Happy Halloween!

With the costume party season upon us, I'd like to remind everyone of what was probably the single greatest newspaper headline ever.

Six Degrees

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

Mr. Bacon: "Hi, Dr. Grumpy, I need to get in to see Dr. Needle urgently, and she's booked out for 3 months. I was hoping you could call her office and ask them to work me in?"

Dr. Grumpy: "Did I refer you there? Are you one of my patients? I'm not finding you in the system."

Mr. Bacon: "No, but I'm a friend of one of your patients, Heddy Paine."

Dr. Grumpy: "Look, I really can't help you... She's not in the system either."

Mr. Bacon: "Well, she says she saw you a year or two ago. She was visiting her uncle in the hospital, and says you were talking to a nurse outside the room of the patient next door."

Thud

Dr. Grumpy: "So... this visit is to follow-up on how you're doing with the medication - Fliniberzap - that I prescribed about a month ago."

Ms. Headdesk: "Yeah."

Dr Grumpy: "It's been a month, so how are you doing?"

Ms. Headdesk: "I'm not any better... I mean, I filled the scrip, but then I left it in a rental car and returned the car."

Pause

Dr. Grumpy: "So you haven't started it?"

Ms. Headesk: "Not really, I mean... no."

Dr. Grumpy: "Why didn't you just call so we could send a new script in?"

Ms. Headdesk: "I left your phone number in the car, too."

Touché

Mary: "Okay, Mrs. Humor, I have your follow-up down for next Tuesday, at 8:15 a.m. I should warn you that Wednesday's test of the national Emergency Alert System activated our microchips and turned Dr. Grumpy and all of the staff here into zombies."

Mrs. Humor: "Like anyone would notice."

FML

 Current insurance company hold music is an endless loop of "O Fortuna."

Stayin' Alive

My 11:00 patient, while we were talking at my desk, took cans of Red Bull and beer from his backpack, mixed them together in an empty water bottle, and is drinking it.

Sunday morning, 5:58 a.m.

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

Ms. Simon-Bond: "Hi, Dr. Grumpy... there's a dead cat on my back patio."

Pause

Dr. Grumpy: "Why are you calling me?"

Ms. Simon-Bond: "I... I guess because I didn't know what to do about it."

Pause

Dr. Grumpy: "I didn't know you had a cat."

Ms. Simon-Bond: "I don't... I don't know whose cat it is."

Dr. Grumpy: "Okay, this really isn't something I can help you with, or even a reason to call me."

Ms. Simon-Bond: "My internist said the same thing."

Your EHR is making you look stupid

EHR (or EMR) is the generic name given to the various medical chart systems that have been crammed down our throats. Most are worthless.

The problem is that they're primarily designed to meet regulation-required "quality metrics," to show that we told someone to quit smoking, wear a seatbelt, or take prenatal vitamins regardless of whether the patient is a 6 month old infant, 28 year old guy, or 97 year old woman. Because, you know, those things are for more important then talking about the patient's chest pain or new-onset hemiparesis.

As a result, the EHR's are full of horseshit that tell you absolutely nothing about the patient that  relates to, say, WHY THEY CAME TO THE DOCTOR.

When I was in training I was taught that, within the SOAP format (subjective, objective, assessment, plan) your note should tell a story of sorts: what's happened to the patient, what do you think it all means, and what are you going to do about it. It should be written so that the other doctors involved in the person's care can understand what you're thinking and doing. It also should be that way so you can pick up the thread when the patient returns.

That, sadly, isn't the case anymore. Now a note is just a string of vital signs, discontinued prescriptions, the same family history that's in every previous note in the chart, cut & pasted test results (some going back years and completely irrelevant now) and boxes that have either been checked or unchecked.

Physical exam, for example. To describe the tongue, most neurologists include it in a stock phrase like "Cranial Nerves II-XII are normal." If something isn't normal, most ad an "except for..." or "with the exception of..." and go on to describe the issue.

Of course "normal" isn't good enough for an EHR. Neither is "intact," "unremarkable," or "within normal limits." You have to have computer-generated shit like this:

After all, why use one word when 36 will do?

Here's another example. It's no longer enough to just put something like "family history is unknown" (you often hear that in the adopted) You need a whole, stupid, repetitive, idiotic, PARAGRAPH to say that:

Then there's horseshit like this. Although labeled as "Previous Therapy" it doesn't even mention therapy, just a nonsensical sentence:

 

 

Or similar gibberish which basically says "we didn't do any of this, we aren't sure why we did or didn't, but it met some quality measurement goal so it doesn't matter."

 

Then there are things that are just plain ridiculous, like this:

Or this:

This doesn't exactly inspire confidence, either:

 

Or this strange complaint:

 

On that note I think I'll save the rest of my bad EHR excerpts for another day. Fortunately or unfortunately, I doubt I'll be running out of them any time soon.

Keep the party going

Demented Church Lady: "I can't believe you and my kids won't let me drive! All of you are going to hell for this!"

Dr. Grumpy: "Okay,  at least I can go to the Jimmy Buffet concerts."

Her daughter nodded and gave me a fist bump.

Phrase

 If this guy doesn't stop saying "I don't know, you know?" I may have to throttle him.

Thank you for the music

"Some of it's magic,

Some of it's tragic,

But I had a good life all the way."

 

Goodbye, Jimmy. Thank you.

'Murica

 1:00 patient called me a "Pinko Jew." What a country.

Hard at work

Your hero, Dr. Grumpy, is (along with a lot of other docs) certified by the American Board of Psychiatry and Neurology (ABPN).

You can be certified in either or both (I have no idea why anyone would want both).

All of us neurologists and psychiatrists pay the board a hefty amount to stay certified. It's a few hundred bucks a year, and every 10 years it's a few thousand more to prepare for and take a written test to maintain certification. This is in addition to all the continuing medical education required.

What the ABPN does with this money, besides writing new test questions and issuing certificates, I have no idea. But, in a recent newsletter I received, it was nice to see that the money is being put to good use:

Show and tell

My 11:00 brought a friend to the visit, who was silent for most of it.

Dr. Grumpy: "Okay, Annie will get your tests set up... do you have any questions?"

Ms. Patient: "No. It sounds like a good plan."

Ms. Friend: "I have a question, I, um , had surgery on my coochie last month, and am worried that the scars aren't going to heal..." she stands up, drops pants "do you think those will go away?"