Who's Throwing Stones Here?

DO NOT EVER CHEW ME OUT FOR MY DIET COKE HABIT WHEN YOU JUST TOLD ME YOU DRINK 2-3 SIX-PACKS OF BEER AND SMOKE 2 PACKS A DAY!!!

Um, Not In My Office

I was flipping through a throw-away medical journal last night when I came across this picture.

Gotta tell you guys, if I did something that looks like this to a patient (especially one in hot pink undies!) I'd get my butt dragged in front of the state medical board.

(click to enlarge)

It's That Time of Year, Again!

The season for sharing is almost upon us, and my kids have started early by sharing some irritating variant of the creeping crud with me.

So in honor of that, I'm going to steal (uh, I mean copy and properly credit) from my esteemed colleague The Mother this excellent post on managing family illness.

She has extensive training in 2 remarkably difficult fields, being both a Mother (of 4 boys) AND a doctor, and so is eminently qualified for all kinds of stuff. Like me, she is a history buff. She can be read at mothershandbook.net.

The Care and Feeding of Illness

by The Mother

Wednesday, October 21, 2009

In the light of the mounting cases of the flu among my bloggy friends, and the fact that, where I live, even DOCTORS can’t get the H1N1 vaccine, I feel compelled to do what I can to make everyone’s lives just a little bit easier during the (nearly mandatory) ten days when the household goes to pieces.

The care and feeding of a sick family, while not an exact science, certainly has a few well-established principles.

1. No wife is allowed to be sick alone. Husband will immediately find a way to be sicker.

2. The child with the most tests that week will get sick first. The child who is in preschool and has absolutely nothing to do with his life (and, because he has nothing to do with his life, MUST be entertained) will miraculously escape disease.

3. They don’t make enough trees for a family of six to all have colds at the same time. Ditto decongestants.

(Corollary to rule 3: You will run out of decongestants within a day. You will buy the biggest box you can legally buy, and then run out in two more days. You will then be forced to beg your neighbor to go to the pharmacy and score you some decongestants. This corollary leads to:

The Mother’s Rule of Decongestant Procurement: Go buy the biggest box you can get, NOW. Set your calendar alarm for one month from now. Repeat, whether anyone gets sick or not.)

4. Even if the mother is on her deathbed, she has to do chores. Someone has to feed everyone and buy toilet paper (and tissues).

(Corollary to rule 4: Everyone gets sick the day before grocery day, when you have no food in the house.)

5. Everyone starts throwing up the minute MOM gets nauseous.

6. Children who are vomiting have an amazing knack of finding the most expensive, least cleanable thing in the house on which to do it.

7. Every sick child regresses at least three years.

8. Husbands who are sick regress to childhood. Somewhere around three or four years of age. The age where they, too, must be constantly entertained.

9. Even with 900+ channels and three televisions, there will be nothing on TV that will keep your children and husband busy for even an hour. Ditto the entire collection of DVDs.

(Corollary to rule 9: The internet gods will pick that week to upgrade their systems, taking down WOW and all of the streaming video sites every five minutes.)

10. (applies only to Jewish households) No matter how much medical education hubby has, he is absolutely convinced that Chicken Soup fixes everything. Sick wife will either be standing over a stove with a pullet or phoning her mother-in-law begging; extra points if she chooses option B.

Hey, I don’t make the laws of physics. I just report them.

Games People Play

Medicine is a business. Believe me, as a doc in solo practice I REALLY understand that. I want to help people, but also have to pay Mary & Annie, and my mortgage, and Diet Coke bills, and office rent, etc.

In a perfect world, healthcare would be free and unlimited. But our world isn't perfect, and the issue becomes balancing finite dollars against virtually infinite need.

We all try to do our best (I hope) to care for patients within our means.

Unfortunately, the system gets abused from all sides.

1. Insurance companies sometimes try to rip-off doctors and hospitals (and many others in between).

2. Hospitals and doctors (and many others in between) sometimes try to rip-off insurance companies.

3. Futile care is often given, usually due to family members feeling guilty. All of us in this business have seen a 90+ year old person with advanced dementia and other serious medical issues, being kept alive with machinery at a family's insistence.

4. Unnecessary admissions for bullshit reasons are common, and a huge waste of resources. My esteemed colleague ERP recently wrote an excellent post on this over at WhiteCoat's Call Room.

5. In my career I've known some system-abusing nurse managers. For example: Years ago I worked at a hospital where one floor's nurse:patient ratio was supposed to be 1:4. Instead, it was often 1:5 or 1:6. This lowered quality of care and increased nurse burn-out, and most docs sure noticed it (I don't go to that hospital anymore).

At a meeting to address these concerns the floor manager was asked why this problem kept occurring. She explained to us that her year-end bonus was based on how far under-budget the floor was, and that she needed to run the floor understaffed because she was trying to afford a down payment on a new car.

