You VILL have foot pain!

Hazards of misspelling "fasciitis:"

Making a point

Dr. Grumpy: "What's the pain like?"

Mrs. Bun: "It's stabbing, aching, burning, stabbing, throbbing, stabbing, itching, dull, stabbing, sore, stabbing, sharp... Did I mention stabbing?"

"Spam, spam, baked beans, spam, eggs, spam..."

Attention patients:

Those of you who've met Mary and Annie know my staff is pretty awesome. But, due to some recent confusion, I'd like to point out what my staff is NOT here to do:

1. Arrange tee times, make restaurant reservations, and look into available flights. We are not the hotel concierge desk.

2. Drop-off or pick-up your dry cleaning. This is not a service my practice offers.

3. If you have a letter to mail, and want Mary to put it with the rest of our outgoing stuff for her daily run to the mailbox, she doesn't mind. Asking her to look up addresses and postage rates, or to supply you with free stamps, is going too far.

4. Babysitting. This is a big one. WE ARE NOT HERE TO BABYSIT YOUR KIDS. Pissy and I only see adults, and consequently do not keep toys or copies of Ranger Rick in the lobby. We do not want your kids drawing all over our magazines, walls, and lobby furniture. Supervising them is also not the responsibility of other patients in the lobby - I see Alzheimer's patients, for fuck's sake. If you can't control your kids you will be asked to leave and given the option of rescheduling when you can get a sitter, or just seeing Dr. Darth across the street.

5. We are not going to help your kids with their homework. This is a medical practice, and my staff is busy. If junior needs a piece of scratch paper or to borrow a pencil, that's fine. But we are not here to teach spelling, algebra, or quantum mechanics.

6. Look up movie times. I mean, I can't remember the last time I saw a patient who didn't have a smart phone. There's an app for that. The fact that you handed your phone to a toddler to keep them busy is not an excuse.

7. We absolutely, positively, do not keep diapers (for ANY age) on hand. Either bring your own or hit the Target down the block. And DO NOT even think of changing them in our waiting room. There's a bathroom 15 feet down the hall.

8. Call your order over to Starbucks, Chipotle, or wherever. It's not like you even offered to treat us.

9. Give advice on pet care. We are not the vet. They are 2 blocks over, and do a great job. The fact that between us the staff has 8 dogs does not make us an animal hospital.

10. Pick up your trash. There's a trash can out in the lobby. Leaving the detritus of your McGrease lunch or little balls of snot-loaded tissues on the lobby table is rude, gross, and unacceptable.

11. Find you a pharmacy, or therapy place, or hospital, or pretty much anything in Montana. Or Canada. Or South America. Or anywhere outside of Grumpyville. Let's face it, we have enough trouble figuring out what pharmacy to call HERE when you give us directions like "it's near the place with blue awnings," "the one by the Denny's," and (my favorite) "across the street from the homeless guy in the baseball hat."

12. Call numbers you got from Craigslist of people selling furniture, clothes, themselves, etc., then reporting back to you on what we found out.

13. Buy shit that your kid is selling for a school fundraiser. Don't even go there. You wouldn't like it if we hit you up for cash outside of your office co-pay.

14. Answer your cell phone while you're with the doctor, and take messages. They do this all day for me, and I'm paying them. You are not. It can go to voice mail.

Thank you.

Ibee Grumpy, M.D.

Guest post

Dr. Coogie writes in:


Last night I got called down to ER to admit a guy for syncope.

Dr. Coogie: "What happened?"

Mr. DUI: "Well I was drinking beer at Boobpile and I passed out."

Dr. Coogie: "How long were you out?"

Mr. DUI: "Not sure. I woke up on the floor with everyone around me, but then realized I still had more beer to finish, so I had some more beer and decided I should get checked out."

Dr. Coogie: "Okay, and then you had someone bring you here?"

Mr. DUI: "No, I had spilled beer on my clothes so I drove home to change, then drove to the ER, and here we are."

Meeting of the minds

With the school year winding down, the twins are off to Wingnut Elementary's end-of-year school music camp, to spend 4 days in the cool pines of northstate. There they'll practice their instruments, terrify wildlife, irritate hunters, and likely violate the endangered species act.

