Doctors really should practice what they preach.
My typical workday lunch is fat free vanilla yogurt with somewhat gourmet-ish granola to go with it and a piece of fruit. Healthy and it doesn't leave me dragging in the afternoon. Today my yogurt and granola was very good, but not completely satisfying. I thought to myself, "Hey there's left over dessert in the fridge from our drug rep lunch yesterday." I set a land speed record to get to the fridge and found an Applebee's brownie sundae.
Excitedly I brought it back to my office and took a bite. It tasted way too good. I decided to look up how many calories it was. Officially this treat is known as the Low Fat Fabulous Brownie Sundae. I thought, "Great! It's low fat."
Upon closer inspection, however, I noticed it was still 326 calories, probably more than my yogurt and granola combined. I took one more bite and tossed the rest. Good Country Doctor.
The Country Doctor
Tuesday, July 07, 2009
On Edge
Change, even positive changes, can be stressful.
It is fair to say this summer has been a summer of change for our practice. Two months ago we moved from our location of 110 years into a new building. Just last week our office manager of 18 years retired and now someone very capable, but new, occupies her position. In this midst this summertime business has been as busy as ever and every day more and more new patients decide to make us their medical home.
Despite all of this good stuff, office morale has never been lower. People feel unsettled in where things are and how to go about their daily business. People are being asked to do more than ever and things which they haven't been accustomed.
Things will of course settle out and this too shall pass. In the meantime, though, we need to find ways to keep our staff going, reward their efforts, and to see the light at the end of the tunnel. Change is hard.
The Country Doctor
It is fair to say this summer has been a summer of change for our practice. Two months ago we moved from our location of 110 years into a new building. Just last week our office manager of 18 years retired and now someone very capable, but new, occupies her position. In this midst this summertime business has been as busy as ever and every day more and more new patients decide to make us their medical home.
Despite all of this good stuff, office morale has never been lower. People feel unsettled in where things are and how to go about their daily business. People are being asked to do more than ever and things which they haven't been accustomed.
Things will of course settle out and this too shall pass. In the meantime, though, we need to find ways to keep our staff going, reward their efforts, and to see the light at the end of the tunnel. Change is hard.
The Country Doctor
Wednesday, June 24, 2009
Entitlement
For many who work in the health care arena the word entitlement first brings to mind Medicare. For those of us somewhat more jaded and cynical, images of patients on Medicaid overusing the health care system pop into mind. Yesterday I had a patient who demonstrated entitlement comes in all shapes and sizes.
He's a middle aged man with a good job with a good traditional health insurance plan. He had been using a name brand medication whenever he had an outbreak of...cold sores, yes, let's say cold sores around his mouth. He had been on this medication for two or three years and it always worked well for him.
This year his insurance plan decided it wasn't going to pay for this unless he met the criteria on the dreaded prior authorization form. I brought him in for an appointment which he was none to pleased about, so he could help me fill out the form and answer the questions his insurance company was asking. I explained this gave me the best chance of getting all of the information correct to help him get this medication approved, but he still bitched and moaned about having to pay a co-pay. (I diplomatically neglected to say, "Hey, buddy, you don't come in and I don't get paid to fill out your insurance company's stupid form.")
A week later we receive the denial. I called in the generic for him unless he wanted to pay cash for the name brand or go without, it was his choice. This was not like he needed insulin to survive or anything. We're talking, what was it? Cold sore, yes, cold sores.
Even more livid now, he scheduled the appointment with me yesterday to again to tell me to, "Just take care of this for me, okay?" When I told him he could appeal, but I was not going to take any further action he was just beside himself. You'd think he had been denied the right to vote. He blamed all of this on socialized medicine. Biting my tongue and wanting to stay on schedule I happily gave him the name of our elected state insurance commissioner and told him to take the matter up with him.
Now what I wanted to do as he went on his diatribe was grab him by the scruff of the neck and take him to the exam room two doors down where a woman sat with chronic kidney disease and a current kidney infection. She had delayed follow up on the chronic issue for over five years and had waited weeks to be seen for her urinary tract infection hoping it would clear on its own only to have it advance. She has an good honest job, but without health insurance. One month of his name brand medication could have paid for diagnosis and treatment of this infection when it was still limited to her bladder and she was much more entitled to those health care dollars than he was.
The Country Doctor
He's a middle aged man with a good job with a good traditional health insurance plan. He had been using a name brand medication whenever he had an outbreak of...cold sores, yes, let's say cold sores around his mouth. He had been on this medication for two or three years and it always worked well for him.
