Monday, February 28, 2005

Walk more, eat less

From Kevin,MD:
Who says it is impossible to lose weight? By simply walking more (and eating a more healthy diet) 20,000 Iowans have lost over 65,000 pounds over the past three years.

The subjects are grouped in teams and record their steps by wearing a pedometer. The total distance walked by the group thus far: 4.8 million miles.

Many people think that in order to lose weight they must exercise vigorously. They then find it easy to make excuses for avoiding their activity (too expensive, too far to drive to the club, not enough time to change into the snazzy work-out duds, et cetera).

The importance of just increasing the number of steps walked in a day is cleared reflected in this simple program, entitled Lighten Up Iowa.

The take-home message - Walk more! Eat less! Don't try to do it alone - get a partner!

I just tell my patients to park at the far end of parking lot before going into Walmart!

Use of Air Ambulances

Interesting post at Cut to Cure regarding the increased use of air ambulances and crashes.

When I was in the Navy, helicopter transport was fairly routine. However, we were still just a little bit more nervous when it came to flying a patient. We had pilots who needed flight hours and they didn't have to justify the gas if it was for a medevac. Plus, my corpsmen were always excited about flying and usually only got to do it for medevacs.

I flew in a few medevacs while in the Navy but will never forget the night a helo went down in the Pacific off the coast of Camp Pendleton while flying a patient. The flight surgeon was just along for the ride. Everyone on board died. I don't remember the details of the medevac, but ever since I critically evaluate the risk of flying a patient.

In my community ER, we have not infrequent need to transfer a patient. Often the nurses will assume the transport will be by helicopter. But I always wonder whether the ground transport will be just as effective and possibly less risky. Certainly less costly.

When the computers crash

Interesting commentary on EMR.
In an essay published in The Journal of the American Medical Association in 2002, internist Steven Angelo wrote about the day his hospital computer crashed. For a few hours, the intensive care unit staff was unable to track a patient's blood pressure or heart rate by looking at a monitor. The chairs in the unit's nursing station, he wrote, slowly emptied out: The doctors and nurses had gone to sit with their patients.

In our clinic, the computer monitors are placed so that the doctor can watch the screen or the patient, but not both. Frankly, it's not much of a contest. The monitors are mesmerizing, with their colors and windows, boxes and beeps, menus of pills ripe for the prescribing. Walk down the row of offices and you see the patients looking at their doctors, and the doctors looking at their screens.

Last week, when the system crashed, we looked at our patients instead.

Monday morning in the ER

This morning I worked in the ER for a mere 4 hours. I saw about 20 patients. I didn't really keep track, I was too busy. I think about 5 of these had to be admitted. When I left, there were about 12 charts for patients waiting to be seen and more checking in. It was all I could do to keep up with the yellow triage charts and some of the greens had been waiting for hours.

What is it with Monday mornings in the ER? I can understand that a private office, which has been closed for two days, may get swamped on Monday, but why the ER? We were open all weekend. Why do these people wait until Monday morning to come in?

I might think it was the weather. Locally, we had sunny, warm days on Saturday and Sunday, but it was cold and rainy this morning. But the nurses assure me that all Monday mornings are like this.

You can't control when you are going to get dyspneic or have chest pain, can you? But what about the 71 year old man who was seen in the ER on 2/3 and given 10 days worth of antibiotic? He assured me this morning that he was still taking his antibiotic as ordered and hadn't missed any doses. HUH? He also told me that he called his pulmonologist's office as soon as he left the ER on 2/3 and was given a f/u appointment for the end of March. Now, as busy as I was, I had to call the doctor's office to try to get this guy an earlier appointment. I found out he had missed three appointments since 2/3 and has one scheduled for this Friday. I discussed this with him and discharged him. But I am concerned that he won't show up on Friday. Hopefully, he will back to the ER if necessary. I don't know if I will ever see him again, or if he will be OK. I feel for him, though.

Friday, February 25, 2005

JCAHO BS

You know, I'm old enough (and that's not very old) to remember when hospitals didn't have interference certification by JCAHO. We just went about our business.

JCAHO initially offered services as a voluntary certification to demonstrate that the examined hospital followed it's own guidelines. This became a competitive edge. A hospital could advertise itself as JCAHO certified. Now it has become required by insurance companies.

The first time I had to experience JCAHO was as the chairman of the medical records committee at a Navy hospital. We didn't have to deal with insurance companies, but I suppose the brass wanted the merit badge. That was back when JCAHO didn't tell you how to do business, but merely evaluated whether you followed your own guidelines. Of course, now JCAHO dictates.

The reviewer for medical records was a surgeon. One of the rules we had in place was that an operative report had to be in the chart "within a day" of the operation. We received a "major" violation for one chart where an emergency c-section was done at 2345 and the op-note was dictated at 0030. No joke. It wasn't the same day. Fortunately, we were able to appeal our way out of that one (with his supervisor, the surgeon never relented.) But wouldn't you think a surgeon would understand that getting the op-note dictated in less than an hour after an emergency c-section was pretty good?

Now I find out that JCAHO wants to get into the business of certifying staffing organizations, such as the ER company I work for. How fast can we run away from this one?

Tort Reform

This article, Tort reform restores the courts, says:
Bravo to the U.S. Congress for passing the Class Action Fairness Act, which will help rein in our legal system that has run amok. With this legislation, consumers are the winners.

