Overheard in ER

Dr. Urgent: "What brings you to ER today?"

Mr. Couth: "I got a big, huge, ball of shit in my ass and it fucking hurts."


Attention medical students: we at Dr. Grumpy, Inc., will not be held responsible for your grades if you use the above quote when presenting a case to your attending.

Wednesday afternoon

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

Dr. Equine: "Hi, thanks for calling me back. I'm a horse veterinarian at Grumpyville Racetrack. Do you have a patient named Mr. Adipose?"

Dr. Grumpy: "Uh, yeah... I just saw him this morning."

Dr. Equine: "You ordered an MRI on him?"

Dr. Grumpy: "Um... What does this have to do with the racetrack?"

Dr. Equine: "I'm going to guess he's a large fellow."

Dr. Grumpy: "Why..."

Dr. Equine: "He just called my office to see if we had an MRI for horses he could use."

Hey, it's for a good cause

Previously I've featured such tasteful fundraisers as:

The Alzheimer's Association "Night to Remember" ball

and

A Parkinson's support group's "Shaken, not Stirred" happy hour.


Now, thanks to a reader submission, I've found:

Thank you, M!

Fly me to the moon

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

Ms. Pisces: "Hi, I need to get in to see Dr. Grumpy right away!"

Mary: "Well, you're in luck. We just had a cancellation, and he can see you this afternoon..."

Ms. Pisces: "Oh, no. It will have to be next week. My astrologer says the horoscope doesn't favor an appointment this week."

Groundhog Day

A few weeks ago I wrote about the recent disclosure of Medicare payment data to the public. I finally got around to running my own numbers from it, and found my total take was around $70,000.

Now, normally I don't care how much other docs are getting. I try not to pay attention to those things, as it's none of my business. But, due to a recent news story, I decided to look up the stats on another doctor.

The doctor in question is an interventional cardiologist, practicing in the northeast. His father is also a cardiologist, and they work together. Sounds nice huh? A family-run medical group.

Anyway, per the 2012 Medicare data, that year Uncle Sam paid this gentleman $313,375.23. DISCLOSURE: I suck at math. Really. So this number could be completely wrong since I had trouble making sense of which column was which, and then I had to multiply across, then add.

Now, like I previously pointed out this is gross, not net. Like all of us out there, I'm sure the good doctor has insane office overhead to cover. This guy is in a field, unlike mine, where you truly are saving lives, and you can't put a price on that. And I'm also not in the business of telling other people how to spend their money. After all, I blow most of my immense fortune on a Diet Coke habit.

So what does this successful cardiologist spend it on? Well, he supports local businesses by spending $135,000 at a strip bar.

I am not making this up.

"I need it all in singles. Don't ask why."

Granted, this wasn't all at once. It took him 4 visits over 10 days last November at Scores Gentlemans Club to reach that amount, averaging $33,750 per visit. It was a cold winter, and I think we all needed to warm up (at the Grumpy household we cranked the heater up and got out extra blankets). Perhaps it was national "Support your local strip bar week" (if it was, I missed the memo).

I haven't been to a strip bar since a bachelor party in residency, but don't think I could spend that much on drinks, tips, and lap dances if I tried (although I haven't tried, either). Maybe I wasn't going to the right bars.

But it gets better. The good doctor (Zyad Younan, M.D.) put the charges on he & his dad's business credit card. Can you imagine how proud the elder doctor Younan felt when the AMEX statement came in? "EKG supplies, ultrasound gel...  $135,000 at The Boob Palace? ZYAD!!!"

Regrettably, daddy's reaction to his prodigy's spending habits hasn't been in the news. He probably grounded him and took away the car. These things don't look very good on IRS audits.

I'm really not sure how Dr. Younan, Jr. was planning to claim this as a business expense. Granted, he's a heart doctor, and the heart is located in the chest, and I'm sure there are a lot of chests displayed at Scores. Perhaps it was a research project he was working on ("I want to put my stent in your vessel"). He could also have been recruiting a new partner, though not necessarily for the practice.

"You say it's a study to repeatedly check my femoral artery pulse?"

So, to recap thus far: a successful cardiologist blew $135,000 in 4 visits at a strip bar, using his business AMEX.

But wait, that's not all!