This year his insurance plan decided it wasn't going to pay for this unless he met the criteria on the dreaded prior authorization form. I brought him in for an appointment which he was none to pleased about, so he could help me fill out the form and answer the questions his insurance company was asking. I explained this gave me the best chance of getting all of the information correct to help him get this medication approved, but he still bitched and moaned about having to pay a co-pay. (I diplomatically neglected to say, "Hey, buddy, you don't come in and I don't get paid to fill out your insurance company's stupid form.")
A week later we receive the denial. I called in the generic for him unless he wanted to pay cash for the name brand or go without, it was his choice. This was not like he needed insulin to survive or anything. We're talking, what was it? Cold sore, yes, cold sores.
Even more livid now, he scheduled the appointment with me yesterday to again to tell me to, "Just take care of this for me, okay?" When I told him he could appeal, but I was not going to take any further action he was just beside himself. You'd think he had been denied the right to vote. He blamed all of this on socialized medicine. Biting my tongue and wanting to stay on schedule I happily gave him the name of our elected state insurance commissioner and told him to take the matter up with him.
Now what I wanted to do as he went on his diatribe was grab him by the scruff of the neck and take him to the exam room two doors down where a woman sat with chronic kidney disease and a current kidney infection. She had delayed follow up on the chronic issue for over five years and had waited weeks to be seen for her urinary tract infection hoping it would clear on its own only to have it advance. She has an good honest job, but without health insurance. One month of his name brand medication could have paid for diagnosis and treatment of this infection when it was still limited to her bladder and she was much more entitled to those health care dollars than he was.
The Country Doctor
Thursday, June 18, 2009
Think Before You Write
I flipped through a new patient's chart on nursing home rounds yesterday and came to the section of copied pages for his recent hospital admission related to intractable pain from widespread metastatic cancer. I arrived at the hospital orders and read:
1. Hemoglobin A1c added to blood already in lab
2. Hospice consult
If you work in health care hopefully you can see the dissonance to these orders immediately. A hospice consult for a patient with wide spread metastatic cancer is self-explanatory. A hemoglobin A1c, however, is a test for diabetes to measure how well blood sugars have been controlled for the past three months. Patients with a good hemoglobin A1c will have fewer long term complications from diabetes.
I generally don't make it a habit to second guess other practitioner's logic, but this one eluded me. Did he really think this through or am I missing something here?
The Country Doctor
1. Hemoglobin A1c added to blood already in lab
2. Hospice consult
If you work in health care hopefully you can see the dissonance to these orders immediately. A hospice consult for a patient with wide spread metastatic cancer is self-explanatory. A hemoglobin A1c, however, is a test for diabetes to measure how well blood sugars have been controlled for the past three months. Patients with a good hemoglobin A1c will have fewer long term complications from diabetes.
I generally don't make it a habit to second guess other practitioner's logic, but this one eluded me. Did he really think this through or am I missing something here?
The Country Doctor
Wednesday, June 17, 2009
What's in a Word?
Think about the last time you casually told someone about a medical appointment. Chances are you said something along the lines of, "I went to (fill in the blank) doctor," or, "I took my child/parent/friend to (filled in the blank) doctor." This subtle word change used to fill in the blank can unmask a world of differences in the nature of that doctor-patient relationship.
"I went to a doctor," has a certain lack of specificity. It could have been one of many doctors. Perhaps the person doesn't feel as though they really have a personal physician, so he or she just went to see a doctor perhaps at a walk-in clinic or convenience care. Perhaps he or she sees many different doctors of various specialties and the appointment is just another doctor's visit blending in with all the rest.
I certainly wouldn't want to be on the receiving end of, "I went to that doctor." Whereas a doctor might be too impersonal or anonymous, that doctor may be overly specific and has an accusatory tattling ring to it. "Ooh, ooh, that one! I went to that doctor! He did it!"
Many word this statement with the fill in the blank after the word doctor and not before as in "I went to Dr. Jones." This isn't too bad, though somewhat formal. It's a personalized response without any negative intonation to it. It's okay.
For my part though I always prefer when I overhear one of my patients saying, "I took little Johnny to the doctor." It is this phrasing that even without mentioning a name is the most personalized. Even if little Johnny sees a team of specialists, there is only one the doctor. Who the physician actually is goes without saying; it is understood. "You know, the doctor." There's a connection there.
Much of the art of medicine is learning to read between the lines and simple word choices are most definitely a part of that. This also shows the minutia one's mind can wander to on a slow Tuesday afternoon in the middle of summer.