Our nation's courts serve, in part, to enable our citizens to resolve civil disputes in a fair and timely fashion. Excessive litigation distorts the courts' purposes, undermines respect for our civil justice system and delays justice for citizens entitled to due process. Some "excessive" civil lawsuits have become legendary. The McDonald's hot-coffee case has made the rounds of TV talk-shows and emerges as a source of cynical comment by jurors during jury selection. Too often, plaintiffs and their clever lawyers ask juries to provide compensation for the failure of common sense and the absence of accepting personal responsibility for one's choices. That's probably not the role the Founding Fathers envisioned for our civil courts.
On the other hand, another author, who I won't publicize with a link, tries to inflame by listing several examples and saying "These lawsuits — and the wrongs that they address — don’t sound frivolous to most people. But make no mistake; lawsuits like these are the target of 'tort reform' and the various efforts to reign in 'frivolous lawsuits.'" He wrote:
Corporate lobbyists have invented another new “crisis.” It’s called “lawsuit abuse,” a big money effort to call attention to the “frivolous lawsuit crisis.”

If you don’t know what a “frivolous” lawsuit is, think of the suit against the tobacco industry. Because of this lawsuit, the industry had to pay billions of dollars in damages. The suit showed that the industry deliberately concealed information on the dangers of smoking, in the hope of getting another generation of children addicted to its cigarettes.

Another “frivolous” lawsuit may force the asbestos industry to pay billions of dollars to workers who developed lung disease or died of exposure to asbestos. Lawsuits have proven that the industry concealed evidence of the dangers of asbestos from its workers for decades. Asbestos manufacturers were concerned that it would be hard to find workers if they knew that the job might kill them.

A third type of “frivolous” lawsuit stems from situations like Love Canal, where a whole community found it was raising its children in toxic waste produced by area industries. Many of these children were born with birth defects, or developed neurological or muscle disorders that prevented them from living normal lives. “Frivolous” lawsuits threaten to make such polluters compensate their victims.

Of course, no one except this author is calling these "frivolous" or arguing that these should not be pursued.

Earlier, I referred to the technique of arguing against program cuts by describing a sympathetic beneficiary who probably wouldn't be cut anyway. This is different. This is the classic "straw man" argument, where the writer describes several situations that are not objectionable to almost anyone and states that his opponent takes an unfavorable position regarding them. The problem is, no one has actually argued that the situations he described are objectionable nor that they should have been prohibited.

However, these two types of arguments are similar in this way: Both describe examples that almost anyone could agree are sympathetic and useful to address. Perhaps those involved in these examples would be adversely affected by the changes proposed. I think most people would agree that a program (or tort reform proposal) should contain enough slack to cover those in need and realize that the slack will allow some undeserving to participate. This is OK, but where do you draw the line? That is a hard call, but not made easier by false arguments regarding examples that are not borderline, that do not fall into the discriminatory zone of benefit.

I think you will find these comments on Asymmetrical Information interesting.

Marketing Drugs

As you can tell, I am a real believer in the free marketplace. But, is this really the best way to be spending our health care dollars:
Pharmaceutical companies spend more than $50 million, on average, for pre-launch marketing of drugs that are expected to become blockbusters (exceeding $1 billion in peak annual sales), according to a new report, "Pharmaceutical Product Commercialization: Pre-Clinical to Phase III Resource Allocation" ( http://www.PharmaCommercialization.com ), published by pharmaceutical business intelligence leader Cutting Edge Information.
From Pre-Launch Pharmaceutical Marketing Budgets Exceed $50 Million

I really don't think this (US Poll Backs Bigger Gov't Role on Drug Prices) is the answer, however. More and more physicians are electing not to participate in MediCare because of the atrocious reimbursement. Do the people in this poll understand what will happen if price controls are instituted? Drug company investors will just find something else to do with their money and the health care industry and the general health of the US will suffer.

Thursday, February 24, 2005

Domino Theory?

One way where Irag is indeed like Vietnam is the Domino Theory. You remember, if Vietnam falls all the other countries in SE Asia will fall like dominoes. It turned out to be inaccurate in SE Asia, but it seems to be applicable in the MidEast.

Look at these links, via Instapundit. First, a Syrian officer states that he trained Iraqis as terrorists to disrupt the process in Iraq. In the same editorial, the author described that Sudanese and Egyptians were trained in Syria to carry out attacks in Iraq. In this article, we see that the pro-Syrian government of Lebanon is being urged to resign and that a "neutral" one replace it.

Recently Syria has been implicated in the murder of Rafiq Hariri, increasing the "intense pressure to end Syrian domination" of Lebanon. Lebanese citizens are calling for elections.

Let's see: Afghanistan, Irag...Lebanon, Syria, Saudia Arabia? How many does it take to make a trail of dominoes?

More, from the Washington Post:
"It's strange for me to say it, but this process of change has started because of the American invasion of Iraq," explains Jumblatt. "I was cynical about Iraq. But when I saw the Iraqi people voting three weeks ago, 8 million of them, it was the start of a new Arab world." Jumblatt says this spark of democratic revolt is spreading. "The Syrian people, the Egyptian people, all say that something is changing. The Berlin Wall has fallen. We can see it."
Read the whole thing, via Chrenkoff.

Didn't Lebanon used to be a country all on its own?

UPDATE:
I'm behind in my reading. See the second item on Best of the Web, also.

Wednesday, February 23, 2005

Government sponsored EMR?

An argument for and against. As I have commented before, Medviews frequently writes in favor of government intervention. My view is that the marketplace will determine what is best.