So Tuesday afternoon was the parents' meeting with the teacher leading the expedition. It was allegedly mandatory (though they didn't take attendance). Mrs. Grumpy had happy hour a meeting at her job, so I went.

I got there early, and, out of habit (amazing how we default in a classroom), took my traditional college/medical school seat (3rd row from the front, 2nd seat in). Other parents came in. A cardiologist I know, whose daughter is in the same class, came in and sat next to me.

As Mr. Allegro was trying to get the SmartBoard to work (this involves tapping it, swearing, hitting it harder, swearing, tapping it lightly, swearing, wash, rinse, repeat) Mrs. Mysomom came in. She carefully looked over several seats before selecting one that met her standards, and started to set her purse down. Then she stopped, whipped out latex gloves, put them on, pulled out a pack of bleach wipes and began scrubbing down the desk and chair (which weren't visibly filthy) before tossing the gloves and wipes in the trash and Purelling her hands.

After a few minutes the presentation began. Mr. Allegro showed us a brief video about the camp (which looked like a lot of fun, BTW), went over some rules and other points, and finally opened up the floor for questions. Boy, that was a stupid idea.

Mom 1: "It says here that no electronics are allowed. What about phones?"

Mr. Allegro: "No phones. They distract the kids from the lessons. We also don't want the boys and girls texting each other after lights out."

Mom 1: "But then how am I supposed to know where you guys are, and that you arrived safely?"

Mr. Allegro: "Either Mrs. Hendrickson or I will send a group text to all of you when we get there."

Mom 1: "Yeah, but what if something happens to both of you, like you're killed in a bus crash on the way, and the kids need help?"

Mr. Allegro: "Well, the driver also has a phone, and the bus has GPS and a radio connection to its company."

Mom 1: "It's very important that I be aware of where Sherman is at all times, 24/7. I'm his mother, you know."

Mr. Allegro: "He'll be with us, and you'll be notified if there are any problems."

Mom 2: "Wait a minute. You're not driving the bus?"

Mr. Allegro: "No, the bus is chartered from Pinto Transportation, who supply the driver."

Mom 2: (getting out paper and writing notes) "Who is the driver? What are his home and cell phone numbers?"

Mr. Allegro: "I don't know. They..."

Mom 2: "You don't know? Do you know anything about him? Does he have a police record? Is he in good health?"

Mr. Allegro: "Well, I have to assume..."

Mom 2: "You mean he might not be? THIS IS THE PERSON RESPONSIBLE FOR MY DAUGHTER'S LIFE AND YOU DON'T KNOW ANYTHING ABOUT HIM? I'd like to see his medical records before the trip. Have them sent to my home fax. Get his name so I can Google him, too."

At this point a parent wandered in late and asked a few questions that had already been answered during the initial presentation, visibly annoying everyone

Mom 3: "What about the bus? Is it new? Old? Have a history of accidents?"

Mr. Allegro: "The company supplies the bus, and I don't know which one we'll..."

Mom 3: "So for all we know it was recently in a major accident and has shitty brakes. That's SO reassuring. Can we review its maintenance records in advance?"

Mr. Allegro: "Uh, you'll have to call Pinto Lines."

School janitor walks in, is surprised to see people in the room, apologizes, leaves.

Mom 4: "What is the closest hospital and emergency room to the camp?"

Mr. Allegro: "Uh..." (grabs a notebook) "West State Regional Hospital."

Mom 4: "Is it a Level I Trauma center?"

Mr. Allegro: "It has an emergency room. What does 'Level I Trauma' mean? I'm just the music teacher!"

Mom 5: "Do you know if it has board-certified physicians? Michael is always falling off roofs."

Mr. Allegro: "The kids aren't going to be on the roof. They're not allowed there."

Mom 5: "That won't stop Michael. Where there's a roof to fall off of, he'll find a way."

Mom 6: "It says here the kids aren't allowed to bring firearms, tobacco, alcohol, or illegal drugs?"

