This could mean a lot...

From a patient intake form yesterday afternoon.

(click to enlarge)

Delay in game

I went up front to get a patient from the lobby.


Dr. Grumpy: "Mrs. Fourdown? Come on back to my office."

Mrs. Fourdown: "Oh dear. Can you take someone else ahead of me?"

Dr. Grumpy: "No, you're the only one here right now, and it's time for your appointment. Is something wrong?"

Mrs. Fourdown: "No, but I just started a crossword puzzle."

Annie's desk, September 8, 2010

Mr. Jade: "So what's my sed rate?"

Annie: "5".

Mr. Jade: "Is that good?"

Annie: "Yes".

Mr. Jade: "Did you ask the doctor?"

Annie: "Yes. He said 5 is fine."

Mr. Jade: "Was that today that you asked him?"

Annie: "This morning."

Mr. Jade: "Is 5 in the normal range?"

Annie: "Yes."

Mr. Jade: "What is the normal range?"

Annie: "Less than 20."

Mr. Jade: "So that's less than 20?"

Annie: "Yes."

Mr. Jade: "Which is normal, right?"

Things that make me grumpy

B12

Sounds simple, huh?

1 letter, 2 numbers. One of the B vitamins. It's important in a number of body functions, particularly the nervous system and blood cell production. It's in pretty much all meats and vegetables, and multivitamins you can buy.

To me, it's also a good example of what's wrong in health care.

Let's take Mrs. Olde.

She goes to her internist, and is complaining of feeling weak and tired. So he checks a B12 level, thyroid labs, and other stuff.

A week later, she's out with some friends, and trips in a movie theater. She breaks her leg, and lands in ER. She gets admitted to the hospital.

There she mentions that she feels weak and tired to the admitting hospitalist. So, with the usual pre-surgical labs, she checks a B12 level, thyroid labs, and other stuff.

She does fine in surgery, but afterwards has a mild anemia, which doesn't improve. So after she gets out of the hospital she goes to a hematologist. This doctor doesn't have any of the previous tests, and so orders another B12 as part of the work-up.

While she's recovering, she's taking Percocet for her broken leg. She mentions to her daughter that her memory is foggy, and so the daughter takes her to see a neurologist.

The patient comes to the neurologist. He thinks the problem is due to Percocet, but to cover himself he orders a head CT. Since he doesn't have access to her hospital records, and she doesn't have any of her previous labs with her, he orders a bunch of blood work, including a B12, thyroid labs, and other stuff.

Story over.

Now, a B12 level, according to Local Lab, costs $198. So this lady has had 4 done, for a total of $792, in less than a month. B12 levels generally don't change that dramatically in a month, so only 1 was really needed (yes, I know some of you are thinking a methylmalonic acid level is more useful than a B12, and I agree with you. But that's not the point here. And try getting Medicare to pay for an outpatient methylmalonic acid).

$198 isn't that much, is it? But multiply it by thousands of patients a month with similar stories. That's a HUGE amount of money wasted. And then extrapolate it to many other redundants tests: CBC's, TSH, chest X-rays. And then add pricier items (though not as commonly reduplicated) like CT's and MRI's.

I generally don't order labs if I know a patient has recently had them. I try to get the old records, then order anything I need that hasn't already been done. But many docs don't do that. And sometimes the patients are less than helpful. They forgot they had stuff done 2 weeks ago. Or don't remember the name of the doctor/hospital who did them, making it impossible for me to track them down (you'd be amazed how many times people have no idea what hospital they were in recently, or what doctor ordered their tests).

I'm guilty of this myself. Yesterday I admitted a guy to the hospital, who told me his outpatient work-up hadn't included any labs. So I ordered a bunch. This morning I came into my office to find everything I had done last night was also done 3 days ago, and was sitting on my fax machine. According to the hospital labs, the total cost on these duplicated labs was $1278.

I don't think the patent did this intentionally. He'd either forgotten, or (and this is common, believe it or not) thought that the labs his internist ordered wouldn't be ones a neurologist would want, and therefore didn't count.

Redundant tests, I think, are a huge waste of money. I'm not sure what the answer is here.

Some would say we need to have ALL these records in a humungous database, searchable from anywhere, and protected by elaborate security checks. This would likely be the best answer, but I think all of us have huge concerns about the security and privacy issues involved.

Better communication between doctors would help. You have no idea how much I appreciate it when a referring doctor sends labs and test results in advance, or even with the patient. That way we all save time, money, and blood on further tests.

Another option is to put the patient in charge of their records. Some are good at this, bringing copies of labs going back to their childhood. But most don't. Giving them a memory stick or CD with past tests sounds good, but those things can be forgotten. Or lost. Or not work on a different type of computer.

I don't have an answer for this. I wish I did. A good solution on a large scale would likely save a huge amount of time, money, and aggravation for all of us.

Yes, I have kids

I have a patient who always starts his sentences with a long "Ohhhhhh..."

Like this:

Dr. Grumpy: "How many physical therapy sessions have you had?"

Mr. Star: "Ohhhhh... maybe 5 or 6."


