Grim Reap what you Sow

We knew that it would happen, but how do you explain business to people who have never been in or ran a business. In healthcare, the private insurance elective procedures generate the revenue that covers the expenses of all the other care. We told our Blue Dog that if the healthcare bill goes through, private insurance will cost more, patients will have higher deductables and will therefore not have the procedures that pay the bills to keep the hospitals open. They didnt listen. People cant afford to have thier total joints, knee scopes and such and as a result hospitals are going broke and cutting services. So, they "expanded healthcare" by making sure that there was nobody who could afford to give it.

They also said that people who are high risk could buy insurance in "co-ops", these dont exist, so these people dont have insurance and still need medical care. The hospital in the Blue Dogs home town is now closing at the end of the year.

1-900 Healthcare

I decided earlier in the week to see how much of my clinic I could accomplish over the phone if I had too. It was astounding. I figured out that at least 45% of the patients that I saw in the office could have been diagnosed and managed with a brief phone call. Many of the pateints were consultations from other doctors who just wanted a specialists opinion, others were just follow up.

I then started to wonder. We see the pateints in the office because that is how we get paid. What if we got paid for the phone calls? What if the standart of care included telephone consultations? I could see a lot more patients so the shortage of specialists in rural areas might be decreased. The cost of these consultations would be cheaper.

Oh, wait a minute. The last thing Medicare would ever do is something that would allow more patients to be cared for in a cheaper way. Afterall, they set what is and what is not paid for.

Magical Thinking

Late last night several of us were in the little office in the ER while we waited for the OR to get ready for the second of the emergent cases of the night. One of the ER docs was there watching the news that was showing some of the Presidents speeches of the day. The ER doc went on a kept muttering, "Magical Thinking". I asked what he meant by that and he said, "he says things like he thinks that just by saying them they will come true, you know like jobs, economy, the whole bit. Just look at him, he is about to have a major psychotic break!" Before I could ask further, we had to go to the OR but I couldnt help but wonder. If the president does have a psychotic break, who makes the call? I mean, is there someone whose job is to keep track of the sanity of the commander in chief and Baker Act him if he goes supratentorially dysfunctional? If he does get Baker acted, is there some plan set up to have a competency hearing? Who is part of that hearing? For that matter, does a presidental canidate ever have to pass a psychological evaluation?

Not the Patient!

There are many times when a patient comes in with either a family member or friend who tries to hog the whole patient visit by talking about their own medical problems. I had one today who didnt even let the patient get a word in edgewise. The patient's friend wanted to talk about her own bypass and how she had all these test. I finally had to explain that it was her friend medical issues that the visit was for. No sooner had I said this then she started talking about how she had belly pain. Eventually, I interupted and asked the patient if I could talk to her in private and asked the patients friend to step out. With the friend out of the way, I was able to talk to the patient and get her the treatment she needed. The patient's friend used the time out of the room to fill out a survey that said I was rude and inconsiderate. I wanted to tell her that it was a patient satisfaction survery and she was Not the Patient!

MBA Medicine

It was one of those meetings. I was the only physician or medical person for that matter at the governance meeting of the medical center. Everyone else was either a businessmen, accountant or lawyer from the administration. One by one they presented data on the finances of the medical center. Which DRGs we made money on, which we lost on. Then came in the team for marketing. they showed us the demographics of are area, age, income. They explained that we needed to be focusing on certain patients with our advertising and our services so they would want to come to our medical center. With each presentation, the term patient was lost and customer was substituted.

When the presentations ended there were all kinds of questions about how to market to the "customers" and why certain ones do not come to the downtown hospital. Finally, it was my turn. I asked "Where do our patients come from?" I got the look of looks, and then with exacerbation, the MBA of marketing pulled up the slide of the demographics of the referral area. I just look at him and stared. Finally, I said. "Look, patients have primary care docs. You chased them all out of the hospital. They want nothing to do with you. When Mrs. Smith calls her doctor because she is not feeling well, he is going to tell her where to go. Hospitalists are great, when they work with or for the internists and family docs, not when they work for and only for the hospital. When is the last time you have seen or talked to any of the primary care docs in your pretty demographic slide?"

"If you want to market, work with the primary care docs in the referral area. Show them that you are going to give their patients' the best care. Streamline admissions, testing and follow up care. The referring docs are your customers." "If you want to market you are the best heart center, convince the PCPS and the outside cardiologists." "Ms. Smith is going to go where her doctor tells her she will get the best care."

The rest of the people at the meeting just started at me like I was an alien and then began to discuss their confustion why the biggest Ortho group was moving its cases to the other medical center.

Puttin it Bluntly

It was the usual type of case in the OR. As I went to sew up the fascia, the needle wouldnt go through the tissue, in fact it broke right in half. We then spend the next five minutes trying to free the piece of the needle that was stuck in the tissue. When I looked at the package, it was the usual 3-0 vicryl SH but then it said "blunt"!

It turns out that a while back there was a study that showed there may be a decrease in accidental needle sticks in OR personnel if blunt needles were used because they were less likely to penetrate a surgical glove. At one point it was even recommended that they be used in some closures. On more careful examination, it turns out that the real reason there were less needle sticks was that the blunt needles were useless and pushed to the side.

So, some government suit decided to mandate blunt needles (OSHA and JACHO), so all the needles were replaced without letting the surgeon know! I had to to fill out 3 forms for each needle that I use now that I want sharp to satisfy these new mandates!

I wonder what will happen next, will they take away scalpels and make us use plastic sporks?

Yellow Omega Sign

(on the inside bottom corner of the patient chart) One of our internist was really upset today. He is one of the most caring physicians I have met. He was beside himself. It turns out that a patient had demanded narcotics and he said no. As a result the patient went onto a physician rating site at slammed him so that if you Google his name, that rating turns up. That made me wonder. If patients can anonomously rate docs, why cant docs do the same for patients?

When I was a resident, we would put a yellow Omega sign on the inside bottom corner of patients charts who were crazy or obnoxious. That way the poor sod who had to take care of them next would be prepared. I wonder how we can do that now in the digital age? Think of it, we could identify those that are faking disability, those who are hypochondriacs, those who are noncompliant, drug seekers, the whole bit.