Mr. Allegro: "Correct. Those will be provided there."

Me and the cardiologist crack up, the others glare at us. Mr. Allegro regrets having tried to joke.

Mom 7: "Why can't they have their phones on the bus at least? It's a 4 hour drive"

Mr. Allegro: "Because we don't want them brought at all. The bus has TV screens, like on planes, and we're taking movies to watch."

Another parent comes in late, asks the same questions that had already been answered during the initial presentation and for the first late parent, further annoying everyone.

Mom 3: "What are the movies rated?"

Mr. Allegro: "G and PG. I think we have 'Wreck-It Ralph,' 'Frozen,' 'Monsters University,' and "Despicable Me 2.' "

Mom 3: "Doesn't 'Wreck-It Ralph' promote violence? I think I read that in Crazyfuck Parent Today."

Mom 2: "No, it doesn't. Besides, from the way your daughter treats mine I'm pretty sure she's used to violence."

School janitor walks in again, is still surprised to see people in the room, apologizes, leaves.

Mom 7: "I don't want Cindy to see 'Frozen' again. She'll come home singing that stupid song that makes me want to slit my wrists."

Mr. Allegro: "You're certainly welcome to send any DVD's of G and PG movies you want, and I can let the kids vote on it."

Mom 4: "These kids are only 12. They're not old enough to make decisions like that."

The cardiologist takes 2 chocolate bars out of her purse, offers me one. A lady behind us says "you're doctors and you eat that shit? Remind me to never come to you." We both ignore her.

Mom 8: "Susan gets headaches a lot, so I want to send her with a bottle of Tylenol. Is that okay?"

Mr. Allegro: "Sure, just fill out the medication form that was in your packet. There's a full-time nurse at camp, too."

The cardiologist whispers to me "Rachel takes Adderall. I thought about writing on the form that the teacher should give it rectally to see what they'd do, but Rachel would never speak to my again." We both snicker, other parents glare.

Mom 5: "How do we know it's really Tylenol, and your daughter isn't selling something?"

Mom 8: "Really, Beth? You should pay better attention to your own son's issues."

Yet another parent comes in late, asks the same questions that had already been answered during the initial presentation and 1st & 2nd late parents, further annoying everyone.

Mom 9: "Is the camp nut-free?"

Mr. Allegro: "Yes. Please don't send snacks with your kids, they'll be provided for them."

Mom 3: "Is your son allergic to nuts?"

Mom 9: "Not that I know of, but I keep them out of the house anyway in case he becomes allergic."

Janitor walks in again, is still surprised to see people in the room, apologizes, leaves. Cardiologist whispers "Is he one of your dementia patients?" Lady in front of us turns around and goes "Shhhh!"

Mom 10: "What about gluten free?"

Mr. Allegro: "No, but we can make arrangements. Does your daughter have Celiac disease?"

Mom: 10: "No, she tested negative, but I still won't let her have gluten. I read that it's being put into foods as part of the government's secret eugenics program."

The cardiologist grabs and squeezes my forearm so hard that she draws blood, I kick her under the table. Lady next to us thinks we're playing footsy and looks disapprovingly. I briefly consider pretending the twins are Kosher just to liven up the party.

Mom 11: "Will you guys be in tents?"

Mr. Allegro: "No, it's a dormitory with 2 wings, girls on one side, boys on the other. The adults will be in the hallway between them."

Mom 1: "Does it have fire sprinklers?"

Mr. Allegro: "Uh, I think so..."

Mom 1: "Are the safety inspection certificates online, where I can see them?"

(School janitor walks in again, is still surprised to see people in the room, apologizes, starts to leave. Cardiologist grabs my arm, drags me out after the janitor).

Janitor: "Can I help you?"

Dr. Cardio: "No, we just needed to get out of there."

Dr. Grumpy: "I think you broke my arm."

Dr. Cardio. "I don't care. I couldn't take it anymore. And you couldn't, either."

Dr. Grumpy: "No shit."

Janitor: "Moms today get crazy at these meetings. They'll be there all damn night."

Click

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

Ms. Cell: "I've tried calling your office 5 times today, and the calls keep getting dropped."

