He's dead, Jim

This question came up on a survey last night (PD = Parkinson's Disease):

I really love the 5th answer. In all honesty, I can't recall ever having received a patient referral from a pathologist.

Which is probably good.

Department of the Obvious

Actual headline this afternoon in USA Today:

Thank you, SMOD!

Tuesday afternoon

Mary: "I can't believe it's this empty."

Dr. Grumpy: "Maybe because it's summer."

Mary: "The phone is barely ringing this afternoon."

Dr. Grumpy: "You should start calling people."

Mary: "Who should I call?"

Dr. Grumpy: "I don't know. Just get out an old phone directory, and start randomly calling people. Tell them they have an appointment tomorrow."

Mary: "Yeah, right. Who's going to believe that?"

Dr. Grumpy: "When they say you have a wrong number, tell them they were referred for memory loss."

IT'S A MIRACLE! HALLELUJAH!

Dr. Grumpy: "What can I do for you, sir?"

Mr. Wheelchair: "My legs are completely paralyzed! I can't walk!"

Dr. Grumpy: "How long has this been going on?"

Mr. Wheelchair: "2 months, and no one can find a cause for it."

Dr. Grumpy: "Do you..."

(patient's cell phone rings, and he looks at it)

Mr. Wheelchair: "Hang on, doc, I have to take this. Let me step out."

(Gets out of wheelchair, walks out to lobby, mumbles into phone for a minute, hangs up, comes back and sits in wheelchair)

Mr. Wheelchair: "Anyway, they tell me there's nothing wrong with me, and that my tests are normal. It's very frustrating, because I can't move my legs at all, and..."

Thank you for this interesting consult

Actual chart note I saw on Friday:


"Patient has history of Alzheimer's disease. Currently has obvious memory deficits. Will consult neurology to see if they can find a cause for his memory loss."

Broadcast journalism

Yes, folks, this actually aired today on California TV station KTVU.






They've since apologized, and both they and the NTSB are blaming the error on an unidentified "summer intern."

Patient quote of the day

From a retired surgeon:

"I had surgery for osteomyelitis as a kid. We didn't have all that fancy antibiotic shit they do now."

Fun with Mary

Sometimes an annoying patient won't take no for an answer.


Mr. Pest: "So, Mary, can we get together this Saturday?"

Mary: "No, thank you. I have plans."

Mr. Pest: "Come on... we'll have fun."

Mary: "I'm not interested, sir. I have a boyfriend."

Mr. Pest: "You could still go out with me."

Mary: "Okay, how about you and I take a drive over to Southtown this weekend? Could you pick me up?"

Mr. Pest: "Sure, but Southtown? By the prison? That's a terrible area. Why do you want to go there?"

Mary: "My boyfriend needs a ride home. He's being released on parole."

Mrs. Grumpy agrees

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

Nurse Newbie: "Hi, I'm the nurse taking care of Mr. Harry Plegia, in room 842."

Dr. Grumpy: "What can I do for you?"

Nurse Newbie: "Well, there was a consult written for you to see the patient 3 days ago, and we never heard back from you. I was wondering if you'd even gotten it, and when you'd be by to see him?"

Dr. Grumpy: "Um... I did the consult 3 days ago. And I've been following him daily since then."

Nurse Newbie: "Really? Because there was a family member here about 2 hours ago, who was looking through the chart, and told me he wanted to get another MRI. I don't know how he got the chart. Anyway, I called the hospitalist, and he told me to run it by you."

Dr. Grumpy: "Two hours ago? That was me! I came over and told you I wanted to do another MRI, but the computer ordering system was down when I tried to put it in."

Nurse Newbie: "That was you? Not a family member?"

Dr. Grumpy: "Yes!"

(pause)

Nurse Newbie: "Doctor, you really should dress better."

Pulp

Miss Print: "Hello, Throwaway Rags, can I help you?"

Dr. Grumpy: "This is Dr. Ibee Grumpy. You guys shipped me a huge box of magazines for my lobby."

Miss Print: "Let me see. Yes, you're on our list to receive 50 copies a month."

Dr. Grumpy: "I didn't order them, and I don't want them. Please take me off the list."

Miss Print: "Have you looked through our magazine?"

Dr. Grumpy: "Yes. It's 90% paid advertising, extolling the virtues of Wirth-Liss Pharmaceuticals overpriced medications."

Miss Print: "Well, Wirth-Liss Pharmaceuticals is paying for every neurologist to receive 50 free copies to share with your patients. Education is important. You can place them in your lobby."

