WWMJD?

Last week I was reviewing a research protocol which included the Beck Depression Inventory.

While looking through the questions I came across this one, and all I could think of was "How would Mick Jagger answer this?"

The Benjamins

Contrary to popular belief, even if you don't have a co-pay up-front, you still may end up paying a chunk of your bill. So we get calls all the time from people who don't understand the concept of a deductible or percentage of cost, angry that we had the audacity to charge them for their visit (maybe I should be angry at my landlord for charging me office rent, huh?).

Blood work is also an issue. Several insurances, especially Medicare, have a whole list of diagnoses you need to have in order for them to pay for your labs. This list is hysterically obsolete and unrealistic.

Yeah. Like those.

I'm in the middle here. If I order too many labs, Medicare will claim they weren't necessary for the condition (in spite of a crapload of medical literature saying otherwise) and the patient will get cranky because OMG THEY HAD TO PAY FOR SOME OF THEM. But if I don't order all the labs I run the risk of missing something and getting sued over it. The defense of "the insurance won't pay for the test" is legally worthless in court.

So I order what I think is appropriate. I'd rather get yelled at by patients over their bill then roasted by a lawyer for malpractice. By ordering it, I put the ball in the patient's court. If they don't want to have the test, that's their decision. But at least I tried.

So what happens when you go to the lab? Before they draw blood, you sign a form saying that you agree to pay any charges your insurance doesn't cover (for the record, you do that at my office, too. And probably every doc's office. If you didn't know that you just haven't read the fine print).

Then, if you sign it, they'll do the labs and bill your insurance. It there's any left over, they'll bill that to you.

This is where things get iffy, especially with Medicare and their outdated list of tests that will only be paid for IF you have a certain condition.

Let's say, for example, that a Medicare patient is having a neuropathy work-up, and needs a vitamin B12 level done. Most docs order a B12 level. I  do, too sometimes, but generally prefer checking methylmalonic acid (MMA). Due to its role in B12's metabolic pathway, it's actually more sensitive for B12 deficiency than B12 itself. You can see a normal serum B12 in people who are metabolically deficient in it, but the MMA nails it.

I order the MMA level. Of course, Medicare, with guidelines written during the Nixon administration, doesn't recognize it as a valid part of a neuropathy work-up. Yeah, craploads of medical research since the late 80's say otherwise, but who am I to argue with the Medicare rule book?

"Damnit, Jim, I'm a doctor, not a Medicare desk jockey."

So I order the methylmalonic acid anyway. Why? Because my job is to correctly diagnose the patient.

The bill for the MMA level gets sent to insurance, where it's screened by some of the last functioning TRS-80's left on Earth. Their programming sees "MMA level ordered for neuropathy. Test not needed per our guidelines. REJECT!"

The lab doesn't get paid for the MMA. They'll now send me a note asking for any more diagnoses that might get it covered.

So, in my 15 seconds of free time each day, I crack open the chart and fill out the form with EVERYTHING the patient has (hypertension, migraines, halitosis, genital herpes, 1948 exposure to mumps) hoping one of them will somehow get it to pass through the TRS-80's scanning on the 2nd try.

Sometimes it does, and we all live happily ever after. Other times it doesn't, the patient gets a bill, and calls my office.

Now Annie will usually take a crack at it, calling the lab and consulting a Ouija Board to see if we can find anything else going on with the patient that might get it paid for. I sign off on it, and we submit it for the 3rd go-round. I'd say this works maybe half the time. The rest of them... the patient gets another bill.

Some people recognize that healthcare isn't free, and that I'm doing my best to care for them. They pay their bill. Others, however, go apeshit and call to scream at us.

They demand I find a way to make their insurance pay it, even if it means fraudulently changing the ICD codes (nope). Or that I pay it myself (nope). Some of them even threaten me:


"Get this paid for, OR ELSE!"

"If this isn't paid, I'm complaining to the state medical board."

 "This needs to be covered, or you'll hear from my lawyer."



Because now it's MY fault that I'm trying to provide decent care.

What's really irritating is that these same people screaming about me ordering a test they now don't want to pay for... would also be the first ones in line to sue me if I didn't order it and missed the correct diagnosis. I try to be thorough, and want to figure out what's wrong with you. Plus, in the sad calculus of modern medicine, my fear of being sued trumps your wallet every time.