Mary: "I'm sorry. What can I help you with?"

Mrs. Cell: "You could get your phones fixed so they don't keep dropping my calls!"

Mary: "Ma'am, usually that's not at our end..."

Mrs. Cell: "Of course it is! I call your office from my cell phone, and the call gets dropped. You think that's a coincidence?"

Mary: "Have you tried calling from a land line?"

Mrs. Cell: "So now you're saying it's MY fault? Is that it?"

Mary: "No, but..."

Mrs. Cell: "Look, I need to..."

(silence)

Gender pronouns

Seen in another doctor's note:

Before you write in - the patient hasn't had gender reassignment. Simply a doctor who doesn't proofread.

Overheard in the living room

Craig: "Did the girls have a sex ed lecture today?"

Marie: "Yeah, in the classroom at the back of the library."

Craig: "We were in the cafeteria classroom. Ours showed all these disgusting pictures of sex diseases."

Marie: "Yeah, the nurse made us look at those. They were gross. One thing looked like a vagina with an eyeball on one side."

Craig: "We had this one picture. I thought it was, like, a really burned and infected tongue, but then Mr. Cooper said it was a diseased penis. It was so gross. Jacob Myers ran outside and threw up in the grass."

Marie: "Was that near the back door of the cafeteria?"

Craig: "Yeah, why?"

Marie: "The nurse stepped in it when we were going back to our classrooms, and began swearing."

Craig: "That's gross, too."

Marie: "Her shoe was all covered with barf."

Craig: "Yuck."

Marie: "Cindy put a picture of it on FaceBook."

Walking in New York

The Colbert Report
Get More: Colbert Report Full Episodes,The Colbert Report on Facebook,Video Archive

Great attending quotes from training

"If a patient demands to have daily office appointments with you, let them. They're the ones paying for it, and you have to be there anyway. They'll get bored and stop after 1-2 weeks. This is a war of attrition, and you'll always win."

Free

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

Mr. Gratis: "Hi, I need to see the doctor."

Mary: "Okay... We have an opening tomorrow at 2:30. What insurance do you have?"

Mr. Gratis: "I don't have insurance."

Mary: "All right, our cash prices are..."

Mr. Gratis: "Oh, there's no charge for the visit. I was referred by Boondock Hospital."

Mary: "What?"

Mr. Gratis: "I was seen in the ER at Boondock Hospital last week, and they told me I should see a neurologist. Your name was on the list they gave me."

Mary: "Yes, but we still charge for the visit."

Mr. Gratis: "It's supposed to be free. A hospital referred me!"

Mary: "I understand that, but it doesn't mean we don't bill for our services."

Mr. Gratis: "I can give you the name of the doctor there. Can you bill her? Or the hospital?"

Wonder powers activate!

Medikidz is a company that sells medical comic books for kids.

I get it. I was a kid once, and loved comic books. In fact, I think there were educational ones at my pediatrician's cave office then, so I'm glad they're still using them today. (I just wish there'd been a good one for biochemistry during med school).

These are the Medikidz superheroes:

I haven't read the comics, but it looks like they fly around on a giant red corpuscle. Being a neurologist I kind of like the knobby-kneed brain in the background. I'm not sure what to make of the guy in front, as generally I prefer my superheroes to wear pants. There's also the guy behind him on the left, who's carrying eating utensils in his belt. This is not standard JLA equipment.

Anyway, the reason I'm even on this subject is that recently the annual Neurology meetings were held in Philadelphia, and my top field agent, SMOD, was there.

Like many companies, Medikidz had a booth on the exhibit floor. I've seen my share of these. Pleasant sales reps in professional attire extolling the virtues of whatever they're selling.

But not Medikidz. To SMOD's horror, their reps were wearing the superhero outfits:

"For this I got a college degree."

They look kind of lonely. It's good to have a job, but still pretty humiliating to have to be at an adult medical convention wearing spandex and a cape. Normally you only see this kind of outfit on Halloween, when shopping at Walmart, or in the personals section of Craigslist.