Dr. Grumpy: "I don't want them in my lobby. I put them in the recycling. And I don't want to get anymore."

Miss Print: "You're depriving your patients of an opportunity to learn about their treatment options."

Dr. Grumpy: "I'm not going to argue with you. Either cancel my subscription, or let me talk to your supervisor."

Miss Print: "I'll cancel it. But you're really doing a disservice to your patients. They deserve better."

Phonetics

In the mid-2000's there were several government hearings concerning the safety of the COX-2 family of drugs (Vioxx, Bextra, and Celebrex).

A colleague of mine was working for the FDA at the time, and had to sit through hours of testimony on them. He sent me this remarkable e-mail after one:

"Today we had a military doc testify. He told us that the drugs are important in military use, because they can get injured soldiers back into battle sooner.

"He finished his speech by declaring 'Soldiers need COX-2!'

"And that just doesn't sound good when spoken."

Great copywriting moments

"Maybe an orthopedist would be better?"

Source: Here.


Thank you, M!

Footprint?

I'm not sure what to make of this.

This fan-shaped area of flattened grass wasn't there when we left yesterday morning, but it was definitely there when we got home late afternoon. It looks like a giant footprint:

Mello investigates

Anyway, if your pet therapod has escaped somewhere in Grumpyville, I think it was in my backyard today. Hope that helps.

Thank you for sharing

Mary: "Okay, I'll let Dr. Grumpy know you're here, and he'll take you back in just a minute."

Mrs. Knickers: "Do you have a bathroom I can use first?"

Mary: "Sure, it's that door to your left."

Mrs. Knickers: "I need to change my underwear. You wouldn't believe the drive I had here."

Fiat lux

Dr. Grumpy: "Let's go to my exam room..." (walks into exam room, flips on lights)

Mrs. Photic: "OH MY GOD! DID THE LIGHTS JUST FLICKER?!!!"

Dr. Grumpy: "Uh, I think so, when I turned them on. They're fluorescent."

Mrs. Photic: "THIS MEANS SOMETHING!"

Dr. Grumpy: "Everything is fine, ma'am. It only means they're on. Have a seat over there, and let me take your blood pressure.."

Mrs. Photic: "They're not going to flicker again, are they?"

Dr. Grumpy: "I don't think so, but they're old fixtures."

Mrs. Photic: "If they do, I'm leaving. For all I know you're one of them."

Um, okay, you can call it that

Frank & Craig were at sailing camp on Lake Grumpy yesterday.

This picture was in the "Sailing Instructions" pamphlet they were given.

Immature? Why yes, I am!

History reruns

June 30, 1908.

One of the most remarkable events in history happened on this date. And it's mostly forgotten.

At 7:14 a.m. a MASSIVE explosion occurred near the Tunguska river in Russia. I'm not exaggerating. The force was somewhere between 5-30 megatons. Think about that: an explosion between 150 to 1000 TIMES the power of the Hiroshima nuclear bomb. And it happened 37 years before the nuclear age began.

And, purely by chance, it happened in a fairly uninhabited part of the Earth.

To this day its exact cause is unknown, and it's simply called "The Tunguska Event." It's generally believed to have been a meteorite or comet that exploded before hitting the ground.

The shock wave it sent through the ground was a 5.0 on the Richter scale. Every tree in an 8 km (5 mile) radius from the center was killed, and the force of the explosion covered a total of 830 square miles (2,130 square km). An estimated 80 million trees were knocked over by the force- all of them pointing away from the center. A few were left standing, scorched black, with all their branches stripped off. People were knocked off their feet, and windows shattered, hundreds of miles away. The pressure wave was measured as far away as England. For the next several months there was a change in the density of the planet's upper atmosphere.

An eyewitness 40 miles south of the explosion, reported that "At breakfast time I was sitting by the house at Vanavara Trading Post, facing north. I suddenly saw that directly to the north, over Onkoul's Tunguska Road, the sky split in two and fire appeared high and wide over the forest. The split in the sky grew larger, and the entire northern side was covered with fire. At that moment I became so hot that I couldn't bear it, as if my shirt was on fire; from the northern side, where the fire was, came strong heat. I wanted to tear off my shirt and throw it down, but then the sky shut closed, and a strong thump sounded, and I was thrown a few yards. I lost my senses for a moment, but then my wife ran out and led me to the house. After that such noise came, as if rocks were falling or cannons were firing, the earth shook, and when I was on the ground, I pressed my head down, fearing rocks would smash it. When the sky opened up, hot wind raced between the houses, like from cannons, which left traces in the ground like pathways, and it damaged crops. Later we saw that many windows were shattered, and in the barn the iron lock had snapped."