My office's best attempts failed. Now what happens?

The patient, like everyone else out there with bills, has to either pay them or go to collections. I did my best to help. I'm not going to practice second-rate medicine and risk missing something. They don't have to get the tests, but once they've signed off on the lab form and had them drawn, it's their responsibility. Some of these labs are hundreds to even a few thousand dollars, and they're being asked to pay for, say, $89.46 on labs that totaled $1015.58 (yeah, that's from a recent one that crossed my desk). I'm going to point out that's less than 10% of the total charge.

If you go to Target for a ginormous $900 TV, and they sold it to you for $80, you'd be thrilled. But in medicine? You go bananas that it isn't free.

"$79.99, and it wasn't even Black Friday."

Once my two appeals to get it covered have failed, I'm done. I did my best. I also remind myself that, even if I do find a way to get you out of paying for them... it means everyone else (including me) is.

My sympathy on this issue has run out. I'm tired of people demanding I care for them, then not wanting to pay their fair share of the costs. If I DIDN'T order these tests, and missed something, they'd come back and sue me. But if I do order them they whine.

My view has become it's their decision to have them or not. It's a tax deduction if they want to see it that way, but healthcare is NOT FREE. Someone is paying for it, even if it's not the patient. Everything that gets covered by insurance is passed on to the rest of us in the form of higher co-pays and premiums.

Providing competent medical care is not something you can sometimes do well and other times do a half-assed job on. You either go big or go home, so I choose to go big. The same applies to the patient. If you want an incomplete work-up, that's fine, but don't go wailing when something was missed because you refused testing. By the same token don't expect quality care to be free.

You get what you pay for.

Mary's desk

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

Mrs. Grate: "I need to make an appointment with Dr. Darth."

Mary: "I'm sorry, you've got the wrong office. This is Dr. Grumpy's."

Mrs. Grate: "Okay, but I'd like to see Dr. Darth. Does he have anything open on Thursday?"

Mary: "Dr. Darth is across the street, you'll have to call his office. Let me give you their number."

Mrs. Grate: "If you have the number, can you please call them? I'd like something for Thursday, preferably in the afternoon."

Mary: "Ma'am, I can't make an appointment for you at another neurologist's office. I don't know what their schedule is, or what insurances they take, or their hours..."

Mrs. Grate: "You young people have never heard of customer service."

click

Seen in a chart

Thank you, K!

Google

Yesterday morning Craig was up early and trying to cook pearl barley for breakfast (no, I have no idea why, considering we have a pantry full of instant oatmeal). So, in the enterprising nature of modern life, he grabbed an iPad to ask Google how to cook pearl barley. As he typed some suggestions came up:

He woke me up (it was my day off, thanks Craig) laughing at this screen.

Drug addicts: I'm not sure microwaving urine will destroy whatever's in it, but it will give it that toasty "fresh from the bladder" warmth. Don't put it in for too long, or your parole officer will wonder why your urinary tract operates on the Kelvin scale. It will also make your kitchen and microwave stink (attention readers: do not try this at home).

For the record, when Craig discovered it took > 1 minute to microwave barley he decided on instant oatmeal.

I didn't even try to go back to bed.

Starry Starry Night

Last night Snowball somehow managed to knock over his allegedly spill-proof dog chow bowl (he's good at that sort of thing).

Anyway, while I was cleaning it up, I noticed how some had landed:

For those who don't recognize it :

Memories...

Back when I was interviewing for medical school in the mid-80's, I had one interview that was just an in & out same-day trip, with a 1 hour flight each way. So I wore my suit and went to the airport with just my wallet, plane ticket, and keys.

My dad, working in his unofficial capacity as the family travel agent, had found me a cheap ticket on Etohair. This airline (now long defunct) had the interesting approach of unlimited alcohol for all. So, being a Diet Coke and rum aficionado, and a poor college student, and hosting a party that weekend, I pretty much kept asking for another rum & DC at 5 minute intervals and pocketing the little bottles. The flight attendant knew what I was doing, but it's not like anyone else was different. No wonder they folded.

Anyway, after landing I caught a cab to the med school and stopped off in their lobby bathroom.

Looking in the mirror there, I suddenly noticed that my suit pockets were all bulging with little bottles that made it look like I'd been shoplifting. Having a fuck-ton of rum stuffed in your pockets, I realized, was not going to be conducive to a good impression for a guy hoping to become a future doctor.