Dear Medikidz: if you want to attract neurologists, you should wear Star Trek costumes.

Relevance

On the fax machine yesterday morning was a note from Dr. Intern's office, about a lady who has an appointment tomorrow.

It said: "Please evaluate Flora Betapir for Alzheimer's disease. Records attached."

The attached records were:

Right hand x-rays from 1999

A mammogram report from 2002

and a Pap smear report from 2005

Sigh.

True colors

Last week, for those of you who missed it, Los Angeles Clippers owner Donald Sterling temporarily became the most hated man in America. This is actually pretty impressive, as it involves leapfrogging over politicians, television pundits, lawyers, doctors, and the barista who can never get your order right.

Mr. Sterling's downfall came because of overtly racist statements. This rapidly brought him condemnation from politicians, celebrities, and pretty much anyone with a microphone or Twitter account. People lined up around the block to announce they would boycott Clippers games if he wasn't removed, and team sponsors jumped ship fast.

So, guess who can't boycott Mr. Sterling? I can't. Or anyone in the healthcare field.

Sure, I can refuse to go to his games, or live in one of his buildings. But if he shows up in my office or hospital, I wouldn't turn him away. And neither should any doctor or nurse.

This is one of the hardest things in medicine. Regardless of how we may feel about a person, or disagree with their beliefs, we still have to do our best to help them when they need us. I've taken care of neo-nazi white supremacists, militant black supremacists, dirtballs who shoot police or kill innocent people just because they don't like them... the list goes on. Sterling's condescending boardroom racism is minor league compared to these guys.

It's part of the job. Whether they come to you in the office, or you're seeing them in the hospital, you have to set aside your personal feelings and do your best to help. Dr. Samuel Mudd spent 4 years in prison for providing medical care to John Wilkes Booth - a conviction yet to be overturned.

I never discuss politics with patients, as it's bad for the relationship. But that doesn't stop some from bringing it up, sometimes expressing blatantly racist or antisemitic views. I've had people tell me all blacks should be shipped to Africa, or Jews or homosexuals killed. Do I agree with this? Hell no. But I also believe that part of being a doctor is caring for anyone who seeks my help, regardless of personal feelings for them.

In hospitals they have it even worse. Nurses and doctors there have to deal with people who are drunk, high, verbally abusive, and sometimes violent. And, again, they do their best to help those no one would want to. As professionally as possible.

Like most people these days I don't support or like Mr. Sterling. But that wouldn't stop me, or any number of doctors, nurses, or paramedics from doing our best to help him if he needed us. Because that's what we do.

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:

This is a good thing

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

Miss Poppy: "Hi, I need to make an appointment with Dr. Grumpy."

Mary: "Okay, we can see you..."

Miss Poppy: "Wait, first, I need to know if you guys are connected to that big database where you can see which of your patients are getting narcotics from other doctors and when and how many and all that stuff."

Mary: "You mean the state monitoring program? Yes, we are."

Miss Poppy: "Never mind."

click

How ya doin'?

"It's been a busy year. I had to have all kind of treatments from the eye doctor. A few months ago I had this weird feeling in my eye, and had my friend Jan look at it. She's a librarian at the kids school, so I figured she reads all kinds of stuff. She thought maybe I had a fungus in my eye, and I'd once heard of a guy that happened to on the news, so it seemed like I should treat it. My oldest boy is on the high school football team - they were in the state playoffs last year if you remember - and is always having jock itch with burning and red stuff in his crotch. He has these tubes of fungus cream for it in his bathroom, so I rubbed it in my eye for a few days, but that only made things worse. So I went to the eye doctor and he said the cream wasn't supposed to go in my eye because it damaged something and I had to have all kinds of treatments for it. It really ticked me off because you'd think Jan should know better."

1 in 206

Dr. Grumpy: "Do you have any other medical issues?"

Mr. Methuselah: "They said I had arthritis on a bone somewhere. Do you know which one it would have been?"

That's some pen

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

Mr. Waterman: "I need your help. The pharmacy is refusing to give me my seizure medicine! They claim you didn't order it. I know that's a lie, because I saw the doctor do it."