As anyone who owns a credit card knows, sooner or later the card company wants to get paid (they're funny like that) and sent a bill to Dr. Younan. Like any honest, law-abiding, boob-ogling, dad-fearing cardiologist, he should pay it, right? And, if he had, none of this would even have made the newspapers.

But he didn't.

Instead, he claimed that he didn't have to pay because he was drugged. EACH TIME (I assume he means something beyond alcohol) and therefore has no recollection of being there.

Now, this, in my opinion, is pretty far-fetched. Okay, maybe once is semi-believable. I mean, stranger things have happened. One minute you're walking out to the doctor's lot, the next you're waking up and finding out you spent a fortune at a strip club. Maybe it was aliens. Or terrorists. Or your ex.

BUT 4 TIMES? I mean, that's one seriously good drugging job. If I'd blown that kind of money in a strip bar, I'd at least like to remember what I got for it. But not this unfortunate fellow. Whatever they used to drug him must have been pretty strong to make him not only forget, but to return to the same place 3 more times. Holy déjà vu, Batman!

"It's February 2nd, and I've been drugged by a stripper. Again."

The good doctor's refusal to pay is so steadfast that Scores has filed suit against him for the amount. They claim to have video of him in their fine establishment, acting, I assume, somewhat coherently. To date I haven't seen it listed on Youtube.

So, in summary:

1. No matter what Medicare actually pays your doctor, IT'S NOT WHAT THEY'RE TAKING HOME. The overhead for a medical practice is higher than you think. Probably much higher.

2. Don't let that hair-netted lady who puts out the bagels in the doctors lounge slip something into your coffee. You never know where you'll end up, sometimes repeatedly.

3. If you want to go to a strip bar, more power to you. But trying to charge it to your dad's business AMEX card may not be a good idea.

4. What you do with your hard-earned money is up to you, but remember to pay the bill. Because if you do, they won't sue you to get their money, and this sort of thing won't end up in the news.

5. $135,000 is a helluva lot of money to blow at a strip bar. I think my record was $50 for my share of the bachelor party.

Weekend reruns

From 2009:


Today ended with me doing a telephone and internet conference with 15 other neurologists across the country to review data on a drug that's in development.

The meeting took place after we were all home. So you'd hear the occasional sounds of home life. A kid yelling, a dog barking, somebody laughing in the background, etc.

Usually these things go fairly smoothly. Tonight's, however, had 2 noteworthy interruptions:

Interruption #1:

The "click" of a receiver being picked up, and suddenly a young female voice cuts off the moderator:

Young female: "Daddy! My boyfriend is supposed to call tonight! Why are you on the phone?"

Neurologist X: "Britney! Get off the phone NOW! I'm in a meeting!"

Young female: "Daddy! This isn't just any boy! This is TREVOR!!!!!!!!!!!!" (click)



Interruption #2

The moderator was asking a few questions. He was interrupted when a neurologist with a New York accent apparently had an interruption at home, and loudly said:

"What? Tell him to fuck off! I'm on the phone!"

Seen in a hospital chart.

No. I have no idea what #4 means.

Striptease

Mr. Larsson is sitting in the lobby, reading old issues of People, during his wife's appointment. Suddenly he walks up to Mary's desk, holding a small plastic box.

Mary: "Can I help you, sir?"

Mr. Larsson: "Do you have a land-line?"

Mary: "Yes."

Mr. Larsson: "I need to make a call, and can't use a cell phone."

Mary: "Okay, that's fine, just come around the counter there."

He sets the plastic box on the counter, comes over to the desk, and starts unbuttoning his shirt.

Mary: "What are you doing?"

Mr. Larsson: "I need to send a pacemaker report to my cardiologist's office, and we don't have a land-line at home."

He tosses his shirt on a chair and starts attaching clips from the box to his chest. 

"Wanna see the scar?"

Mary: "Um, I don't know how to send a pacemaker report..."

Mr. Larsson: "Can you unplug one of your phone lines and hand me the cord?"

Mrs. Larsson and I finish her appointment. She opens my office door and walks up front.

Mrs. Larsson: "ARNE! PUT YOUR SHIRT ON!"

Mr. Larsson: "But I need to..."

Mrs. Larsson: "NO! I told you, we'll stop at Dr. Senning's office tomorrow, and you can do it directly. You don't need to do this today!"

Mr. Larsson: "But Dr. Grumpy has a land-line!"

Mrs. Larsson: "So does Dr. Senning! Here's your shirt! I'm sorry, Mary, he's just very obsessive about this."

