Ideas From TAP. And Spooky Polls.

Nobody has an ideal health care solution.

BUT

My esteemed colleague over at The Angry Pharmacist put up an excellent post a few days ago. I want to direct everyone's attention over to it. He makes some valid points and backs them up with reasonable arguments, and I think it's worth reading.

AND

What makes health care reform so hard, and so scary, is stupidity on both sides.

I missed this story when it first came out, but my awesome reader Lisa was kind enough to send it to me.

Basically a firm called Public Policy Polling surveyed 900 voters here in the USA, asking them if the government should stay out of Medicare.

To my horror, 39% said "Yes"! So, more than a third of eligible voters are entirely unaware that Medicare IS a government program, and always has been.

This poll cut across a frighteningly broad swath of income and education.

At least I get blog material from them.

And a great big DR. GRUMPY THANK YOU TO MY READER LISA K. for bringing this to my attention.

We Have Medication For People Like You

I saw a new patient today, who brought his briefcase. I don't care. Maybe he hates leaving it in his car. Maybe he's a courier. Maybe he's a part time nuclear "bag-man" for the President. Whatever.

I asked him if he'd had any headaches recently.

He opened the briefcase, pulled out a HUGE notebook, flipped through it for a minute, then said:

"Yes, mid-afternoon on October 10, 2003. I took 1/2 of one of my wife's Percocets for it, and it resolved in 45 minutes".

The notebook and briefcase can't come back here anymore.

Boredom, Redefined

One of you wrote in this morning that you're trapped in a boring teleconference, and so to kill time you decided to add up my monthly posts over time, and graph them.

And then you sent it to me.

(click to enlarge)



While I appreciate this kind of devotion, I have to say a few things:

1. I hope you're not a pilot flying a plane that's just overshot your destination because you're playing on a laptop doing this.

2. If you aren't really in a meeting, and do things like this for fun, you need a life.

Fun With Patients

Attention! Alert! Local Grocery has Coke stuff on sale for $2/12-pack!

When this happens I stop by pretty often after work. They only allow you 5 cases per person, so I make repeat trips, with varying combinations of Diet Coke, Coke Zero, and Vault Zero being thrown into my trunk until:

1. My rear tires are squashed flat.

2. My arms fall off.

3. The store runs out

4. I max out my credit card.

So today I was there, deciding what my next soda run should consist of. I was so engrossed in this serious issue that I didn't see it coming.

I was sighted and approached by a patient.

An Alzheimer's patient.

Bill.

Bill: "Uh, excuse me? Hello."

Dr. Grumpy (looking up): "Yes, I (oh shit!), oh, uh, hi"

Bill: "I know you, um" (he leaned forward, and to my horror I realized I had my hospital ID clipped to my shirt) "You look familiar, um Ibee Grumpy?"

Dr. Grumpy: "Yes, Bill, how are you?"

Bill: "Don't tell me, it'll come! I know! You work here!"

Dr. Grumpy: "No, Bill, I'm..."

Bill: "Can you tell me where cereals are? My wife told me to get some Corn Flakes."

Dr. Grumpy: "Uh, aisle 16, that way, about halfway down."

Bill: "Thank you."

As he walked away, and I was stunned at my good fortune, I realized he had a box of Corn Flakes in each hand.

"I've been aware of the time going by,
They say in the end, it's the blink of an eye."

(If you recognize the title- congratulations!

For those who remember, one of my 20+ high school reunions has been coming up, and it was this past weekend. [If you don't remember, I commented on it last month here and here.]

The following is a personal letter I wrote to a friend after my 20th reunion a few years back (he didn't attend). I re-read it last night, and decided my feelings haven't changed since then. So I'm putting it up for your perusal. I should note that in the 20 years prior to the reunion I'd had only incidental contact with anyone from my high school class, except for the one I wrote the letter to.

It was interesting. I didn't go to any of the previous ones, and almost didn't go to this one. But I'm glad I did.

20 years is a long time. It erases a lot of animosity. At some point you find that the majority grew up and became (reasonably) mature, decent human beings. I found there was no competition like there might be at 5 or 10 years. At this point most everyone is set in their lives and has answered the elusive questions of "who am I and what do I want to be?"