The Country Doctor
"I went to a doctor," has a certain lack of specificity. It could have been one of many doctors. Perhaps the person doesn't feel as though they really have a personal physician, so he or she just went to see a doctor perhaps at a walk-in clinic or convenience care. Perhaps he or she sees many different doctors of various specialties and the appointment is just another doctor's visit blending in with all the rest.
I certainly wouldn't want to be on the receiving end of, "I went to that doctor." Whereas a doctor might be too impersonal or anonymous, that doctor may be overly specific and has an accusatory tattling ring to it. "Ooh, ooh, that one! I went to that doctor! He did it!"
Many word this statement with the fill in the blank after the word doctor and not before as in "I went to Dr. Jones." This isn't too bad, though somewhat formal. It's a personalized response without any negative intonation to it. It's okay.
For my part though I always prefer when I overhear one of my patients saying, "I took little Johnny to the doctor." It is this phrasing that even without mentioning a name is the most personalized. Even if little Johnny sees a team of specialists, there is only one the doctor. Who the physician actually is goes without saying; it is understood. "You know, the doctor." There's a connection there.
Much of the art of medicine is learning to read between the lines and simple word choices are most definitely a part of that. This also shows the minutia one's mind can wander to on a slow Tuesday afternoon in the middle of summer.
The Country Doctor
Sunday, June 14, 2009
Budget Cuts
Proton pumps inhibitors such as Prilosec, Nexium, Aciphex, and Protonix have become so commonly used in medicine to say they are given out like candy would be to over state the popularity of candy. Unfortunately these are also expensive medications.
The legislature passed some $42 million in cuts to the state's Medicaid budget this year. Included in the cut backs are no more proton pump inhibitors for patients on state insurance unless a documented ulcer is present, the patient has a zebra of disease called Zollinger-Ellison Disease, or they are willing to surrender their first born child. It was in this context about a month ago a man in his fifties switched from his proton pump inhibitor to ranitidine (Zantac).
While this patient was in his fifties he really had the look of a man in his seventies from years of abusing his body with smoking and probably more alcohol than was good for him. He took an ibuprofen like anti-inflammatory medication for his arthritis to try to limit the amount of narcotic pain medication. He did well with this combination until a few weeks after the state declined to cover his medication for his stomach.
Last week he came in to see me as white as lab coat. His hematocrit had dropped to transfusions levels, so I admitted him and tanked him up with four units of blood. When he was scoped, the anti-inflammatory medication had worn a hole in his stomach. He'll recover from this hospitalization and now he'll get his proton pump inhibitor.
Now it would be simple and simplistic to conclude the state's to blame for this stomach ulcer requiring a hospital admission and multiple transfusions. This patient had abused his body for years and now his health was catching up with him. The pharmaceutical industry certainly has not looked to lower the cost of its products. The public expects the latest and greatest medications. Doctors have let themselves be lured into driving up health care costs through prescribing expensive medications when less costly ones will do.
Now if we can only all figure out a solution to this problem we have caused.
The Country Doctor
The legislature passed some $42 million in cuts to the state's Medicaid budget this year. Included in the cut backs are no more proton pump inhibitors for patients on state insurance unless a documented ulcer is present, the patient has a zebra of disease called Zollinger-Ellison Disease, or they are willing to surrender their first born child. It was in this context about a month ago a man in his fifties switched from his proton pump inhibitor to ranitidine (Zantac).
While this patient was in his fifties he really had the look of a man in his seventies from years of abusing his body with smoking and probably more alcohol than was good for him. He took an ibuprofen like anti-inflammatory medication for his arthritis to try to limit the amount of narcotic pain medication. He did well with this combination until a few weeks after the state declined to cover his medication for his stomach.
Last week he came in to see me as white as lab coat. His hematocrit had dropped to transfusions levels, so I admitted him and tanked him up with four units of blood. When he was scoped, the anti-inflammatory medication had worn a hole in his stomach. He'll recover from this hospitalization and now he'll get his proton pump inhibitor.
Now it would be simple and simplistic to conclude the state's to blame for this stomach ulcer requiring a hospital admission and multiple transfusions. This patient had abused his body for years and now his health was catching up with him. The pharmaceutical industry certainly has not looked to lower the cost of its products. The public expects the latest and greatest medications. Doctors have let themselves be lured into driving up health care costs through prescribing expensive medications when less costly ones will do.
Now if we can only all figure out a solution to this problem we have caused.
The Country Doctor
Tuesday, June 09, 2009
Good As New
Patient comes in for an appointment this afternoon and tells me, "In case you ever have dentures, if you feel like you're going to throw up, take them out first."
"Okay, why?" I asked curiously.
"A few years ago my wife got sick and she started throwing up. Well, she just shot her lower plate right out and down the toilet. You know a lower plate would have cost $2000 to replace,... but we got it back."