They leave. The door closes. Mary and I stare blankly at each other for about 10 seconds. Then collapse in hysterics.

Monday afternoon

I had a nice elderly couple in. She had mild-moderate dementia, and I was looking over her previous test results.


Dr. Grumpy: "It looks like your internist did a pretty decent work-up. Unfortunately, I have to agree with him that she has Alzheimer's disease."

Mr. Amyloid: "Yeah, that's what her daughter and I both figured. What about..."

Lady Amyloid: "We just got married!"

Dr. Grumpy: "Really?"

Mr. Amyloid: "Yep. We've been together for 10 years, but got married last week."

Dr. Grumpy: "Congratulations!"

Mr. Amyloid: "We weren't ever planning on it, but after Dr. Intern told us the news I decided we should while she still knew how much I love her."


After 15 years in this job, it takes a lot to get to me. That did.

Think

For those of you who haven't seen it, this excellent piece was on KevinMD today.

For those of you who don't believe this is what American medicine has come to... you should. I've felt the same things other docs have more times than I can count.

For those of you looking to a career in medicine... I repeat what I said last Thursday: GET OUT NOW.

Weekend on call

This past Saturday morning I was dragged in kicking and screaming consulted at the hospital to see an elderly gentleman. He'd fainted while playing bingo at the Mishwauketomee casino the previous night.


Dr. Grumpy: "What happened, sir?"

Mr. Bingo: "I just wanted to get out and do something. Ever since my wife died all I've done is stay at home endlessly and stare at the walls. I just couldn't take it anymore, and wanted to get out. So I went over to the casino."

Dr. Grumpy: "I'm sorry sir. How long ago did your wife die?"

Mr. Bingo: "Yesterday morning."

Sigh

Mrs. Diopter: "My husband sees things now."

Dr. Grumpy: "When did he start hallucinating?"

Mrs. Diopter: "Oh, not that. He just got new glasses."

Holy shit! I'm rich!

Last week, for those of you who are keeping score, the government released its list of how much Medicare pays doctors. The total for 2012 was...

(drumroll)

$77 billlion dollars.

If you like zeroes, that's $77,000,000,000.

"Are you sure? That's a lot of zeroes."

Now, there are roughly 850,000 docs out there who take Medicare. Which means (on average) each of us is getting $90,588.24 from Uncle Sam (this is ONLY Medicare, not other insurance companies).

Of course, that isn't even close to the truth. The released data also shows that 2% of the doctors out there are getting 25% of the take. So for those 2%, they're each getting $4,529,411.76.

As I'd expect, none of those guys are neurologists. And the last number (as big as it is) is peanuts compared to what your average insurance company or hospital CEO got as a Christmas bonus alone.

"My kid found these. We didn't know what else to do with them."

So which docs are getting the big Medicare money here?

1. Hematology/Oncology

2. Radiation Oncology

3. Ophthalmology

4. Rheumatology.

WOW! Those guys must be rich!

Nope, that's not it either.

Figures are misleading. While I believe in transparency, the raw numbers can be manipulated easily to make them show pretty much what anyone (usually a politician) wants.

That giant government payout is, in large part, what they're getting for supplies. These specialties have a few things in common:

1. They're primarily office based.

2. They have high overhead costs.

3. The first three are at high risk of being sued.

4. The first 2 are dealing with horribly sick patients, which cost more money to take care of.

I'm sure you're saying "why isn't neurosurgery on the list?" The office-based cost is the main reason. Most of their good work is in a hospital, and the facility supplies the medical equipment, drugs, staff, and operating room. The surgeon, like me*, shows up and brings her expertise (and the charges for it) with her, but the rest of the costs (and billing for them) get paid to someone else. 

*That noise you hear is the horrified inhalation of neurosurgeons because I just mentioned them in the same sentence as neurologists.

So, okay, the oncologists must be rich.

Of course they are! They're part of the secret government-medical conspiracy that's making you smoke tobacco and eat horribly unhealthy food against your will, causing you to get cancer and need their services.

Get real. Yes, they're getting reimbursed a decent chunk of change. But that's gross, not net. Most oncology practices have an office infusion suite to do chemotherapy. This is done there because it's more convenient for the patient, and a helluva lot cheaper for the insurance, to do it in an office than a hospital. But cheaper is a relative term.