For the best I've read on the weakness of government dictation of market issues, see Thomas Sowell.

Let's imagine an issue, which can remain undefined, on which the government has knowledge worth 2 million. Now imagine that ten percent of the US population each has knowledge worth one. Obviously the government has vastly more knowledge than any individual. However, the population as a whole has vastly more knowledge than the government.

For example, what if the government were tasked to decide what type of fertilizer we should use on our lawns and how much and how often. I'm sure the resources of the government could create an awesome panel with incredible horticulture experts that know more about fertilizer than any of us. This panel would be tasked with determining what types of fertilizers would be produced, in what quantitites and where the fertilizers would be distributed.

What the panel couldn't know is the individual preferences for what we want from our lawns, what we want to use them for and what we want them to look like. Also, imagine all the different types of soil, climate, etc. Allowing the marketplace to dictate the manufacture and distribution is vastly more effective. Just ask the farmers in the former USSR. The fields in the lands of the former USSR were very productive prior to central control but were devestated by central control of resources, including fertilizer.

There is no way that central control can understand the multitude of issues the way that the population at large can.

In the case of EMR, Dr. Henochowicz is concerned that there could be an electronic tower of Babel:
There are at present about 1800 different EMR systems on the market. Which do you choose? Which companies providing the product will still be in business 2 years from now? How will all the EMR systems talk to each other? Will we truly have an integrated nationwide network where patient information can transferred from one system to another?
His solution?
We need to have a coordinated, government led effort to get practices to go electronic. Subsidies need to be allocated on a means tested basis. Clinics that provide care to the indigent need more support than Park Avenue physicians. We also need to establish a uniform standard for EMRs. This was done with the internet through the designation of html as the standard mode of communication. The VA system has been suggested as the model for this standardization. This is a great idea, and government should get all the important players in the private sector together to make this happen.
I don't recall that the government was involved in specifying html as the standard for the web. When was the last time anyone thought the VA system worth emulating?

I agree with Dr. Henochowicz that it would be better if EMR's could communicate. Those of us who are old enough remember BetaMax vs VHS. This was resovled without goverment intervention. What about the standards for CD-ROM, DVD's and audio CD's. No goverment intervention there, but any one of us could trade DVD's (within regions) without trouble.

Trent McBride wrote:
It's ridiculous to think that 1 million physicians across this country, caring for 250 million people, can come up with one, and only one, set of standards and regulations to usher in a project that will cost tens of billions of dollars. Even assuming that this were possible, it's a horrible idea. The best EMRs will result from simultaneous systems running in parallel across the country, with trial and error finding out what works and what doesn't. It's ludicrous, and downright dangerous, to believe that physicians as a collective have the knowledge to know in foresight what will constitute the best set of standards for everyone's EMR.

If you allow the marketplace to dictate the results, over time a few dominant systems will emerge and will create a standard. Be patient. For Heaven's sake, don't invite the government in.

Bredesen Watch

Grand Rounds

Are up at Catallarchy! Expand your horizons.

Tuesday, February 22, 2005

More thoughts on screening

It is frustrating to me to hear women refer to "my annual," meaning their PAP smear and pelvic. I know of no reputable group that recommends annual PAP smears in low risk women, as most women are. The nurses with whom I work are generally in this group. Monogamous for many years, no history of positive PAP smears, no history of STD's, etc. But even these educated medical professionals are seduced by the routine of annual pelvic exams.

I asked an OB/GYN colleague what she recommended. She told me that she continues to do annual PAP's, even in low risk patients, even in post-hysterectomy patients, because, "That's the only way to get them to come in every year." Yeah, but for what? Why ask these women to come in every year? Why are you doing bimanuals in post-hysterectomy patients? What are you looking for? The answer is usually something about ovarian cancer. But no authority has recognized bimanual exams as effective screening tools for anything, let alone for ovarian cancer.

My patients would be amazed when I would try to educate them regarding the actual recommendations for these exams. Of course, some of them were skeptical and probably went elsewhere to get these tests. It's hard for me to practice EBM when some of my colleagues are ignoring the evidence and performing these unnecessary tests.

Screening tests

RangelMD has a great site and I recommend you keep current on it. Recently he posted on Misleading ads for whole body scans. I agree with him that this is not an effective screening tool. In order to be effective as a screen, a test must meet certain criteria:
  • The test must be able to detect the disease at a stage early enough to make a difference in the outcome. Example: bimanual pelvic exam for ovarian cancer. This test can detect the disease, but by the time the cancer has progressed enough to be palpable, it cannot be treated successfully.
  • The test must be acceptable. Bilateral mastectomy or oophorectomy or prostatectomy would detect the respective cancers, but would not be acceptable (or cost effective.)
  • The treatment must be less morbid than the disease. Example: Many patients would choose not to treat cancer with radiation and chemotherapy if this will not result in a significant extension of life.
  • When applied to a large enough population, the cost of the test must be acceptable to society as a whole. In other words, the cost per year of life saved after treatment must be acceptable. This includes the cost of negative work-ups for false negative tests. There is also the psychological cost of telling a patient that he has a positive scan and then the confirmatory testing is negative.
  • The test must be sufficiently sensitive and specific.
In addition, the disease must be prevalent enough in the population to make detection reasonable. It would not be useful to test for sickle cell disease in Northern Europeans.

So, while whole body CT may be effective in detecting certain diseases, the evidence is mounting that it is not an effective screening test.