I stood there, in a public bathroom in the medical school lobby, frantically trying to think. I had no bag to put it in. I didn't want to throw it away, either.

The janitor came in, wondered why I was taking so long to wash my hands, grabbed some toilet paper rolls out of a supply closet, and left.

And suddenly, I had an idea. Hoping no one else came in, I frantically yanked 20 rolls of toilet paper off the closet shelf, piled all the rum in the back, and put the TP in front of it.

I went on with my interview, wondering if the janitor was going to have a wild party at his place that night with my bottles.

After the last interview I ran in there, hoping not to miss my flight.

To my horror, the supply closet door was locked.

Using a credit card and my car key I managed to get it open. As I dug through toilet paper rolls for the rum, the school's dean (who I'd just interviewed with) wandered in, looked at me, and asked if I needed anything.

I mumbled "the stall was out of paper," grabbed a roll, and shut myself in the toilet area. I waited with bated breath while he peed and left (didn't wash his hands, either). Quickly grabbing my precious rum, I was still stuffing it in my pockets as I ran out to hail a cab.

I made my flight. Barely.

My roommate and I had a great party that weekend. We didn't run out of rum.

I was accepted at that school.

Annie's desk

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

Mr. Call: "Hi, I just got a letter that my Snotziva-XR pills won't be covered starting next week, on the first."

Annie: "Yeah, we got the same fax. I already sent in the form requesting an override for your case."

Mr. Call: "But how long will that take to get reviewed?"

Annie: "Well, it says 10 days, and last year it took... let me see... exactly 10 days for the same thing. So I'll guess 10 days until we have the override."

Mr. Call: "But the 1st is five days away!"

Annie: "But you just called for a refill last week, looks like we approved it."

Mr. Call: "You did, I picked it up. It was for 30 pills."

Annie: "Okay, so you've got enough for a month. We'll have it cleared before then."

Mr. Call: "But what do I do on the 1st?!!! If it's not covered, don't I have to stop taking it?"

Annie: "No, take the ones you just refilled."

Mr. Call: "Am I allowed to do that? I won't get in trouble?"

Annie: "Um, no. You'll be fine."

Mr. Call: "But it says they're not covered after the 1st. They don't send a repo-man to take the pills back?"

Annie: "No, I promise."

Mr. Call: "Oh, good. I was really worried they'd come for the bottle."

Ockham must be horrified

Seen in a chart, from the "throw stuff at the wall and see what sticks" school of differential diagnosis:

Dragon gone bad

On rounds yesterday I encountered a urologist in the doctor's lounge, laughing hysterically as he proofed his dictations (done by the hospital's Dragon system).

His sentence “due to ejaculatory problems he runs into issues during intercourse.”

Had been changed to  “due to ejaculatory problems he runs into her shoes during intercourse.”

I cracked up, too.

Another round for my staff

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

Mrs. Lost: "Hi, I'm here at the pharmacy, and my prescription isn't ready."

Annie: "Really? I called it in last night. You're at the Walgreen's, at 5th & Hamilton?"

Mrs. Lost: "I think so."


In background:

Mrs. Lost: "Hey, is this the Walgreen's on 5th and Hamilton?"

Male voice: "No, this is the CVS at 5th & Hamilton. The Walgreen's is across the street."


Mrs. Lost: "No, it's not here."

Annie: "Well, didn't I just hear someone tell you it's at the store across the street? You're in the wrong drugstore."

Mrs. Lost: "I guess so. Can you call and tell them to have someone carry it over here?"

Annie: "No. You'll need to go get it. You're in the wrong store."

Mrs. Lost: "But it might start snowing any minute now. I saw that on the weather."

Annie: "You can drive across the street."

Mrs. Lost: "But then I have to walk to my car."

Annie: "How far away is your car?"

Mrs. Lost: "It's at the Walgreen's across the street. The CVS didn't have any open parking spaces."

"Wadda ya want, I'm tired."

Seen in a hospital room:

"It's not like anyone actually reads them."

Thank you, W!

Monday reruns

I've always liked the Muppets. One of my favorite songs is "Rainbow Connection," as performed by Kermit at the beginning of their first movie.