Even people who I hated once and never wanted to see again I was glad to see, oddly enough. Instead of being enemies they're now simply people I share a common background with, and it's interesting to talk to them and see where life took them. You don't really have time to sit and talk to anyone for more than a few minutes, because everyone is constantly running to the next vaguely familiar face (or name tag) to say "Hi". Most conversations are long enough to cover your spouse, your job, your kids, and where you've lived in the past 20 years, and then it's on to the next person. In a strange sort of way I imagine an afterlife would be the same way.

I was amazed at how many people came from all over the country just for this, also at how many are on their 2nd and 3rd marriages already. Some have kids who are taking the SAT's themselves. A lot of people (including me) had twins.

Cindy, that girl we were both chasing back then, looked about the same, very thin, same face, just a few more lines. Her short brown hair is now long and dyed raven black. She never married, never had kids, and is still looking for Mr. Right. In fact, she asked me if I knew anyone. I think the whole thing is interesting. As you pointed out in our phone call, she came across as unattainable to everyone back in high school. And now she's the rare one who's still alone.

What's interesting is that on talking to them now, I found that almost all the girls I had crushes on back then are so unbelievably incompatible with me that any relationship with them would have been short-lived, if it had actually happened at all. It's amazing what hormones did then, and what the retrospectoscope shows now.

Ron wasn't there, though he lives locally. Some people had gotten his phone number, but he never returned their calls (said his voice on the machine was still the same, though). No one has had any contact with him for over 10 years, and the ones who had the most recent contact said he'd become very bitter and unhappy, which is why they'd stopped keeping in contact with him. Diane commented that she felt like "he'd become someone who needed rescuing, but nobody else could help him".

Phil and Lisa married and had kids. Phil was an obnoxious jackass in HS. Now I found him to be a polite, decent person who was actually interesting to talk to. He has some sort of administrative job. He's very quiet and down to Earth. Time, raising kids, and having a mortgage and bills has a way of doing that to people. Lisa is now thin as a rail. Phil must weigh 300 lbs.

Pete works locally for an insurance company. He is the same personality as he was then, but pleasant and mature. Not married, no kids. Looks about the same but now has long hair down his back. Mrs. Grumpy, who'd never heard of him before, saw him come in and said "Who is that guy? He looks like the missing link." I think that sums it up.

In high school Pete had this POS 1972 Toyota jeep, that looked like it was about to fall apart. He still has it, was parked next to my car. Oddly, after 20 years, his once-POS 1972 Toyota Jeep is now likely worth more than my 2000 Maxima. Time is a great equalizer.

One of the girls, Laurie, I went back to 6th grade with. Others I went as far back as 4th grade with. The night after the reunion, Laurie was on the local news in a feature story on what it's like to be fighting breast cancer and be raising young children. She hadn't mentioned any of it to anyone there all night.

Sunday afternoon was the final reunion event, a family picnic at Local Park. It was a lot of fun. You realize from watching everyone that the only accomplishments and achievements that really matter to everyone are their kids.

The low-point of the reunion was when I introduced Mrs. Grumpy to Cathy, an old friend from the school paper. Mrs. Grumpy asked her when she was expecting. She wasn't. I told Cathy that Mrs. Grumpy had had too much to drink (actually she doesn't drink at all, but Cathy didn't know that).

We all got a 2-CD set of top hits from our high school days. Scary to think the songs are 20 years old. In front of the ballroom was a table, where several current Local High band students were selling raffle tickets for a fundraiser. Later in the evening I was returning to the ballroom after using the restroom, and the students at the table were looking over the songs on the CD they gave us. They were making comments such as "who is Duran Duran?" and "Boy, I think my dad listens to these guys.".

Perhaps more frightening was when the MC pointed out that when we were in HS "Born in the USA" by Springsteen was released as the FIRST CD SOLD IN THE US.

They had a slideshow going on in one corner the whole night, with various old and new pictures. The most interesting slides:

Arnold Schwarzenegger as Conan the Barbarian then and now as governor.

Michael Jackson on the cover of Thriller, and on his mug shot (remember- this letter was written several years ago).

Madonna then, and still Madonna, now.

In an ironic note, an item on the "Onion" recently was "What did we think we'd be doing with our lives by now:

"1. Dancing professionally
2. World famous truck driver
3. Overseeing vast empire of some sort
4. Making at least assistant manager
5. Presenting own line of designer handbags
6. Owning a car with gull-wing doors
7. Not this telemarketing shit, that's for sure."