Another thought:
In my community, patients can access these scans without a physician's order. There is not specific physician responsible for the f/u of any positive results. What happens to the patient with a lung mass who doesn't get f/u? Who gets sued?

I remember when I was doing OB and patients would ask for an ultrasound "just because." It got to the point where it was an expected part of being pregnant, and not just a test that was done for specific indications. The patients would often ask for a video of the ultrasound. There were people in the community who were doing ultrasounds at the patient's home just to provide a tape. My group was very nervous about this. The patients did not realize that there was no reassurance associated with these ultrasounds, that they were being provided for entertainment purposes only. Several of my partners were presented with these tapes and asked to review them to "make sure my baby's OK."

Sunday, February 20, 2005

Great Joke

On Powerline:
When Osama bin Laden died, he was met at the Pearly Gates by George Washington, who slapped him across the face and yelled, "How dare you try to destroy the nation I helped conceive!"

Patrick Henry approached, punched him in the nose and shouted, "You wanted to end our liberties but you failed."

James Madison followed, kicked him in the groin and said, "This is why I allowed our government to provide for the common defense!"

Thomas Jefferson was next, beat Osama with a long cane and snarled, "It was evil men like you who inspired me to write the Declaration of Independence."

The beatings and thrashings continued as George Mason, James Monroe and 66 other early Americans unleashed their anger on the terrorist leader.

As Osama lay bleeding and in pain, an Angel appeared. Bin Laden wept and said, "This is not what you promised me."

The Angel replied, "I told you there would be 72 Virginians waiting for you in Heaven. What did you think I said?"
Instapundit observed:
The people at the hospital are very nice, but this leads me to wonder what would happen if you did the equivalent of those mental-hospital experiments, where normal grad students tested out as crazy after 6 weeks in a mental hospital. If you took 100 healthy people, then put them in a hospital for 2 weeks of this sort of thing and tested them again, I'll bet that they'd be significantly worse off. People joke about the sleep interruptions, or about the bad food, but it's really no joke when you're in there for a while. I wonder why they don't do better?
I've often written orders that if the patient is asleep when the time for the order comes up, leave and come back later.

Glenn, to answer your question, it has to do with the infamous shift change , something that doctors have come to fear. In this case, unless the attending physician orders a specific time, daily weights are generally done by the night shift. This is because the day shift has to get the patients fed and ready for the days treatments/tests. Night shift ends at 7 AM and the "shift change" activities usually begin between 6 and 6:30. So weights have to be done between 5 and 6. Also, the doctors are rounding early in the morning and want this info on the chart.

I can't tell from what you have written, but I don't see any reason why the InstaWife is even getting daily weights. Probably a routine order. It is very reasonable to ask her doctor to cancel the order.

I advise all of my patients to ask the doctors these types of questions. Often, the situation can be fixed easily.

UPDATE: Additional comments by Shrinkette, hat tip to KevinMD. Although, my experience as a physician seeing these weights done is that the least experienced staff member does them and there is very little additional info gained in terms of responsiveness, etc. When the staff uses different scales on different days, it's hard to rely on any documented weight change unless it is large. This issue was best addressed by one ward who numbered their scales and required the staff member doing the weights to list which scale was used and to use the same one every day.

Have a blog, lose your job?

A friend of mine, at work, sent me this link: Have a blog, lose your job? Of course, whenever you say bad things about your boss or your employer, you risk your position. Even if you aren't fired directly, you aren't viewed the same and you won't be given the breaks or opportunities you might have otherwise. In addition, any trust is lost.

I'm not worried. I have a good job at a good company (actually, more than one) and a good boss. You will read criticism on this site, but nothing that will endanger my job. Not because I'm censoring myself, but I actually don't have anything bad I want to say.

You will not read insider info regarding my company.

Wednesday, February 16, 2005

To Prescribe or Not To Prescribe

Read this post by Dr. Charles. He laments his inability to impress the patient with his knowledge as much as Dr. Sven can with his smile.

In the ER, this is even more of a problem. At least in my private office, I have developed something of a rapport and reputation with my patients. They are there because they chose me, as opposed to simply getting me by the luck of the draw.

In the ER, I often don't have much time to teach my patients or to explain what we are doing. They don't know me and don't want to tell me whole truth (and nothing but the truth.)

I know that if I don't write that 4 year old with a URI a prescription, his mother will take him to his local doc the next day and there is a better than even chance he will get one there. Guess who is wrong? That ER doc that you don't even know or the doc you purposely chose who has cared for your kid for 4 years?

I have had complaints in the past that "that doc told me my kid wasn't even sick." I can assure you I have not said this, even if it is frequently true. Now what I tell the parent is:

I can understand your concern. I understand why you chose to come in to the ER and I think a lot of people would have made the same choice. I don't see a bacterial infection that I need to treat with antibiotics, but it is obvious that your child is sick. She has a bad cold and the only reason she is doing as well as she is doing is the excellent care and attention you have given her.I don't want the fact that I am not going to give her an antibiotic to make you think that I don't think she is sick. She definitely is.

You just have to reassure them that you believe their kid is sick and that they made the understandable choice to come in for an evaluation. I add:

The only thing I am 100% sure about is that I am never 100% sure about anything. If things worsen, don't hesitate to come back or go in to see your local doc. He might see evidence of a bacterial infection that isn't present right now. At that time, he might want to prescribe antibiotics.
The Art of Medicine in the ER.

Monday, February 14, 2005

Grand Rounds are up!

Check this compendium of posts from the medblogosphere! Hosted this week by Sumer's Radiology Site.