Annie: "Okay, let me look in your chart."

Mr. Waterman: "I'm all out, too."

Annie: "It looks like he wrote a prescription at your visit. Did you give it to them?"

Mr. Waterman: "Did I give what to them?"

Annie: "The prescription he wrote."

Mr. Waterman: "He didn't give me one! He sent it to them."

Annie: "But... In your chart it shows he gave you a handwritten script. What did you do with it?"

Mr. Waterman: "My copy? I tossed it. I didn't think I needed it."

Annie: "That was the prescription! Why did you throw it away?"

Mr. Waterman: "I figured it was sent from his pen as he was writing it."

Dr. Grumpy: dementia magnet

The day is over. Mary left. I wander out in the hallway and am waiting for the elevator.

An older gentlemen in a tweed cap comes up to me:

Tweed Cap: "Excuse me, where is the cardiology suite?"

Dr. Grumpy: "Um, there's a cardiologist on the 4th floor, and another on the 8th. Do you know the doctor's name?"

Tweed Cap: "No, my sister had a heart attack earlier, and they told me she was here, in room 745."

Dr. Grumpy: "Oh, you're looking for the hospital. That's across the street."

Tweed Cap: "This isn't the hospital?"

Dr. Grumpy: "No, it's an office building."

Tweed Cap: "It looks like the hospital."

Dr. Grumpy: "No, you have to go outside, head east, and cross the street. There's a foot bridge over traffic."

The elevator opens and I get in it. So does Tweed Cap. I go down to the parking garage under the building and get out. So does Tweed Cap.

Tweed Cap: "So now we are in the hospital?"

Dr. Grumpy: "Uh, no, this is a parking garage."

Tweed Cap: "But it connects to the hospital, doesn't it?"

Dr. Grumpy: "No. See that staircase over there? Take it up 1 flight, and you'll see the hospital right in front of you. There's a bridge across the street there, and you can take it right over."

Tweed Cap: "Thank you."

He got back in the elevator and the doors closed.

Great headlines

"Quick, Phil, get a headline ready that we can edit to use regardless of who wins."

p.s. The picture is also from the wrong game.

Seen in a hospital chart:

So, based on this detailed exam, we can assume which of the following:

The patient...

A. Is dead, and the doctor is in the morgue by mistake.

B. Has escaped, and left a mannequin in the bed.

C. Is a parrot.

D. Wait, how the hell is that part of a mental status exam?

E. The doctor billed this as a level 5 visit.

Quote of the day

"I take a blood pressure pill, or maybe it's for my cholesterol. Actually it might be a blood thinner. Anyway, it's one of those."

Pathology

Dr. Grumpy: "Any major illnesses in your family?"

Mr. 12A: "No."

Lady 12A: "Your mom had diabetes."

Mr. 12A: "Is that major?"

Lady 12A: "I think it's major."

Mr. 12A: "I don't."

Lady 12A: "What do you consider major?"

Mr. 12A: "Where did you go to medical school?"

Poke into others as you'd have poked into you?

Ya know, I heard the Golden Rule a lot in childhood, but don't remember this part of it...

Gives a new meaning to "the Midas touch," eh?

Thank you, BW!

Why I do what I do

It's been 4 years since I last ran this piece, and I think it's worth putting up again.


It ain't much to look at.

Two, maybe three pounds of grayish-white goop. It's not even solid in a living person. More like Jello that floats around in it's vault.

But it's amazing. From that sloppy goop has come remarkable stuff. It's sent a robot to land on a moon of Saturn. It's explored the bottom of our deepest oceans. Built the Taj Mahal. The Great Wall of China. Painted the Mona Lisa.

Go listen to the remarkable Bach's "Toccata and Fugue in D minor". Not just the famous opening 30 seconds or so, but the whole 9-10 minute thing. That all came from the goop, long before it was heard or played on an instrument, it was just a series of electric signals jumping from nerve to nerve. The piece is over 300 years old. The mind that created it has been dead for over 250 years. And humans will likely be listening to it long after my great-great-great-grandchildren are dust.