And I have to say, when he does the "Ohhhhhhh..." thing, it's REALLY hard not to yell "Who lives in a pineapple under the sea?"

Tuesday morning, 1:55 a.m.

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

Mrs. Wokeme: "Yes, I see you for migraines, and I have one. What should I do?"

Dr. Grumpy: "Didn't I give you a prescription for Painbegone? Have you tried one?"

Mrs. Wokeme: "No, but I have the package right here. It says to take as needed for migraine."

Dr. Grumpy: "So take one, if you have a migraine."

Mrs. Wokeme: "Okay. I just wanted to be sure. I thought I once read that 'take as needed' was some sort of medical code meaning I should call the doctor first."

Tips from Dr. Grumpy

I'm spending this holiday weekend being abused by my kids AND evil archenemy (the Wii Fit trainer). So to keep you guys entertained until I return to my desk, I'm providing awareness of important news stories (this and the previous post).

Obviously, if you're a veteran of huffing paint/glue/whatever, I don't expect you to still have all brain cells working.

BUT here's a tip: walking around with the lower half of your face spray-painted a lovely shade of metallic gold, like this guy, WILL NOT help you blend in with a crowd (at least most crowds).


I'd like to thank my reader Kayden for submitting this.

NEW! Treats pain AND fatigue!

I'd like to thank my reader Ellie for submitting this.

(click to enlarge)

Excuses

Dear Patients:

Apparently this 3 day weekend snuck up on many of you, to the extent that you frantically canceled yesterday's appointments at the last minute. I assume this was so you could leave town/start drinking/both early (Americans love a reason to drink. I think we're the only country that steals holidays from other countries, like St. Patrick's Day or Cinco De Mayo, just to have an excuse to drink).

Anyway, the day started with a typically full office schedule, but by the time you guys were done canceling, I'd worked a total of 2 1/2 hours, and we gave up and closed down at 1:25.

I appreciate those of you who were considerate enough to call. This is actually preferable to the ones who simply don't show up, leaving me in suspense. At least by calling you let us know we can shut down early.

I'm sure some of you had legitimate reasons not to come in. But it's hard for me to tell. So here, in no particular order, are some of the excuses we received.

1. I broke my arm.

2. My kid broke his arm.

3. My car died on the freeway, and I'm up here on the off-ramp waiting for a tow-truck (the message on this one featured loud music and a guy ordering beer in the background).

4. My hemorrhoids are killing me.

5. I don't remember why I see you anyway (possibly legitimate given the nature of my practice).

6. My ex-husband is in town.

7. My kid lost my car keys.

8. I have to go to Costco.

9. My cat threw-up.

10. I'm in the middle of my pap smear, and my GYN just called out for an emergency, and I'm up in the stirrups and don't know when she'll be back.


THE WINNER, however, has to go to Mr. Bowman. He's been a reliable patient of mine for a long time, and knows I'll forgive him. He also knows my sense of humor. And he left this message (Mary didn't get it, but I did).

"Hi, this is Mr. Bowman. I need to cancel my 2:15 appointment today because OH MY GOD! IT'S FULL OF STARS!" (click).

Have a good weekend everyone.

Good answer

Dr. Grumpy: "Is that mark on your eye a lifelong thing?"

Mrs. Literal: "Well, it's been there since I was born. Before that I'm not sure."

Geography FAIL!

Okay, I'm doing a research survey this morning, and screen #1 asked me which country I resided in. So I checked "USA".

The next screen came up, and asked me what state I lived in. It featured a drop-down menu with all the states. And the "A's" went like this:

Alabama
Alaska
Alberta
Arizona
Arkansas...


I REALLY hope they did that to see if I was paying attention.

Another one bites the dust

I don't do that much teaching anymore. I like it, but the constraints of time with a family and solo practice make it damn near impossible.

But I still do it, albeit rarely, on special requests from friends, nurses or docs I know, etc. And yesterday was one of those days.

I got my start in a college program where I shadowed docs to see if I wanted to be one, and so I have a tender spot for those kids. Last week one of the hospital nurses called me. Her son is in his 2nd year of college, and is thinking about medicine. She was calling around to see if anyone would let him watch for a day. And since I'm a softy, I said sure.

He shows up, neatly dressed, trying to look young, eager, and professional. My first patient was in for an EMG (electrical test of the nerves and muscles), and she didn't have a problem with the student watching.

I fired up the machine, and made some notes. Joe College leaned over my shoulder to see what I was doing. I stuck a needle in the patient's deltoid, and turned to the machine to look at the results.

There was a loud "thunk" behind me. The patient and I both turned to see Joe College sprawled unconscious on my exam room floor.

The patient began laughing. I pulled the needle out of her arm and called Mary for help. We got Joe out to the break room as he woke up, and got him some water.

By the time I was done with the EMG he was gone. He'd told Mary he was thinking about becoming a pharmacist or accountant. He also asked for her phone number.

History FAIL!

"I had my kids way back, in the 1970's. They were complicated births, because they hadn't invented the C-section yet."

Only outside Sleepy Hollow

Mr. Patient: "My chiropractor says this is because the top of my neck attaches to my head. Is that a common problem?"