Saturday, February 12, 2005

Tort Reform

The Senate easily approved the most sweeping tort reform measure in a decade yesterday, the first in a series of bills that the strengthened Republican majority hopes will curb frivolous lawsuits.
The Class Action Fairness Act, which Democrats had denied a floor vote in the last Congress by filibuster, passed on a 72-26 vote.

Read the whole thing. Notice the vote total. During the last Congress, at least 40 Senators voted to continue the filibuster. Somehow, at least 14 changed their mind. Senator Daschle, can you explain this? Oh, wait, you aren't here anymore, are you?

It's about time

Viagra Spammers Targeted. I'm very careful about my e-mail and have managed to avoid the bulk of these.

Friday, February 11, 2005

MedPundit's EMR oddysey continues

MedPundit fells that there is something valuable in holding a paper file that is missing from the new EMR's.



When I hold a paper chart in my hand, it's almost as if the chart has something of the patient's character about it. I get a better and quicker sense of the patient (at least established patients) holding a paper chart than I do looking at an electronic record. No two paper charts look exactly alike. Some will have corner turned here, a scratched out line there. And there's something about a handwritten page that brings back clearer memories of the previous visit than the typewritten one. (I found this true for transcribed dictation, too.)


I agree with her. The other day I read in an EMR that a patient's gait was "cautious." When I had an opportunity to discuss this patient with the doc who wrote this, she said, "In the paper copy of my notes, I see that I drew a box around the word 'cautious.' " That meant a lot to her and demonstrated the importance of this observation. In the EMR, this emphasis was missing.

Bredesen Watch

From South End Grounds:



What to do about all of this....The first thing is the State GOP must recruit and fully fund a credible challenger to Bredesen. If he is given a pass in the '06 election, you can spell "second term" I-N-C-O-M-E T-A-X. He can pass it, he can do it with popular support and he can still run for higher office. You might think I'm wrong. But let him run unopposed and you'll find out how right I am.

Should you say I'm Sorry?



"We've got an idea worth listening to," said Doug Wojcieszak, who lost his brother because of a medical error and is a spokesman for The Sorry Works! Coalition. "Apologizing and fully disclosing medical errors are proven to reduce lawsuits and liability costs..."

The group aims to educate physicians, lawyers, insurance companies and patients across the country that an honest apology for medical errors followed by fair compensation is the best way to decrease insurance premiums and keep physicians from leaving.


We've all seen articles about malpractice lawsuits where the plaintiff just wanted the physician to acknowledge the mistake and say, "I'm sorry." But we are afraid that apology will be used against us. Many states' reform efforts include language to prevent those apologies from being used as admissions of wrong doing.

From GoodFellas

Ray Liota to Joe Pesci: "All I'm saying is, you're a funny guy!"

Chris, please don't shoot me!

Reporting HIV

Good post, from DB at DB's Medical Rants.

I guess size does matter:

Apparently, analysts feel that Pfizer is so big that it can't grow at a rate sufficient to maintain stock values.


But given its size, the company must generate $5 billion in new revenues to achieve double digit sales growth, and some analysts doubt its pipeline products are enough for Pfizer to reach that goal. That's led some to wonder whether Pfizer is just too big and if a business model built around numerous billion-dollar products works in an era of hypersensitivity about drug costs.

A comment from Dreaming again reminded me to point out that I work for a commercial disability insurer, not Social Security. SSDI is a different animal altogether. The company for whom I work has individual and group policies and I don't even know how many different contracts there are. Each contract has specific language that has to be applied to each determination.

Look at your car insurance, for example. You can buy a policy with a clause that pays for a rental car while yours is in the body shop, or not. It is not reasonable for you to argue "Well, this policy paid for the rental, why won't you?" You probably didn't get the rental car coverage to save money.

When an employer purchases a group contract, they do the same thing. They tailor the contract to balance between the needs and the costs. One employer may buy a policy that has exclusions for pre-existing conditions and another employer may not have that provision.

Social Security functions under different rules that most commercial insurers. Approval by Social Security may influence the decision of a commercial insurer, but you should not presume that approval by Social Security means that your medical condition will also meet the terms of your commercial policy.

Thursday, February 10, 2005

It is amazing what you can buy from Amazon. This is neat.

More Disability Training

OK, I don't want to sound like I never see a valid claim. We pay approximately 98% of the claims submitted. I only see the ones that someone else has screened and denied for some reason. The most common reason I will find medical support for impairment when a previous reviewer didn't is the submission of additional information.

When I was in private practice before I started this job, I didn't record certain observations that may have helped my patient. If you notice that your patient has trouble walking down the hallway to the exam room, mention it. Document whether she has trouble arising from the chair in the exam room and if she has trouble getting onto the exam table.

Don't be afraid to order a functional capacity exam.

In all respect to my fellow FP's, an exam and opinion from a specialist will carry more weight. Anyway, if the disease process is so severe that your patient can't work, shouldn't you get a consultation with an expert in that field, even if it is just one visit to confirm your diagnosis and treatment plan?

Don't restrict your comments to specific activities. Feel free to use examples. If a patient has knee pain from osteoarthritis, you may want to say:



Positional activities (such as sqatting/bending/ stooping/kneeling/crawling) are limited to no more than brief periods on a limited basis. For example, it is reasonable that [your patient] would be able to bend/stoop/squat as required to get something out of a floor level cabinet or drawer, but should not assume these types of positions to perform work activities.