There have been other impacts in recorded history, but none this powerful. And, over 100 years later, the scars are still there.



1921: 13 years after the event.







2008: 100 years after the event.


And, just remember: we live in a solar system full of flying objects.

Dear Mrs. Soda,

Please do not leave a message that you changed your mind and want to take a medication.

And, when we call you back 20 minutes later, say that you changed your mind again and now you don't want anything.

Then call just after closing to say you've changed your mind again, and would like me to call something in.

And not have a pharmacy number, or even know what pharmacy you want it called too, when I dial you back.

Then yell at me for not knowing which pharmacy accepts your insurance.

The guilt is strong with this one

It's 4:00. A guy comes in, stands at the counter.

Mary: "Can I help you?"

Guy: "Um... Yeah, I had an appointment today at 1:00, and I got called into work, and called you at around 9:00 to cancel it."

Mary: "Yes... I see that on the schedule. Did you need to reschedule?"

Guy: "I'm not sure... I mean, you're not angry at me, are you?"

Mary: "Uh, no, these things happen."

Guy: "Okay, I've been really worried about that. Thanks!"

(leaves)

Lalataw

I saw this in a hospital chart note this morning:

No, I have no idea what it means.

I've never heard of Lalataw. And I don't know why someone would, or wouldn't, want to be active in it.

Or what it has to to do with a stable guy admitted for a headache, anyway.

No fireworks

Sorry, people.

For all those writing in wanting to know what happened with Mrs 9:30, the answer is... nothing.

After getting off the phone with Mary that afternoon she looked at my office website, and realized just who the male receptionist was.

She called back and cancelled the appointment, then went to a doctor-rating site and wrote a scathing review of me and the appointment that never happened. I suspect she broke her caps-lock key in the process.

Don't ask

Dr. Grumpy: "What was your last hemoglobin A1c?"

Mr. Insulin: "7.1."

Lady Insulin: "Was it? I thought it was 8.2?"

Mr. Insulin: "No, Dr. Endocrine said it was 7.1 at my appointment last week."

Lady Insulin: "That was my appointment. Yours was in March."

Mr. Insulin: "I thought your A1c was 7.9 in March?"

Lady Insulin: "No, that was your appointment."

Mr. Insulin: "Mine was 7.1. You put it in your phone."

Lady Insulin: "I thought you put it in your phone?"

Mr. Insulin: "Why would I put yours in my phone?"

Lady Insulin: (takes out a phone) "Whose phone is this, anyway?"

Mr. Insulin: "I think the 8.2 was Sylvia's. She mentioned it at dinner last night."

Lady Insulin: "Dr. Grumpy, can you call Dr. Endocrine for us?"

We're gonna turn it on. We're gonna bring you the power.

Holy crap! Is that Morgan Freeman?

For those of you who absolutely can't bear to lose at videogames, you now have a new way to win.

For only $249 the company FOC.US is selling a headset that will run an electric current through your brain (specifically, the prefrontal cortex). Their website says it will "increase the plasticity of your brain. Make your synapses fire faster." They're marketing it as a way to improve your videogame skills for the "ultimate gaming experience."

Really.

It also comes with an iPhone app to control your jolts. And it's in your choice of red or black.

"Now I can kick my boyfriend's ass at Call of Duty."

Now, I'm not going to knock the uses of electrical brain stimulation. This is an area that's currently undergoing a lot of research as a way to treat disease and help people recover from strokes and other causes of brain damage.

But, on the other hand, let's keep a few things in mind:

1. This is electricity, for fuck's sake. It's dangerous.

2. We used to execute people with this.

3. If winning at Halo is that important, you need to get out more.

I'm sure people from FOC.US will point out that their gadget uses a low level of juice, which isn't going to hurt you (on the other hand, I have no idea if it will help. The last video game I mastered was Atari Adventure).

I have to be a bit skeptical about its benefits. I mean, the internet is full of people selling herbs, magnets, and who knows what else as ways to improve your performance at work, the gym, and in bed. Most have nothing more behind them than some half-assed data and anecdotal claims. While I think the jury is still out on cortical electricity, that doesn't make their claims true.

Another issue is that for many people, after you've plunked down a boatload of money for a game system, they don't have $249 to blow on this gadget. So what do they do?