For those of you who don't know it:





Anyway, it may be corny, but the song got me through some shitty times. After I failed the first anatomy test in medical school (big time, too- I was the class low out of 120 people) I went to a used record store and bought the Muppet Movie soundtrack just to listen to that song. In a sappy sort of way it reminded me of why I was there in the first place, and I pulled my shit together, didn't drop out of school, and forged ahead.

Life goes on. Medicine is still fun. I mean, I like what I do. I have to earn a living, so I might as well be doing something I like.

And then, one day a few years back, I was having an ordinary day at the office. And toward the end of it was served with my first malpractice suit.

Nothing will kick the shit out of you faster than that moment. Yes medical students and residents, you WILL get sued. Get used to it. Someone on Sermo recently wrote "I have believed for a long time that unless you are practicing grossly negligent medicine your probability of getting sued is small." This is a remarkably ignorant statement.

Getting sued is like cancer- something that happens to other people. I think all doctors, on a superficial level, know it will likely happen. But you're still blindsided when it happens to you.

Obviously, I'm not going to go into legal details of the case, or who won, or even if it was dismissed. Because none of those are relevant to this post.

And I'm sure there are plenty of patients out there who can write how horrible Dr. Butcher maimed you. I'm sure some of you have legitimate claims. But I'm not writing about you.

Malpractice isn't black or white. It's really mostly shades of gray. I'm not biased against lawyers, in fact- my Dad is one, and sued several doctors for malpractice. But I'm not going to get involved in arguments about lawyers vs. doctors, either.

My point is just my own experience.

People portray doctors as being arrogant or uncaring. And I'm sure some are. But anytime a case goes bad, it's personally devastating for most of us. Even if you did nothing wrong. Sometimes shit happens despite your best efforts.

It hurts. A lot. You do your best day in and day out, and feel awful when things go wrong. And now someone is accusing you of having committed malpractice in your efforts. They tell you not to take it personally, but how can you not? Hell, they even name your spouse in the suit (really, they do).

You may be absolutely right. The literature may back you up completely. But that often doesn't matter.

You see, there is always another doctor out there willing to testify in court (for a nice fee, of course) that what you did wasn't appropriate. He's Dr. Jukebox. You put in money and he'll play whatever tune they want him to (it pays a lot better than seeing patients). The statements from these whores will make you feel like shit, and the legal language used makes you sound on a par with Dr. Mengele.

No amount of medical competence can prevent someone from filing a lawsuit against you. Even if you did nothing wrong, there's always a hungry lawyer willing to take the case. After all, it only costs about $100 to file a suit, the potential payoff is 1/3 of the winnings, and he knows a Dr. Jukebox who will gladly testify that you're incompetent.

Your medical school teachers won't tell you what it's like to be sued, but I will.

It's devastating.

It kicks the shit out of you. You lie awake at night wondering if you're going to lose everything you ever worked for. You cry. You think about suicide, but have to go on for your family. With this sword of Damocles hanging over your head, you still have to go to work every day, and do your best for the patients who still depend on you. Some days it's pretty damn hard NOT to start drinking.

And, deep down, you wonder: Am I really incompetent? You question your own judgment. Suddenly every headache patient needs a brain MRI. Every person you see is a time bomb. You start to view them as the enemy.

People use the phrase "defensive medicine" in a derogatory fashion, meaning unnecessary testing doctors order to prevent themselves from being sued. But after it's happened to you, hell, you don't give a fuck how much money the "unnecessary" tests cost. You'll order anything to cover your ass.

And no matter what you did, Dr. Jukebox will testify that it wasn't the right thing. And no amount of literature in your favor will change his "expert" (i.e. well-paid) opinion. The people on the jury deciding your fate aren't medical people.

Even if you win, it still doesn't take away the living hell you and your family are put through for the 3-5 years (yes, years) it takes the case to play out. The sleepless nights, the gray hairs, the stress eating that shortens your time on Earth, and the spouse and kids who worry about you.

And, regardless of the case's outcome, it will forever destroy your Rainbow Connection, and the beliefs that once drove you to dream of being a doctor.

It's complicated

Dr. Grumpy: "How are you doing? It's been about a year since your last appointment."

Mr. Optimist: "Going okay. I've met a great girl, and this could be the one. I mean, she threw me and my stuff out of her apartment and called the police on me last week, and I had to live in my car for a few days until I could find a new place, but I think this is part of the road to a stronger relationship."