If your patient has cervical spondylosis, you may want to say:



No prolonged static positioning without the ability to change positions as necessary. Use of a computer monitor, for example, is allowed if [your patient] has the freedom to move her head and change her viewing angle as necessary. However, job activities that require prolonged head positioning, such as an auto mechanic under a car, are restricted.

Disability concepts

As someone who is experienced in analyzing disabilty claims, I would like to share some observations:

  • As mentioned before, don't assume that being an advocate for the patient means advocating for being out of work and for payment of a disability claim. Frequently, the discipline of schedule, regular physical activity and social interaction are more beneficial to your patient. For example, getting up and eating meals at the same time every day are a big part of being employed and also a big part of managing diabetes.
  • As I mentioned in my discussion of this article, be as specific as possible. I will post some verbiage you may find useful. I know that I had no clue how to write restrictions before I started this job.
  • Try to address specific functional capacity issues. Avoid commenting on work capacity or whether your patient can go to work. It is not usually helpful, to the insurer or to your patient, to say "No work" or "Can't work." Even worse is "can't do anything."
  • The job tasks your patient describes to you may not be specifically required for that occupation, especially for another employer. This is why I recommend you avoid making the vocational decision yourself, unless you happen to have some expertise in vocational analysis.
  • Realize that there may be contractual reasons for denial of a claim. Perhaps there is a pre-existing condition clause or your patient was not covered by the policy on the date of disability. I even saw one claim where the employee had not even purchased the coverage and still filed a claim. No matter how impaired he may have been, he was not eligible for benefits.

More to come.

Wednesday, February 09, 2005

For several years, my son has bought me the Dilbert Day-to-Day Calendar. I don't know what happened this year, but I had to buy my own. What's up with that, Kyle?
Medpundit asks, "Who's the better doctor?" and links to this article. All I know is, the older I get, the better older doctors get.
Bredesen Is Presidential Material. Instapundit, here is a republican waiting to vote for Governor Bredesen for president.

State may get sales tax 'holiday'. Give the people what they want.

Gov. launches state pre-K web site. Get on the web to get the "grass-roots" behind you! Convince people that they need it, then get them to fight for it. Whether it's a good thing or not.

But don't let the blogosphere, or BredesenWatch, find out about it.


Maury man charged with TennCare fraud

This relates to this post and this one about where our money is going in our health care system. This morning on the radio I heard a Tennessee legislator stating that the state is the largest drug dealer in the state. According to the story, TennCare recipients are using their benefits to get drugs that they then sell on the street.

Tuesday, February 08, 2005

Flu blogging

Working in the ER right now. I've seen 22 since 6pm. That's a lot more than the usual 2.5 per hour. Who said the flu season was past?
"My duty is to my heart." Isn't this just another way to be selfish?

Years ago, in college, I was walking with a friend. She asked me, "What is your goal in life?" I didn't realize that this was, perhaps, an entry for her to share, and I answered, "I don't know." I probably added a few things about medical school, helping people, etc.

Of course, I asked her the same. Her answer came swiftly, but sincerely, "To glorify God in all that I do."

Wow, hers sure beat mine. I have thought about that exchange almost daily for over 20 years. I can truly say that my goal in life is to glorify God in all that I do. If only I actually did that.

I do not feel a duty to my heart, but to my Lord, my family and my fellows.

Tracy, I hope you know what that question, lo those many years ago, has meant to my life.
Don't miss Grand Rounds! There might be donuts. Hosted this week by Enoch Choi's Medmusings.
I hope the last two posts don't make me seem unreasonably heartless.

I would certainly support the postition by Respectful Insolence regarding the need for coverage for catastrophic illness for the working poor.

This is a very tragic story. Yes, I do have heartstrings and they have been tugged.
Bill would restrict sale of cold medicine used in methamphetamine.

My SWAT teammates who are on the Drug Enforcement Unit describe meth lab busts where they find huge quantities of OTC pseudoephedrine.

Pay attention the next time you are in a store like WalMart. You will see opened, empty, discarded pseudoephedrine packages stuffed in the back of the shelves. The thieves even pop the pills out of the blister packs.

Just another effect of the drug culture. Now we have to buy OTC cold meds, well, actually OTC. No longer stocked on the open shelves.

At least in my community, we don't have to sign for it. But that's probably coming.

Thanks, MedPundit.
See, here it is again. The straw-man. You know, where you accuse your opponent of something so you can argue against it. But, in reality, it is a false, unsupported accusation. The "something" you want to argue against was never done or said by your opponent. But, I guess, it makes for a good argument.

Take this post, by MedPundit. I agree with her position. The cuts in the VA system are not directed towards the poor, the indigent, the needy Iraq vets described in this article. Nobody intends for the quadriplegic from a helicopter crash in Somalia to go without health care. The cuts are directed towards the well-to-do who could have the means to get their care elsewhere. Why should your tax dollars, and mine, go to subsidize someone's Cadillac?

If the people running the system would manage properly, these cuts would not impair the care delivered to the truly needy.

Good call, Medpundit.
Like I said below, opponents or advocates of a particular position/policy can always find a tear-jerker to illustrate their point. However, in this article, "Son's death personalizes tort reform," I don't see that it works. I feel horrible for the family. But the article doesn't describe what the surgeon did wrong or what the act of malpractice was.

After the surgery, it says, regarding the surgeon, " 'Then he took the weekend off,' said Patty." Well, gee, Patty, do you really expect all docs to work 24/7? This suggests that nobody was around to take care of her son, not a reasonable suggestion.

