fix itself.

Wednesday, January 20, 2010

Collating all the form ID-10ts

I hate administrative meetings. I especially hate meetings whose whole purpose is to come up with a standard form to meet yet another JACHO mandated paperwork boondoggle. These never actually have anything to do with patient care, they are just to document, document, document. Then administrators look at the forms and come up with metrics to keep track of just how good we are at filling out the forms! Forms, forms, forms. I would love to have all these people who want all these forms just to go and fill out ID-10ts on themselves!

Thursday, January 14, 2010

Capgras' syndrome

A while back we were having a discussion about government panels that might determine the limits of care for patients. (i.e. death panels) The discussion focused on how much is spent on patients in the last 6 months of their life. One of our pulmonologists who is on the liberal side had pontificated on how we spend so much resources keeping these people alive that he didnt think the panels were a bad thing. I expressed that these patients are usually spending their own resources as they had been the ones that paid into Medicare and their private insurance all these years and are getting their money back. They and their families are deciding how they want their money spent.

Our death panel pulmonologist now has his father in the neuro ICU after a massive stroke. He wants everything done, a trache, peg, longterm rehab vent unit. The works. I though I was having an acute attack of Capgras' syndome, but then remembered liberals what to decide on how to spend everyone's money except their own.

Sunday, January 10, 2010

Écho de la pensée

I was watching the news coverage of how Congress is trying to reshape and run healthcare when out of the blue I heard a familiar voice, faint at first and then louder. A voice of reason from the past, the voice of a spirit echoing my thoughts and ideas!

Saturday, January 9, 2010


I dont know if it is true but it sure seems that the weather affects how busy the ED is. Hot sticky nights seem like a good time to stab someone or to have a major MI and the place is packed, but these frozen nights, the ED is a ghost town. Well, with the exception of some of our regulars and homeless two carbon beverage lovers. The real excitement is when the psyche cases start coming in. This is usually the time of year when they come out of hibernation and begin to act up. You know they are crazy right away because the drunks start moving away from them. I used to think that it was the shorter days that caused people to go nuts in winter, but when I went out into the cold to get into my car and froze my but off, I realized what it was, all that "Crazy Global warming BS".

Friday, January 8, 2010


When we see a patient, we listen to their complaints and then try to ask questions that help us reach a diagnosis or at least a point from which to procede. Some people however are very evasive and instead of answering questions, just say the same things over again and again. A classic one is "it hurts!". So, you ask "what hurts?" and they reply"it does, it hurts!". So, you have to ask "what is it that hurts?" Instead of answering what "it" is, they then go on to a new complaint that is as vague as the first, saying the same thing over and over. Now this new thing hurts, but we have no idea what the new thing is. Each time, they say the same thing over again and again, but it has no meaning! Eventually, they just on and on and you have no clue what they are talking about. When you try to pin them down on specifics, they get frustrated and just fall back on repeating their nonsensical litany. My favorite is when they say "Let me be clear! " and they aren't. I have had to learn to tell some patients that in order to help them, it is important that they try to answer my questions as specifically as possible.

Just out of curiosity, when is the last time the President had to answer questions from the public or the press?

Like Obama and Guns

There is usually a big rush at the end of the year where people who have met their deductable try to get everything in. There is a smaller rush at the start of the year when people who did not meet their deductable the year before decide to get things done so that they meet it in the coming year. That being said, it is insanely busy right now. People are coming out of the woodwork to have everything done before "I wont be able to get it!" This has been everything from total joints to CABGs. One of my friends had a patient demand to have his bypass even though he did not need it yet because he was afraid that Congress would say that he was too old! I guess Cavuto was right when he said good short term investments would be in firearms, ammunition and healthcare.

Wednesday, January 6, 2010

Folie à deux

In the course of a clinical day you often meet some stealth DSM IVrs that take a bit of time to figure out. When I was a resident, we used to put a little Rho sign in the upper right corner of their chart to let everyone know that this person might be a bit on the prolixin deficient side of the reality finish line. Somehow, this little sign came up in a chart review in some lawsuit and their was a big stink so now all we can do is make sure that the patients antipsychotics are highlighted in light yellow. (Doesn't show up when photocopied!) Anyway, these are at least patients that have been identified as crazy. Its the de novo ones that are hard that just show up in the office. I dont know why, but it seems to only take one to be nuts, but it takes two to be really off the deep end. The realy psychotic ones always seem to come to the office with someone else who is at least if not more crazy than they are. Quite often, this person is the friend or the spouse who is the driver. (think about that as you drive home) When the patient explains that everyday at 9:30 a choo choo train comes out of their navel, the other will tell you that he they have seen it and that is why the pateint needs disability. Almost as if they are the enabler of the psychosis. The mental sock puppet master, if you will. The friend will then be the one who goes off at you when can find no evidence of railroad tracks on the abdomen and tell you that you are part of the conspiracy and in on it with "the man". It is almost that the degree of psychosis increases exponentially when you get codependent supratentorials together. (Boy, I would hate to be in a room with Nancy Pelosi and Harry Reid!)

Monday, January 4, 2010

Anaclitic Alogia

I know that often politicians just follow a preplanned formal set of talking points that are given to them from someone higher up in the machine when they try to answer questions but the alogia that was displayed by the Senate Democrats about the healthcare bill was amazing. Watching CSPAN, each spoke with glassy eyes and avoided any specifics and was as elusive as possbile. I dont know who really was calling the shots, but their blind faith was shocking and they better watch out before whoever it is gives them the Kool-Aid.

Hold the Mayo

I was asked by a patient today while the Mayo Clinic group in Airzona would drop Medicare. I told him I did not know the official answer but I can speculate. First, there is a 21% cut in how much Medicare pays doctors . Presently, private insurance pays about 1/3 more than Medicare did even before this cut. So, if can replace your Medicare patients with patients that have private insurance, you automatically make more. So, with the Medicare cuts, you almost have to drop them to stay even. Further, by opting out of Medicare, or becoming non-participating, you bill the patients directly and they are responsible for the hassle of trying to bill and get paid by Medicare. You can also charge what you want instead of only getting what Medicare will pay. Since Medicaid is tied to Medicare, you get out of that as well. You also get rid of all the Federal red tape that is CMS.

I guess the real question is, with the Medare cuts and the hassles of dealing with the goverment, why is the rest of Mayo still participating.