The soul is there. The heart is amazing, but for all our romantic beliefs about it, who we really are is floating around in the goop. It's where hate, love, and everything in between comes from.

It's capable of terrible evil, such as the Holocaust, and remarkable good. Look at the outpouring of altruism that follows disasters. I love my dogs, but if something bad happens to a dog on the next street, they're not going to care. Yet the goop wants to help people who we've never met and have no direct impact on our own lives

My regular readers know I'm interested in maritime history. Why? I have no idea. It's just been a subject I've loved as long as I can remember. I've never been in the navy. The family military history consists of grandparents who served in the army, but never were sent overseas. I can only assume there is some particular molecular structure in my goop that makes me interested in it. Or that made me want to treat other people's goop for a living.

Twin and biological studies have shown that most of who we are is how we came here. Yes, life experiences and background count for something, but the goop is most of it. People with conservative beliefs raise kids who turn out to be liberals, and vice versa, no matter how hard they may try to pass on their beliefs.

Coke vs. Pepsi. Dogs vs. Cats. Mac vs. Windows. I suspect whatever makes us fall on one side or the other of these great philosophical issues is 95% or more in the goop, and we just come that way.

Everything you are, have been, and will be. Have desired, dreamed of, and done. Have felt. It all comes from a few pounds of goop.

And this fascinates me. Because, let's face it, we're just another part of the planet. A collection of complex molecules, electrical impulses, and chemical reactions. That's all people. Anatomically, all humans are pretty much the same. And we're not that different from other mammals. The difference in our genetic sequence vs. that of a mouse ain't much.

And yet that small amount of difference has led to amazing results. The ability to think beyond our own biological needs and to see the world around us for the beauty it contains. To watch a sunset and be in awe, even though we understand the science behind it. And to look up at the night sky, and wonder.

And that never bores me.

Mary's desk

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

Ms. Urgent: "I need to see your doctor right away! My doctor told me to call you guys!"

Mary: "Well, he's out of town this week, but next week we can see you on..."

Ms. Urgent: "Well, how far away is he? I mean, like where he could drive back tomorrow to work me in?"

Mary: "No, he's gone until next week. Now..."

Ms. Urgent: "But I need to see him! Doesn't he have a partner or something?"

Mary: "No, we're a solo practice."

Ms. Urgent: "What about you? Can I see you? You work there."

Mary: "I'm a secretary, ma'am."

Ms. Urgent: "But still, you must have learned enough just from working there!"

Mary: "No. Anyway, next week we have..."

Ms. Urgent: "I could be dead by next week! And don't tell me to go to ER, either! I'm tired of going to ER's. Why isn't the doctor there, anyway?"

Mary: "He took his kids to go visit family. Now, we can..."

Ms. Urgent: "You mean he goes on vacations? What the hell? Doctors shouldn't be allowed to do that! They trade that in to care for people!"

(hangs up)

Spring break

Due to my kids having this week off, we're going to visit family in warmer weather. I will return on March 31, 2014.

Quote of the day

"Since my back injury I've had trouble going down. On stairs, I mean."

Foot, meet mouth

My 2:00 patient yesterday was obviously blind. She had the long white cane, and a guide dog. Mary filled out forms for her. She held onto my arm as I led her back to my office.


Dr. Grumpy: "So what can I do for you?"

Mrs. Two: "I was at the emergency room this weekend. I had a seizure on Sunday, and bit my tongue."

Dr. Grumpy: "Good heavens. Have you ever had a seizure before?"

Mrs. Two: "No. They told me I had another one in the ER after I got there."

Dr. Grumpy: "Where did the first one happen?"

Mrs. Two: "I was in the car."

Dr. Grumpy: "Were you driving?"

Pause.

Dr. Grumpy: "That was a really stupid question, wasn't it?"


She cracked up. It was a few minutes before we could start again.

Thump

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

Mrs. Phleb: "It's been 2 weeks, and I want to know what my labs showed. Nobody called me."

Annie: "Hmmm... I don't see any results in the system."

Mrs. Phleb: "Well, I took the order in. I don't know why they didn't send them to you."