The article described this comment by the Skolniks, "Suing medical providers for malpractice isn't about the money, they said. It's about accountability."

This isn't an article about tort reform. If it was just about the accountability, there is nothing in tort reform law that says you can't sue. It just limits the MONEY!. Hello! You said it wasn't about the money. You can still hold the physician accountable if there is malpractice.

The opposition to tort reform is about the money. Plain and simple.

TennCare Stuff

Hospital firms brace for TennCare cuts. I know that at my local hospital, while not a part of either of these chains, we expect a negative impact of $2.5 million for one year alone.

This article about bankruptcies seems similar to this, by RangelMD.

Whenever there is an article, like this, about TennCare, they always describe some poor soul that nobody could justify removing from the roles. However, I never see any articles listing all the healthy 20-somethings I see in the ER who are on TennCare. These are potentially insurable people who simply elect not to buy insurance and get on TennCare during an acute illness, usually requiring hospitalization, and then just stay on the roles. Then they ask for a prescription for Tylenol because they have no money. Then they spill their beeper and cigarettes out of their purse as they reach for that cell phone that's ringing.


Update:


I'm sorry, I misplaced a link, apparently. The two articles referenced above where that I said were similar indeed are, because I pasted in the same link for both. I don't know where the first is supposed to link. The article was about the onset of inability to work, commonly referred to as disability, caused bankruptcy. So, in addition to the medical costs referenced by Rangel, MD, there is also the loss of income.

Monday, February 07, 2005

The right way to report a patient's disability?

Dude, are you ever wrong! Well, OK, some of your advice is reasonable. I should know, I review medical records submitted in support of disability claims for a living.

Don't provide copies of your patient notes. Rather, provide a summary letter report. Office notes are often your "shorthand," may not be understandable to anyone else, and copies are often illegible. Notes also reflect only a snapshot of the patient's condition at the time of your examination. Without a full explanation, the insurance company might not fully understand the extent of your patient's disability.

It's OK to send a summary letter report. But the advice to avoid sending the actual office visit notes (OVN's) is horrible. The summary letter is basically meaningless without support from the contemperaneous OVN's. I appreciate the additional explanation, but don't try to tell me that the claimant was in great pain and couldn't walk in a letter if your OVN's don't describe this.

Rather than saying, "The patient can only sit for four hours at a time," describe the impairment in broad terms. Use "The patient cannot sit consistently or reliably."

What does "consistently or reliably" mean in terms of ability to perform occupational activities? I don't know and I can assure you the vocational analyst doesn't. As the Attending Physician (AP), you need to specify. I suggest, "Ms. Smith can sit for only 30 minutes at a time with a 5 minute break in between sitting." Or examples, such as, "Walking can be performed incidentally, such as walking to a photocopier infrequently. However, walking as a primary duty, such as delivering interoffice mail, is prohibited." Be as specific as possible. These restrictions will be compared to a job description to determine disability.

A patient who's unable to work could become destitute without the disability benefits to which he or she is entitled.
If appropriate, give your unqualified opinion that the patient is totally disabled and cannot work. It may be helpful to discuss with the patient the duties of his job and bear in mind the definition of disability in the policy.

It is not the job of the AP to determine to what benefits the claimant (patient) is entitled. If you haven't read the contract, you may be unaware of issues such as residual benefits, own occ vs any occ and the dreaded job vs occ issue. Frequently, the definition of disability in the contract is based on "National Economy" or how the job is done across the nation. In the specific job held by your patient, as an administrative assistant, for example, she may be required to deliver interoffice mail. However, in the National Economy, an administrative assistant may not be required to do this activity. Is this the case? I don't know, do you? Disability is a decision that is based on the contract issued, not just the claimant's medical condition. Impairment is a medical issue, but not disability. Do not render an opinion regarding disability or fitness to work unless you are intimately familiar with the claimant's contract and the material and substantial duties of the occupation, not just your patient's job. Describe medical support for specific restrictions and limitations, but not an opinion about fitness to work. How do you know that the employer will not accomodate a specific restriction?

Some good points:

  • Without a full explanation, the insurance company might not fully understand the extent of your patient's disability.
  • Describe your credentials and attach your CV to establish your expertise in treating the patient's condition.
  • Carefully prepare any Attending Physician Statement or other form provided by the insurance company. Attach your CV. Take the time to prepare a thorough response.
  • Most importantly, provide thorough answers. You're not limited to the space provided; attach a separate sheet if necessary. (Great point, the more info the better.)
  • By providing clear and accurate information you are decreasing the likelihood that your patient will have to fight for his claim.

My Recommendations:

  • Don't be offended if a reviewing physician doesn't agree with you. If you take the advice of this attorney and obfuscate the issues, this disagreement is more likely.
  • Don't take it personally. Don't become invested in the outcome of the claim. I don't mean to say that you should not advocate for your patient, strongly if necessary, but remember that there may be issues in the decision with which you are unaware.
  • Provide clear data. Don't try to hide info. I am constantly surprised when medical records arrive with sections blacked out. The claimant has signed a consent releasing all information.
  • Restrict your opinions to medically indicated/supported restrictions and limitations. Realize that your patient may not describe the actual occupational duties completely and accurately. It is not uncommon that I talk with an AP who has stated simply, "She can't work," only for him to find out that the job described to him is not the one his patient does.
  • Don't tell your patient, "You can't go to work." List what activities your patient can and can't do and let the employer decide whether they are willing to accomodate. You might be surprised.