Well, according to a recent editorial in Nature there's concern that people will start doing this as a do-it-yourself project. You could wire up with some batteries at home, or whatever you can find in the garage. There are even companies selling DIY kits for it online. This is where I think the editorial has its best line:

"That’s ‘could’ as in ‘you might be able to’, by the way; not ‘could’ as in ‘it’s a good idea’."

Granted, that's never stopped anyone from doing stupid stuff. Bigger, in the general perception, must be better. If a little battery can improve your score, then shouldn't plugging into your home's AC current be great? By the time you're playing an X-Box hopefully your parents have pulled those plastic things from the outlets that kept you from sticking a fork in them. The target audience here isn't known for being averse to risk.

What could possibly go wrong?

"Mario and Luigi, here I come!"

I also have to worry about how far this could go. What if electricity does clearly improve brain performance? Can't you just see pushy parents wanting to plug their kids in to get a better SAT score? Or a med school gunner wearing some shockware into a test, disguised as earplugs?

This could end up as the academic equivalent of athletic steroids. The next cheating scandal could be some guy tossed out of a math competition for illegal wiring.

Lance was stripped of his high school math letters when it came out he'd been "volting."

So, in closing, my point is this: low-level trans-cortical electrical may have medical utility (personally, I suspect it does). But if that "may" makes you want to shell out more money just to beat your brother at Grand Theft Auto V, then I've got some buildings in Rungholt to sell you.

"Superman warned me the electrodes would do this. Why didn't I listen?"

Thank you, SMOD!

Hazards of "V" and "C" being next to each other on the keyboard

Thank you, M!

"I'd like to buy a comma, Pat."

What are "heart joints?"

"I don't remember those from Netter."

Excuses

"Well, officer, I was in a hurry to get home and start waxing it."

Why I call him that

Drug rep: "Hi, Dr. Pissy. Lunch today is from Dave's Deli."

Dr. Pissy: "Dave's Deli? Why? What did I ever do to you?"

Ooooh! Fireworks!

Yesterday Mary had to take her kids to an early dentist appointment, and wasn't able to get here until 10:00. Annie was stuck in traffic, so I took over the front desk since the first patient, a new one, was scheduled for 9:00.

The patient showed up at 9:30, WAY too late (in my opinion) to try and see a new patient. So I told her she'd have to reschedule. She wasn't happy about it, and asked to see a different doctor, or a PA or NP. I told her we don't have anyone else, and so she finally rescheduled to next Tuesday.

Later in the afternoon:

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

Mrs. 9:30: "Yeah, I had an appointment this morning, and had to reschedule it to next week."

Mary: "Yes?"

Mrs. 9:30: "I just want to complain. The male receptionist who was working this morning wouldn't let me see the doctor. I didn't like that at all."

Mary: "Male receptionist... Oh, that was..."

Mrs. 9:30: "I don't care what his name was. The doctor needs to know his staff is turning patients away. Even if they show up late, it's still inappropriate. My time is valuable."

(long pause)

Mary: "The doctor is aware of what happened."

Mrs. 9:30: "Good. Because I want to be sure to tell him about that guy at my appointment."

Mary: "You'll definitely have the opportunity."

Looking forward to Tuesday!

The joy of Dragon

Seen in a hospital note while on-call this past weekend:

And no, I have absolutely NFC what they meant to say.

Never a dull moment

On Friday we had an unusually exciting afternoon.

A sweet octogenarian waiting for her appointment suddenly developed chest pain and shortness of breath in the lobby.

Mary, knowing how good Pissy and I are at handling REAL medical emergencies, immediately called 911. I'd run over to the hospital for a minute, and so the staff got him to check her blood pressure and hold her hand until paramedics arrived.

By the time I returned paramedics were loading her onto a stretcher to go to ER.

She immediately grabbed my hand and said "Dr. Grumpy, I'm so glad to see you. Before I leave could you get me more samples of Nomohurtz? It seems to be helping."

In days of yore...

Thank you, Ms. Donna!

Sigh

Local hospital decided last week to re-paint the "Reserved Doctor" parking spaces in the front lot.

Mary's desk

Mrs. Damadian: "Hello?"

Mary: "Hi, Mrs. Damadian. This is Mary, at Dr. Grumpy's office."

Mrs. Damadian: "Yes?"

Mary: "We got your MRI report in - the doctor says it's fine - so I'm calling to make an appointment for you guys to discuss your treatment plan."

Mrs. Damadian: "How did he get it?"

Mary: "Well, he said it was fine, but..."

Mrs. Damadian: "I don't care what it showed. I want to know how he got the report."

Mary: "What do you mean?"

Mrs. Damadian: "Did a courier bring it? Or was it faxed to him? Or mailed? Or e-mailed? Or did a radiologist call him? Or did he look it up online?"

Mary: "I believe he looks them up, but it depends on..."

Mrs. Damadian: "This is stupid. I can't believe you don't know. Why don't you find out, then you can call me back and we'll discuss me making an appointment."

(hangs up)

Once upon a time

Wirth-Liss Phramaceuticals makes a hideously expensive drug that has to be administered once a month at the doctor's office. The patient co-pay on most plans is anywhere from $50 a month and up (granted, that's cheap compared to what the insurance company is paying for the rest).

So Wirth-Liss came up with a patient assistance program, where the patient gets $600/year covered by the insurance company, to help lessen the cost burden. Their idea was that this way more patients could afford the drug, so more doctors would order it. I can see the logic.

But the implementation left much to be desired.

Some company genius, with apparently no grasp of reality or human nature, decided the best way to do this was to send every person who qualified for the plan a prepaid credit card with $600 on it. The idea was that Mr. Patient would hand it to the doctor's staff at each visit, it would be swiped for $50 each time, and at the end of the year the card would be empty.

Unfortunately, it didn't occur to them to lock-out the accounts so that they could only be used at a doctor's office...

Basically, they sent patients pre-paid giftcards with $600 on them.

Of course, given human nature, most patients saw this as a windfall, and went on spending sprees. They bought groceries, beer, clothes, toys, a tank of gas, whatever.

Then, when it was time to go to the doctor, they didn't have any money left for the drug. So they opted not to receive it. So the drug wasn't given, and Wirth-Liss Pharmaceuticals, Inc. wasn't able to bill an insurance company for it. And, in fact, they now had a new corporate loss of $600 per irresponsible patient.

Of course, the patients thought this was grossly unfair. They couldn't understand why they couldn't have the drug, when, after all, they'd qualified for the assistance program. The fact that they'd blown their co-pay was beside the point. They also didn't see why they now had to pay cash for the co-pay, since the program person told them they wouldn't have to.

And, of course, they wanted another card.

When the above was explained to them, suddenly they remembered they'd never received the $600 drug card, or it had been stolen, or they hadn't seen it since an alien abduction on the way home from Las Vegas.

The program has since been replaced with one where the card can only be used at a specific doctor's office.

The executive behind it, I hope, has been canned.

The drug reps have the difficult job of explaining the program changes, and why they were made, to doctors and their staffs. Who are laughing hysterically.

Moon river

Dr. Grumpy: "How did the medicine I prescribed work?"

Mrs. Solanaceae: "I never tried it. I looked it up on the internet, and found out it can cause liver problems."

Dr. Grumpy: "Okay... but that's pretty rare."

Mrs. Solanaceae: "I don't care! It's my body, and I'm not going to take a pill that might harm it."

Dr. Grumpy: "You told me you smoke 2 packs a day."

Mrs. Solanaceae: "That's different. It's not a pill."

"Mavericks"? WTF?

Obviously, I'm bored tonight to even be taking a few minutes to type the following.


Apparently Apple is now switching randomly from feline names to beaches. I assume they ran out of cat subspecies.

I'm going to point out that there are still a LOT of felidae names to choose from:

Caracel

Smilodon

Margay

Geoffrey's Wild Cat

Serval

Colocolo

Norwegian Forest Cat

Ocelot

Kodkod


And many others.


NOT only that, but 10.3 was "Panther." Which is a genus. Not a species (okay, so was Smilodon, and they're extinct. But they were COOL).

And 10.1 (Puma) and 10.8 (Mountain Lion) are the same damn animal (Mountain Lion, Cougar, Puma, are all the same creature). For the record, this particular animal has more known names than any other, with at least 40. "I'll take felidae trivia for $200, Alex."

All right. Enough procrastinating. I'm going to go see what Frank spent the day building on Minecraft.

That's why they call it a "blood gas"

Apparently, calling it "Arterial pH" used too many letters...

June 8, 1971

J. I. Rodale (1898-1971)

On this day in history... a man died (big surprise, huh?).

Like the late James Ferrozzo, it wasn't so much that he died, but how he left us. In death, as in life, style and timing are everything.

Jerome Rodale was an early proponent of healthier eating, and his legacy continues today. He was one of the first to support sustainable agriculture, and believed crops should be grown without pesticides. His publishing empire lives on today, with the magazine Prevention, which he founded, and more recent additions such as Men's Health, Women's Health, and Runner's World.

On this day in 1971 he appeared on the then-popular television talk show, The Dick Cavett Show. It aired late-night, but was taped earlier each day in front of a live studio audience.

Mr. Rodale (age 72) was the first guest interviewed, and happily went over his beliefs in living a healthier lifestyle. He promoted the benefits of organic farming, and expressed his optimism over its effects on himself. Things he said during the show included:


"I'm in such good health that I fell down a long flight of stairs yesterday and I laughed all the way."

"I've decided to live to be 100."

"I never felt better in my life!"

"I'm going to live to be 100, unless I'm run down by some sugar-crazed taxi driver."


After the interview, Mr. Rodale sat back in his chair as Dick Cavett brought the next guest onstage (New York Post writer Pete Hamill). As Cavett and Hamill chatted, Rodale made a loud snoring noise, and appeared to doze off in his chair. The audience thought he was pretending to be bored, and laughed.

According to witnesses, Cavett asked "Are we boring you, Mr. Rodale?" (Cavett to this day denies making that remark). Hamill looked at Rodale, then turned to Cavett and said "This looks bad."

Two production interns ran onstage and began doing CPR (unsuccessfully) on the healthy-lifestyle advocate as Cavett took the microphone and asked "Is there a doctor in the audience?"

Cavett, in a 2007 interview with the New York Times, said "I thought, 'Good God, I'm in charge here. What do I do?' Next thing I knew I was holding his wrist, thinking, I don't know anything about what a wrist is supposed to feel like."

Mr. Rodale was later found to have suffered a heart attack. The episode was never aired, with the network choosing to show a re-run in its scheduled place.

But is it artisanal?

Seen on a bowl of drug rep fruit:

Thank you, Karen!

To err is human

Dear American public,

I apologize.

I accidentally cost you $470 last month, and so I owe each of you a $0.000000076.

I actually feel quite bad about this, but more in terms of the money lost and the inconvenience to the patient.

What happened, you ask? Well, I meant to order a lumbar spine CT scan. But due to a busy day and multitasking, accidentally wrote an order for a cervical spine CT. No one questioned it, and so it got done. I didn't realize the error until the report showed up on my desk. I apologized to the patient, and ordered the correct study.

The whole thing is overall harmless. The patient is elderly, and a few additional units of radiation are inconsequential. The 1 week delay in getting the proper test didn't have an adverse impact on his condition.

But still, I feel bad. I'm certainly not out to rip anyone off, especially other taxpayers.

This is, as far as I know, only the second error I've made in ordering the wrong imaging study in the last 10 years. I assume I have the same error rate as other docs for this sort of thing, and the total for mine is around $1100. Given that there are roughly 900,000 practitioners in the U.S., that comes out to $990 million dollars wasted every 10 years. That's enough to pay 20,000 school teachers for a year, or buy the Air Force eight F-35 fighters. Even by government standards it's still a decent chunk of change.

I don't have an easy answer for this. Should I be responsible? If a doc orders the wrong test, should he have to eat that cost? I guess that makes some sense, but someone is going to argue at some point that a test shouldn't be ordered. What happens if I did order a correct test, but then an insurance company claims it wasn't necessary - so should I pay for it?

Or what if the patient (after getting a test bill, of course) claims that I shouldn't have ordered a test, and wants me to pay for it? I've had that happen (I refused) and have learned it's common. I know another doctor who was threatened with a malpractice lawsuit to get her to pay for a study (she stood her ground, and they backed down).

So, I guess the only easy answer is to leave it as it is, and accept the fallible nature of humans. If ordering the wrong CT scan (at no harm to the patient) is the worst mistake I ever make in this business, I'll take it.

Doctors behaving badly

I'm with a patient, when Mary knocks on my office door.

Dr. Grumpy: "What's up?"

Mary: "Sorry, it's Dr. Promissory. He says he needs to speak to you urgently."

Dr. Grumpy: "Okay." (picks up phone) "This is Dr. Grumpy."

Dr. Promissory: "Hi, sorry to interrupt you."

Dr. Grumpy: "What's going on?"

Dr. Promissory: "My wife recently started her own business as a mortgage agent, and I was wondering if you'd considered refinancing your home?"

Mary's desk, June 3, 2013

Guy walks in, stands at counter.

Mary: "Can I help you, sir?"

Counter Guy: "Yeah, um, is this Dr. Grumpy's office?"