Let's look at drugs. One commonly used for breast cancer is Herceptin. This is given once a week, and the list price is $3344 per vial. Another one, Neupogen, is $310 a pop. There's a lot of them like that.

Yeah, but the doctor must charge, like, 2 or 3 times that amount, right? That's why they're rich!

Keep dreaming. You can charge whatever the fuck you want. Medicare will only pay you 106% of the MSRP. Which means, for that $3344 vial of Herceptin, you'll get roughly $3544 back.

So? The doctor is still getting a $200 profit on each vial! That's a lot, you greedy bastards!

Stuff it. Consider the following:

Infusion nurse: $40/hour + benefits.

Infusion chairs: $1500 each.

Mayo stand (a metal table, has nothing to do with condiments): $110 each.

Code cart fully loaded (because disasters happen): $1800 (and it's $1400 to reload it each time it gets used).

Cardiac defibillator (same reason): $1200

IV poles: $70 each

TV set and cable subscription (the patients need something to watch for a few hours)

Wheeled medical stool: $50 each

Then you get into bags of saline, IV tubing, needles, phlebotomy equipment, band-aids, gauze, other medications (Zofran, Benedryl, Phenergan)... you get the idea.

And all of that comes out of the Medicare payments. Of course, the raw number doesn't mention that key point at all.

"And another thing..."

Another point: like many docs these days, the oncologist may have an NP or PA seeing patients. Of course, that person is likely working under the doctor's billing ID (called an NPI). So if both of them get, say, $100,000 back from Medicare, it's listed as money that ONLY went to the doc. And what you're seeing doesn't take into account the salary, benefits, and malpractice coverage for the NP, not to mention all the office supplies and support staff.

Wait, so you mean the money meant for 2 or more people can show up in the Medicare data as being all paid to one doc? Exactly. Doesn't give you a clear picture, does it?

The other fields are similar. Radiation oncology? A radiation machine will easily set you back a few million bucks. Not quite the same as say, a sofa from Penny's. But it's necessary in this line of work, because you can't practice without it (trying to irradiate tumors with the stuff you scraped off your kids glow-in-the-dark Halloween costume isn't helpful).

Then you need trained techs to operate it. Federal licenses and certifications to handle radioactive equipment. And a company that supplies/disposes of used isotopes (selling them to Al-Qaeda is frowned upon).

Ophthalmology? Have you ever been to one's office? They don't have something as simple as my Queens Square reflex hammer ($14 on Amazon). The gadgets they use are big, and to fully outfit a decent ophthalmology office will run you $100,000 to $200,000  - before you can even start seeing patients. Having your cataracts done? Each lens costs the doctor from $1000 to $3000 depending on what you need, not including all the other supplies needed for surgery. So a lot of the money is going to cover those expenses, too.

Rheumatology, like oncology, deals with some pricey drugs. Remicade, for example, is $915 a vial from the company.

Then, for ALL doctors, you have to figure in the other office expenses: computers, printers, chart system, staff, office furniture, office machines, paper, pens, coffee maker....

Yeah, but you guys get most of your office supplies free from drug reps! Sorry, Charlie. That practice was banned in 2008. Now the only thing reps can give us is samples, patient education brochures (which I throw away), and a hurried lunch of tuna sandwiches.

Office space alone can eat you alive. Between Pissy and I we have 2100 square feet. And we're paying $5100 a month for that. That's likely more than your mortgage payment for a house of similar size. And our office doesn't have a pool or wet bar.

Malpractice insurance? For non-surgical fields it's anywhere from $30,000 to $100,000 per year (or more). Surgeons? $100,000 to $300,000 (and up) per year depending on the field. That comes out of your share of the $77 billion, too.

Then, when you finally collect your money, a billing company will get 5% to 10% of it.

So, this is not exactly a high-profit-margin field (medical students: GET OUT NOW). A pretty big chunk of the Medicare money goes to cover just the overhead. Running a medical practice is not something you want to do by cutting corners. When things go wrong, they can go VERY wrong.

I'm not looking for sympathy. I'm just trying to make the point that numbers like this are misleading, and can be twisted to mean whatever anyone wants them to. But when you see how much your doctor is getting for taking care of you, that's not all going in his/her personal pocketbook.

Far from it.

But that doesn't stop me, and most of us, from doing our best to care for you, every single day.

"Ommmmmmmm..."

Seen in an ER doc's note: