Hmmm...

While I was at the hospital yesterday, I stopped in to read some EEG's. The studies always have a cover sheet attached, giving me a brief patient history. One had this on it's paperwork:

"Indication: Patient has spells of "tripping out" when he drinks heavily and smokes marijuana. Dr. Local ordered the study to make sure they aren't seizures."

Boob job

I got dragged in to the hospital today to see a patient, and was walking by the cafeteria.

The sign in front listed today's special as:

"Italian style roasted breasts, with rice."

Hygienic Horrors

It is a really scary, when catching up on the laundry, to realize that in the last 8 days your son has worn only 2 pairs of underwear.

How about a cheeseburger for stroke awareness?

15% off nfl scrubs with checkout code "nfl_jrl"

For various reasons this has been a CRAZY week at my office, and I'm still trying to catch up. So while I'm attacking the giant Pileofdictations Monster, I'm putting up this gripe sent in by Stacey, who's a radiology tech. At least that's what she says. For all I know she's another yak herder in the next valley over from me.

I was walking over to the fitness center on campus today when I was accosted by 3 women at a little sidewalk booth.

They were having a bake sale to raise money and awareness for heart disease. One women piped up as I walked by...she asked me if I would buy something to support their cause.

They were selling cupcakes, BIG cookies, thick slices of chocolate cake, and pastries. To raise money to fight heart disease. And they wanted me to support this fight by contributing to my own vascular risk.

I lost it. I said "Are you kidding me? Obesity is a major cause of heart disease! Don't you think that maybe, just maybe, you should be selling something healthy? Maybe you should try selling something healthy to promote heart health, awareness and raise money at the same time".

They all looked at me like I'd just bitten the head off a puppy and spit it on the sidewalk.

Finally one of them said "Well, we have oatmeal raisin cookies... they're kinda healthy..."

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."