Mary: "Yes, sir. Do you have an appointment?"

Counter Guy: "No, I'm looking for another office. Thanks."

(leaves)

Maaaaaaaaaarrrrrrrrrrrrryyyyyyyyyyyyyyy!

Dr. Grumpy: "Can you smile for me?"

Mr. Poligrip smiles a little.

Dr. Grumpy: "Smile wider. Can you show me your teeth?"

Mr. Poligrip takes out his teeth and holds them up.

Those were the days

I just can't take it

Patient quote of the day:

"I don't want to take a pill just to take it. Because I'll be "taking it" taking it, when I'm not sure I need to take it. But if I have to "take it" take it, then I'll have to take it and will take it. But only if I really have to "take it" take it.

Things that make me grumpy

Times are tough for doctors these days. No one gives a shit, so I'm not elaborating further.

But even big institutions are affected. Take, for example, the venerable MD Anderson Cancer Center in Texas. This giant of oncology has recently been having financial issues, so much so that its president, Ronald DePinho, sent out this e-mail to employees 2 weeks ago:

"For most of fiscal year 2013 our operating expense has exceeded our operating revenue - meaning that we've spent more than we've made from providing patient care services."

He went on to say that because of this shortfall MD Anderson is suspending merit raises and slowing its hiring rate. This is what they call "austerity measures."

Now, every concerned CEO in America has been saying stuff like this, so why am I singling out Dr. DePinho?

Because.

At the same time Dr. DePinho is preaching financial restraint for his cash-strapped institution, he's used $1.5 million of its capital funds (which come from investment income, donations, and patient revenue) to build a 25,000 square-foot (2,322 square meter) office suite for Dr. Lynda Chin at the institution.

Who just happens to be his wife.

Really. I am not making this up.

Dr. Chin is the scientific director of MD Anderson's Institute for Applied Cancer Science. How this justifies her having an office suite that is 10 x larger than the average American home is beyond me. According to the institute it's to "provide an appropriate meeting space with high-level industry decision makers and support a new suite in computational biology." Translation: By using a lot of syllables we're hoping you'll ignore what's really going on here.

And no, I have no idea what "computational biology" is. Maybe that's why my entire office is 1,250 square feet, including the john.

According to an itemized expense report (obtained by The Cancer Letter under the Texas Public Information Act) this ginormous office has $28,000 worth of chairs, sofas, and tables. They also spent $210,000 on fancy translucent glass walls, which required them to get a special permit from the University of Texas. By comparison, the Grumpy Neurological Emporium has used furniture (valued at $948 total), and plain old painted drywall.

So, if you donated money in a loved one's memory to MD Anderson hoping they'll find a cure for whatever cancer killed grandma, there's a reasonable chance your hard-earned dollars went to pay for... upscale furniture and fancy glass walls in an office bigger than your house.

I'm going to close with another quote from Dr. DePinho, found in the same e-mail I quoted earlier about the austerity measures MD Anderson will have to take to survive:

"If we don't make changes now, we potentially will find ourselves in a crisis that will force us to take drastic measures that could hurt our ability to meet our mission... [all will] have to share sacrifices."

Well, almost all.


Thank you, SMOD!

History reruns

May 29, 1914

If you read the popular stuff, you'd think there were only 3 major shipwrecks of the 20th century: Titanic, Lusitania, and Andrea Doria. Obviously, there are many more, even if you exclude 2 worldwide conflicts in the last 100 years. The worst peacetime shipwreck in history, the Dona Paz (Philippines), took 4,375 lives as recently as 1987. And I bet you've never heard of it.

Trans-Atlantic crossings have always been critical to both sides of the Atlantic (look at the chaos caused by the recent Icelandic volcanic eruption). Although the giant liners of Cunard and White Star are best remembered, they were by no means alone. Ships were constantly coming and going, carrying passengers and freight, both ways across The Pond.

Although less glamorous than the liners that sailed in & out of New York, there were many busy ships that called on the Canadian ports. One was the Empress of Ireland, which in 1914 was serving the Quebec City to Liverpool route.

Early this morning, 96 years ago, the Empress was outbound from Canada. She was heading northeast on the St. Lawrence River. It was 2:00 a.m., and most of the passengers were sleeping.

In a thick fog, the Norwegian coal-carrier Storstad struck the Empress on the starboard side. The damage was extensive. There was only limited time to sound an alarm, and electricity failed quickly, plunging the ship into darkness. The Empress was gone in 14 minutes.