"Okay, so what did you do?" More curious than ever.
"Well we hired ourselves a couple of Mexicans for $20 and a six pack and they trudged through the septic tank until they found it. They pulled the plate out and the teeth have never been whiter. Still uses them to this day."
The Country Doctor
(Yes, there were some highly racially prejudiced overtones to this story which I do not endorse, but chose to include it to as a critical part of the story and reflective of my patients.)
"Okay, why?" I asked curiously.
"A few years ago my wife got sick and she started throwing up. Well, she just shot her lower plate right out and down the toilet. You know a lower plate would have cost $2000 to replace,... but we got it back."
"Okay, so what did you do?" More curious than ever.
"Well we hired ourselves a couple of Mexicans for $20 and a six pack and they trudged through the septic tank until they found it. They pulled the plate out and the teeth have never been whiter. Still uses them to this day."
The Country Doctor
(Yes, there were some highly racially prejudiced overtones to this story which I do not endorse, but chose to include it to as a critical part of the story and reflective of my patients.)
Ungrateful Kids
An elder woman in her late seventies came into the office distressed today at her daughter's threat to have her declared incompetent. Somewhat inappropriately I blurted out, "Well, that's nuts!" While she had some minor forgetfulness related mostly to depression, she did not show any true signs of dementia and had no decline in her cognitive ability.
The incompetent one was, of course, the daughter. In her mid-fifties, and my patient too, she had been pressing her mother to buy her a car. Her mother told her that she had bought her six other cars over the years and enough was enough. After supporting her daughter and rescuing her throughout her life, the mother was tired of rescuing her daughter. While I know the daughter has a host of medical issues herself and stories like this don't happen in a vacuum, if my kids ever try this with me...
The Country Doctor
The incompetent one was, of course, the daughter. In her mid-fifties, and my patient too, she had been pressing her mother to buy her a car. Her mother told her that she had bought her six other cars over the years and enough was enough. After supporting her daughter and rescuing her throughout her life, the mother was tired of rescuing her daughter. While I know the daughter has a host of medical issues herself and stories like this don't happen in a vacuum, if my kids ever try this with me...
The Country Doctor
Sunday, June 07, 2009
Rebelling
I'm preparing to be an office rebel. I'm going to start doing something so crazy, so wild, so extreme it may shake our practice to its very foundation. I'm going to start e-mailing patients.
Physicians largely ignore this practice because, well, it just doesn't pay. I can explain someone's laboratories to them in the office and bill for an office visit or I can notify them some other way and not bill for it. In practice most people already do a combination of the two. If someone's lab tests are significantly out of whack that's an appointment. If they're relatively okay, they receive a copy in the mail and maybe a phone call from my nurse. (I don't call patients on the phone unless they are dying basically. I just don't like phones.)
Right now the vast majority of insurance companies will not pay for e-mail. There problem is, e-mailing just makes too much sense. It can be good care for routine type issues whether or not it pays (patients will be instructed not to e-mail if they have crushing substernal chest pressure with exertion).
So why have I waited so long to do this other than the lack of financial incentive and for the sake of office conformity? Security. E-mailing protected health information should really be done securely and if I'm not going to be paid to do this I certainly don't want to shell out the money for it. Fortunately I was scanning around my state medical association site for something completely unrelated when I saw they recommend a particular secure e-mail program which is willing to offer physicians a free two year license.
Now can I convince my nurse to start doing this?
The Country Doctor
Physicians largely ignore this practice because, well, it just doesn't pay. I can explain someone's laboratories to them in the office and bill for an office visit or I can notify them some other way and not bill for it. In practice most people already do a combination of the two. If someone's lab tests are significantly out of whack that's an appointment. If they're relatively okay, they receive a copy in the mail and maybe a phone call from my nurse. (I don't call patients on the phone unless they are dying basically. I just don't like phones.)
Right now the vast majority of insurance companies will not pay for e-mail. There problem is, e-mailing just makes too much sense. It can be good care for routine type issues whether or not it pays (patients will be instructed not to e-mail if they have crushing substernal chest pressure with exertion).
So why have I waited so long to do this other than the lack of financial incentive and for the sake of office conformity? Security. E-mailing protected health information should really be done securely and if I'm not going to be paid to do this I certainly don't want to shell out the money for it. Fortunately I was scanning around my state medical association site for something completely unrelated when I saw they recommend a particular secure e-mail program which is willing to offer physicians a free two year license.
Now can I convince my nurse to start doing this?
The Country Doctor
Subscribe to:
Posts (Atom)