It's just amazing how time flies. As cliched as the phrase is, it's really true. When I was 7 and first learned about Halley's comet, the wait for it's next visit seemed like forever. Now, in the blink of an eye, it's been here and gone. My 3 kids are all temporally closer to high school graduation than I am now. Life happens, so enjoy it.

If there was one thing I learned, it was that I wouldn't change anything. You find yourself thinking about all the alternate paths your life might have taken. What if I had asked this girl out, or gone on that trip, or taken that class. I came to realized that if I could go back and do it all over again, I wouldn't change anything. I'm very happy with where life has taken me, and for all the ups and downs of growing up and growing old I wouldn't trade any of it for anything.

Sunday Afternoon, 4:35 p.m.

Dr. Grumpy: "This is Dr. Grumpy, returning a call."

Mrs. Sickandtired: "Yeah, um, I didn't get any sleep last night, because my kids were both up sick, and now I'm exhausted and have a headache and shaky all over."

Dr. Grumpy: "What's your question?"

Mrs. Sickandtired: "Do you think it would help if I got some sleep tonight?"

My inner voice: "No! I think you should stay up all night tonight, too! Stay up for the next week! Make a big pot of coffee and guzzle it! See how long you can go without sleep, and see what it does to you! Suck it up!"

Dr. Grumpy: "Yes, I'd try to get some rest and see how you feel tomorrow."

Mrs. Sickandtired: "Okay, thank you."

My Dog is Stupider Than Your Dog

I ordered a bunch of books last week and they came yesterday. I opened the box and absently tossed a big sheet of bubble wrap on the floor of my home office.

This afternoon Snowball wandered in, and apparently noticed it for the first time. He went over and walked on it. And a plastic bubble popped.

Snowball leaped back like he'd been shot. He barked and growled at the bubble wrap, going into attack position, ready to lunge if it so much as breathed (it didn't).

After a few minutes of glaring intently at it, he was apparently sure he'd killed it, or scared it into submission. So he went over to walk on it again.

And a few more bubbles popped.

He leaped off it, howling in terror. Ran like hell for the far end of the house. He's now hiding under Marie's bed, shaking all over.

Your Insurance Premiums Hard At Work

One of my normally stable Multiple Sclerosis patients (Mike) went south on me today, so I saw him emergently over my lunch hour.

When this happens, the standard treatment is to give high doses of steroids through an IV line for 3 consecutive days. Generally it's done either with home health going to the patient's house to do the infusions, or the patient goes to an outpatient infusion center each day for 3 days to have it done there.

So I got Annie on it fast. Miracle worker that she is, she found both a nursing service and an outpatient infusion center that could do this over the weekend, giving me both options. Then she called the patient's insurance to get approval for one or the other.

Guess what? Mike's insurance company didn't have a supervisor available to authorize either one of these on a Friday afternoon. And the underling Annie spoke to (and then I got on the phone to argue with them) told me she wasn't allowed to give approval for this, and there was no one else around who could. So what did she suggest? She told me to admit Mike to the hospital over the weekend to do this, since that didn't require pre-authorization!

So let's think about this:

Home health OR an outpatient infusion suite would cost roughly $200-$400 per day (including nurse time, supplies, and drug) for 3 days.

BUT since Bozo Insurance, Inc. didn't have some magical person around on a Friday (which is a workday last time I checked) or anyone else who could approve this, they told me to admit Mike to the hospital.

I called a friend in hospital accounting. The rate for the basic room Mike is now in is roughly $1800/day. This does NOT include the costs of drug, supplies, or physician fees for docs having to round on him (since we're required to). All together, the hospital stay will cost the insurance $2500-$3000 per day for 3 days.

And Mike is pissed, too. Because he'd rather be at home.

And this is where your insurance premium dollars are going, and how your insurance company is working hard to cut back on costs and save you money.

Personalized Medicine

These electronic chart systems are so amazing. This came over my fax a few weeks ago.

The only thing I've done to it is delete the patient's name and hack off the other doc's letterhead. Otherwise what you see is what I got.


(click to enlarge)


For the record, the "copies of my chart notes" never showed up.

Drug Rep Training FAIL!

Yesterday we had lunch from a drug rep marketing an antidepressant. He was new to the office, and the lunch had been set up by his predecessor.

To my astonishment, about halfway through the sales spiel he suddenly asked, "Hey, what kind of doctor are you, anyway?"

"Uh, I'm a neurologist."

"Really? What does a neurologist do? I didn't even know I was calling on one."

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.