Annie: "What lab did you go to?"

Mrs. Phleb: "The one in your building. I did exactly what Dr. Grumpy told me to do!"

Annie: "That's strange. Usually they're pretty reliable. Did you have the blood drawn right after your appointment?"

Mrs. Phleb: "What blood draw?"

Annie: "They didn't draw your blood? What exactly did you do?"

Mrs. Phleb: "What Dr. Grumpy told me! He handed me the order, and said to take it to the lab downstairs. I did that, and gave it to the girl at the counter. She set it aside to answer a phone call, and was talking to some lady about scheduling. So I left and went to lunch with Ed."

Annie: "You were supposed to wait for them to draw your blood. The lab order is just an order."

Mrs. Phleb: "Well, he should have explained that!"

Overheard in ER this weekend

Dr. Urgent: "What do you take for your asthma?"

Mr. Wheezy: "Methadone."

Sunday night call check-out

Dr. Grumpy: "Next is a lady in room 835 who I saw for diabetic neuropathy. I started her on Qualex, and..."

Dr. Brain: "Any exam findings?"

Dr. Grumpy: "No reflexes in the legs, and impaired pin & proprioception in the feet. I ordered some labs..."

Dr. Brain: "Proprioception? Don't you mean 'passive joint position sense'?"

Dr. Grumpy: "Okay. In room 753 is a guy who came in with an acute stroke..."

Dr. Brain: "Wait, this is important. You aren't answering my question. 'Passive joint position sense' is a much more relevant term, and you really should use it."

Dr. Grumpy: "Whatever. Anyway, the guy in 753 is weak on the right. I started him on Aspirin, and an MRI is pending. You'll need to..."

Dr. Brain: "So why do you say 'proprioception' ? The correct term should be 'passive joint position sense."

Dr. Grumpy: "Because it's shorter. In room 734 is a lady with seizures who..."

Thursday night phone message

"Hi, this is Austin, and I'm in the twin's class at Wingnut school. My Dad says he'll get me a new XBox game if I take a girl to the junior high dance, so can you please have Marie call me? Thank you."

Statistics

Rikki Phoneysmile, my least favorite drug rep, came by. I went up to sign for samples.


Rikki: "Now... just tap next to the pill strength you'd like, and sign here..."

Dr. Grumpy: "Okay." (signs off, hands iPad back).

Rikki: "Thank you, doctor. I'd like to leave you with this booklet about Dioxnyl to review..."

Dr. Grumpy: "You've left it with me before. You've been handing it out for over a year."

Rikki: "No, it's a new one. We recently discovered an error in that booklet, and it's now been corrected."

Dr. Grumpy: "What was wrong?"

Rikki: "On the efficacy graph we had the drug vs. placebo curves switched. So it made it look like the placebo was more effective than the drug."

Pause

Dr. Grumpy: (giggling) "Your company has been using a booklet erroneously showing your drug was worthless for over a year and no one realized it until now?"

Rikki: "Um, yes. Have a nice day." (drops booklet on desk, leaves)

Mary: "Did you ever notice that?"

Dr. Grumpy: "Hell no. But it's nice to know nobody else reads them, either."

Texting by voice

Marie's Wingnut School girls basketball team had their first win of the season yesterday, and Mrs. Grumpy sent me the results. So I was trying to get Siri to text "Yay!" back.

Yes, we are

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

Mrs. Chart: "Hi, I have an appointment next week, and I need you guys to get my records before then."

Mary: "Okay, but we can't get your records from other places. You need to contact them, and fax a release."

Mrs. Chart: "I've seen 3 other neurologists, and been admitted to 2 hospitals for my problems. I'd think you'd want to have their notes."

Mary: "Yes, the doctor would, but again, you'll need to contact them and have them send records. We can't get them without a release. You can come in here and sign one, or I can fax one to you."

Mrs. Chart: "I don't have time for that. I'm busy. You need to just call them yourself. You can tell them I told you to."

Mary: "Ma'am, it doesn't work that way. There are privacy laws and..."

Mrs. Chart: "Oh, you're one of those practices. Never mind."