The survivors were picked up by the few lifeboats that had been launched, and were carried back and forth to the Storstad, which had stayed afloat. Captain Henry Kendall, who was thrown into the water as the ship rolled over, supervised the rescue efforts and likely saved many lives by organizing the lifeboats.

All together the Empress took 1,024 people with her. It remains the deadliest maritime disaster in Canadian history. In spite of this, the ship is mostly forgotten today. The St. Lawrence Seaway is a very busy channel. Hundreds of ships steam over the Empress every day, very few knowing of the tragedy beneath them.

The Salvation Army remembers. A large contingent of members (167) were lost on the ship, traveling to a conference in London. There is a monument to them at Mount Pleasant Cemetery, in Toronto.

The Empress of Ireland is in 130 feet of water, well within the range of scuba equipment, but the currents and poor visibility limit diving

Marketing FAIL

How impressed can you be with a medical practice management company that obscures their own contact information on a fax advertising their services?

Thank you, Lee!

Memorial Day

Capt. John P. Cromwell, USN, 1901-1943

John Cromwell was born in Illinois, but his heart took him from the midwest to the ocean. He graduated from Annapolis in 1924.

His initial sea service was on the battleship Maryland, but his abilities led to him being picked for the fledgling American submarine force. He served aboard, and commanded, some of the United States Navy's first large submarines.

After several tours at sea, Cromwell was selected for further training in the complex diesel engines that were critical to submarines of the pre-nuclear era. He rose through the ranks, eventually becoming a division commander.

WWII found now-Captain Cromwell in the Pacific, commanding submarine divisions 203, 43, and 44. His flagship was the U.S.S. Sculpin.

In November, 1943 Sculpin (commanded by Lt. Cmdr. Fred Connaway) put to sea with orders to rendezvous with the submarines Searaven and Spearfish to attack Japanese shipping. Upon arrival Cromwell would take command of the group.

The Americans were preparing to invade Tarawa island later that month. It would be a critical (and bloody) fight to wrest control of the central Pacific from Japanese forces. Cromwell was aware of the operation's details, and was also familiar with the top-secret American ability to read Japanese military codes.

On November 18, 1943, while en route to the rendezvous, Sculpin was preparing to attack a Japanese convoy. A damaged depth gauge, however, caused her to surface rather than go to periscope depth, and she came up directly in front of the Japanese destroyer Yamagumo. Although Connaway quickly dived again, it was too late. Yamagumo pounded Sculpin with a series of depth charges, causing severe damage.

With no way to escape, and more destroyers coming, Connaway decided to surface again and try to fight it out. The destroyer was ready. As the Sculpin came up, Yamagumo's first salvo killed her entire bridge crew (including Connaway) and those running to man the weapons.

Sculpin's surviving senior officer ordered the submarine scuttled, and the crew to abandon ship.

Captain Cromwell realized the secrets he knew could seriously jeopardize the American war effort. The Japanese couldn't be allowed to learn the invasion plans for Tarawa, or that the Americans had broken their codes. While he wouldn't voluntarily talk, there was no guaranteeing he might not break under torture or the influence of interrogation drugs.

He therefore decided to stay with Sculpin forever. He helped the crew abandon her, but made no move to leave himself. He was last seen standing in the control room, watching it fill with water.

His Congressional Medal of Honor was presented to his widow.

Sunday reruns

Ms. Crappystaff: "Dr. Imed's office."

Dr. Grumpy: "Hi, it's Dr. Grumpy. You guys referred Mrs. Brain to me for an abnormal MRI, and I don't have the report. She's here now. Can you please fax that over, ASAP?"

Ms. Crappystaff: "Hang on... Sorry, the doctor just went into a room with a patient, and doesn't like to be disturbed. I can have him call you back later."

Dr. Grumpy: "I don't need to talk to him. I just want you to fax over the MRI report."

Ms. Crappystaff: "I'm not comfortable doing that. I don't know what the report means."

Dr. Grumpy: "I'm not asking you to know what it means. All you have to do is fax it to me."

Ms. Crappystaff: "Don't patronize me. I don't even know who you are."

Dr. Grumpy: "I'm Dr. Grumpy. You faxed over an insurance authorization on this patient an hour ago. I just need the MRI report, so I know what to tell her."

Ms. Crappystaff: "I told you, I'll have Dr. Imed call you to discuss this."

Dr. Grumpy: "The patient is here now. I just need the MRI report. Please fax it over. It's why you guys sent her to me."

Ms. Crappystaff: "You obviously don't understand the importance of patient privacy."

And she hung up.