6. Some insurance companies have policies where doctors are paid a bonus based on how much care they DON'T do (I don't participate in those contracts). In other words. Big Insurance, Inc., says to Dr. X. "Here is $100,000 (hypothetical number) to pay for all our patients' tests this year. If you only spend $75,000, then you get to keep the other $25,000."

This is grossly unfair. In a perfect world the doctor would ignore this. But it ain't perfect, and we all have bills and families, and so it puts the doc in a difficult situation. And of course, if he doesn't do a test and gets sued, who gets nailed? Not Big Insurance, Inc.

These contracts, fortunately, are in rapid decline. They were most popular during the 90's. But are dying now as more and more docs refuse to accept them.

7. Pay-for-performance (also called P4P). This has been kicked around in the last few years. The idea is simple. Docs who have good patient outcomes will get paid more. After all, shouldn't they be rewarded for being better docs?

The problem here is that some conditions are basically untreatable. And some patients don't care about their own health. If something like this happened, WTF would I want to see someone with something incurable, like Alzheimer's disease? I'd only want to see simple stuff with generally good outcomes, like a young, healthy patient with carpal tunnel syndrome or occasional migraines.

If you've had a stroke, or brain cancer, or something else that ain't so good, then good luck finding a doc who's going to take you on with P4P. Because sick people are only going to cut doctor reimbursements since their outcomes will be worse. And, like I said, in a perfect world docs wouldn't look at the bottom line. But in this world we all have bills and families.

Not only that, but if I beg Mr. Marlboro to quit smoking, and he doesn't, and has a stroke, then I get penalized for a poor outcome that was out of my control.

For P4P to work, it's going to need A LOT of tinkering.

8. And my last whine, and the one that got me thinking to write this:

I got called to ER early yesterday morning to give an older gentleman TPA, the clot-busting drug. He had right-sided weakness, but fortunately got better on his own. Later in the morning, however, he worsened again, then got better again, and kept fluctuating. I kept running back & forth between my office and the hospital as the situation changed. I finally got him stabilized with medications, and ordered a bunch of tests (MRI, MRA, echocardiogram).

About 6 hours after I left the floor, I got called by Dr. Hungry Hospitalist.

Dr. Hungry: "Yeah, this stroke guy. Can I send him home now?"

Dr. Grumpy: "He hasn't had any of his tests yet, has he?"

Dr. Hungry: "No. Can't you just do them as an outpatient?"

Dr. Grumpy: "I'm not comfortable with that. He needs a work-up. His last TIA was only 6 hours ago, and I'm not even sure he's neurologically stable at this point. It's too soon to see."

Dr. Hungry: "I'm sure he's stable. Can't you just see him in your office in a few days?"

Dr. Grumpy: "Why are you so eager to toss him,?"

Dr. Hungry: "Um, well, uh, my, um, year-end bonus is based on how short I'm able to keep my average patient length of stay, and I had a really sick lady a few months ago who was here forever, and blew my average to hell, so I really need to bring it down because I've got a med school loan lump sum payment due in January and..."

I hung up on him.

Mary's Desk, October 20, 2009

Mary: "Dr. Grumpy's office, this is Mary."

Ms. Daughter: "Yeah, I need to make an appointment for my Mom, she has Alzheimer's disease".

Mary: "Okay, what about Wednesday at 2:00?"

Ms. Daughter: "No, I need all day Thursday".

Mary: "All day?"

Ms. Daughter: "Yeah, I mean, it's not really an appointment. I've got to drive to Southern City for a business meeting, and need someone to watch my Mom."

Mary: "Uh, we don't do that."

Ms. Daughter: "Come on. The nursing homes charge a fortune for adult day care. Can't I just leave her there for a few hours and you can bill Medicare for an appointment? I'll be back by 4:00, and I'll supply her lunch and insulin."

Mary: "Ummm..., ma'am, we really aren't an adult day care service or care home."

Ms. Daughter: "You won't do this, either? Great. I've tried almost every damn doctor in the area. What is wrong with you people?! Don't any of you care anymore?"

(hangs up)

Holy Toast, Batman!

Following this morning's Darth Vader toast post, so many of my awesome readers have sent me this link that I'm just going to put it up.

This site shows you how to order parts to convert your own toaster into a Jesus toaster.

Uh, That's, Uh, Great, Thanks.

While doing some advance holiday shopping last night I stumbled upon this remarkable gadget.

(click to enlarge)





I want to know if it comes in a Batman model? What about Superman? Or Jesus?

I Don't Really Want To Know More...

I'm in the hospital stairwell, heading for the 4th floor. From somewhere up the staircase a female voice drifted down.

"Sometimes it's like some kind of yogurt, sometimes randomly like cottage cheese..."

Then a door somewhere upstairs closed, mercifully cutting off the rest of the sentence. I'll just tell myself she was discussing a new dairy product diet.

Getting Even

As you may remember, Mary saw fit to torture her poor, aging, employer a few weeks ago.

One of her jobs (besides playing Farmtown online) is to fax my notes to other physicians' offices. So late this morning she had a bunch of them to send.

Around 11:30 the girls decided to order lunch from Chipotle, and faxed over an order. Mary went to pick it up.

While she was out I fished the fax confirmation sheet from Chipotle out of the trash, along with some of the medical office fax confirms on my patient notes. I doctored them up to make it look like she'd accidentally faxed all the patient notes to Chipotle. I put them on her desk, and went back to my office.

When she found them she was frantic for about a minute. Then she came back here to kill me.

It was SO worth it.

Monday Morning, 12:14 a.m.

My cell rings. It's that most dreaded of all numbers, the Local Hospital ER.

Dr. Grumpy: "This is Dr. Grumpy."

Clerk: "Please hold for Dr. Wokemeup."

(pause, bad music)

Dr. Wokemeup: "Hi, Grumpy?"

Dr. Grumpy: "What's up?"

Dr. Wokemeup: "Do you know a patient named Mr. Headbleed?"

Dr. Grumpy: "No, doesn't sound familiar."

Dr. Wokemeup: "I didn't think you would. He's visiting from out of state, and says he doesn't have any local docs. Anyway, it doesn't matter. At the family's request we're transferring him to Major Neurology University Medical Center. Thanks for returning my call."

And he hung up.

Getting Ready for Monday

There are Emergencies, and then there are EMERGENCIES!

From an internist's orders on a 34 year old lady admitted with a stroke (she'll be okay, don't worry):

"1. Brain MRI: Routine.

2. Head and neck MRA: Routine.

3. Echocardiogram: Routine.

4. Bring patient some tampons ASAP!!!"

On Call Follies

Dr. Grumpy (starting to look through a chart): "Why did they consult neurology on this guy?"

Nurse: "He had a seizure this morning. Dr. Stevens came by an hour ago, and thought it was from the antibiotic."

Dr. Grumpy: "Hmmm... Why is he in the hospital in the first place?"

Nurse: "Dr. Stevens? Uh, I think he was making rounds."

Life's a Bitch, and Then You Die

I'm on call this weekend, but am going to bitch about something unrelated.

A friend died last week. Not a close friend, or even someone I'd talked to recently. We did residency together, and practiced in the same city. But as time and geography do, we hadn't been in contact for a while. Not that we ever had a falling out, as much as we had our own lives. Occasionally we ran into each other at various places, and it was always good to see him.

He died of shit luck. That's all. And he was in his early 40's, a year younger than me. When a young person dies we always hope they did drugs. Or committed suicide. Or some risky behavior we can blame it on so we can say, "Geez, I don't do that sort of thing, so it won't happen to me". Not here. Just shit luck that can't really be prevented.

In residency we had all kinds of odd adventures, besides the usual war stories of medical training. Like when our hospital paid for the residents to go to a Neurology Academy meeting in Seattle. A bunch of us played hookie, and used our department stipends to go barhopping. Since we had no money for cabs, we were limited to bars in walking distance from our cheap motel. And they were all gaybars. So we wandered in and out of 10-15 gaybars over the course of the day.

All the geeks in neurology residency (let's face it, that was all of us) would watch Babylon 5 together once a week, and he and I would argue about it for the next week.

When I was trying to decide if I should ask Mrs. Grumpy to marry me, he gave me some advice that helped push me in what's turned out to be the right direction.

And it just sucks. Like me, he busted his ass through a combined 14 years of college, med school, residency, and fellowship. Then building a solo practice from scratch. And now he leaves behind a wife and 4 kids (younger than mine, too).

Anyway, don't mean today to be a downer, and I'm not looking for sympathy. Just venting.

But since this is a humor blog, I'll end it with a memory of him.

He was known for being gruff, and didn't really give a shit about what people thought of him or who he offended.

There was a day in the late 90's, when a drug rep had brought lunch to the practice we'd both started out in. She was obnoxious beyond belief. She would not shut up. And at the end of each sentence she'd ask "With this information, is there anything else I can do to help improve your patient care?"

We were trapped. And being new physicians, I was afraid that if we walked out we'd get in trouble, as her company was sponsoring some research at our institution. Gruff wasn't as concerned with this as I was.

So at one point in her sales monologue from hell, I passed him a note that said "We're trapped and will die here". He passed it back, and had written "I'll take care of it".

A second later she asked her standard "With this information, is there anything else I can do to help improve your patient care?"

And Gruff said, "Yeah! Show us your tits!"

She froze in horror, and in that second we both bolted.

We didn't get in trouble. Better yet, we never saw her again, either.

Goodnight, Dr. Gruff.