Feel free to e-mail me with any questions.

Powerline has posted regarding "The Democrats As They Really Are." Deacon makes this point:

The Democrats don't have to face the voters again for two years, so they no longer feel the need to repress their ugliest sentiments, which defeat has made them feel all the more passionately.

The problem they have is that they don't understand, despite the way the blogs, especially Powerline, influenced the last election, that they are not protected by the two years between now and the next election. The blogosphere is like an elephant. It has a very long memory.

Perhaps they should all read this.
DB rants about drug reps and their gift giving. I join him in congratulating the Iowa practice that will no longer accept drug rep gifts or meals. If we all did this we would benefit by decreasing the proportion of drug costs attributable to this portion of the marketing budget. This has been a PR problem for physicians. Although we know that our decisions are not based on the gifts, it may not be that clear to our patients.

In addition, I am concerned by how many of my colleagues get a large portion of their information from the reps. Those of us who are Internet savvy have read many blogs and articles about the "slant" given the info by the reps and take what they say with a grain (or pound) of salt. We know that we have to verify whatever they say.

A few years ago, I attended the Scientific Assembly of the AAFP. One of the biggests medical conferences in the world. I was amazed at the expanse (and expense) of the pharmaceutical displays. Individual drugs were alloted more floor space than I have in my home!

I was embarassed by some of my colleagues' behavior. They were running around the hall grabbing up goodies, sometimes pushing people out the way. I saw one physician shouting and screaming at a drug rep that he didn't have time to go through the "educational" material required to get the "prize" at the end and that he should be given his "bootie" right away. The gift was a phone card for 10 minutes. Even at the inflated pay phone rates of $0.25 per minute, this doc was debasing himself for a phone card worth only a few dollars. I walked up to him and the thoroughly cowed young rep and held out a $5 bill and said, "Here, go buy a card. Leave her alone." He left without either the card or my $5. What a jerk.

Although his behavior was extreme, it was not completely atypical for that environment. I don't know about you, but I don't need another plastic pen, foam stress ball or refrigerator magnet, thank you.
Medical News Roundup/News on Drugs:

Botox Gone Bad {or You Get What You Pay For}
Nothing is risk free. Vanity has its price.

Vaccine doses could be limited again next flu season.

Pharmaceutical companies are trying to head off price controls by offering discounts to low-income families.

Is anyone out there still writing for COX-2 agents?
Merck, Novartis drugs added to FDA risk list.
Kaiser Orders Ban on Arthritis Drug Bextra.

Thar's money in them there pills!
Barr Suing FDA Over Generic Allegra-D.

And in the medical equipment companies:
Shares hot after letter from FDA.

Lots of buzz about misleading pharmaceutical promotions:
Health, FDA Warns Glaxo on Hypertension Drug Marketing.


Going bare, or nearly so.

In the near future, some Naples doctors may take great satisfaction ripping up — into little pieces — their malpractice insurance renewal notices.
And then, spying the scraps of paper in the trash, they may feel queasy over the dramatic change they're making. It's a leap from the tradition of paying the premium and trying not to let your blood boil, to becoming self-insured for medical malpractice. There's no insurance company there when the lawsuit is threatened.
The NCH Healthcare System has changed its long-held policy and now allows physicians in four specialties to stop carrying professional medical malpractice insurance. Instead, the doctors can self-insure by having an irrevocable letter of credit for $250,000 or escrow account with that amount.

From The Naples Daily News. Requires free registration. I believe in BugMeNot.

Sunday, February 06, 2005

So what is the differential diagnosis for this behavior? There is no way that anyone could consider this normal. The obvious is pica. But I am sure there are some psych diagnoses there.

Thanks, Ann Althouse, for the link.

Saturday, February 05, 2005

Kevin MD commented on the position of lawyers on this survey:



Did you notice that only 2/3 of respondents ranked physicians as "high" or "very high?"
Amazon has instituted Amazon Prime, where you prepay for a year of expedited 2 day shipping. As someone who uses Amazon a lot and usually selects the free shipping, this is a great deal for me. I get 2 day shipping and spread the cost (currently $79) over all the purchases I will make over the next year. Believe me, the per purchase cost will be minimal.

One advantage is that I can use the 1-click purchasing. When you are viewing an item and click the 1-click purchase, that's it. It is added to your cart, purchased and shipped with one click. Even if you are buying something inexpensive, it's OK, because your shipping is prepaid. Under the free shipping program, you had to buy at least $25 to qualify and sometimes had to wait until you had purchased several items.

Friday, February 04, 2005

As I mentioned, Medpundit is blogging her EMR experiences. She commented:

As to empowering the patient, the only advantage my electronic medical record
affords my patients is that I can fax their prescriptions over to the drug store
so they don't have to spend so much time waiting for it to be filled. The EMR is
more an advantage for myself and my staff than it is for my patients. It does
improve patient care somewhat, by improving the organization of the chart, but
the main advantage is to myself and to my staff.


I offer a great advantage to the patient and physician: The Internet.

My favorite system of those I reviewed was web-based. I could access it from any computer with web access, using only a very basic computer system. There was no server to buy or manage.

The software integrated web-based medical references. When I typed in a dx, the software could offer, at the click of a link, additional info, including differential diagnosis, treatment suggestions, patient education materials and websites to give the patient for their own research. As mentioned in an earlier post, immediate access at the terminal to drug references such as Tarascon, Pepid, and others allows for the best drug choices based on the newest information and offers built in drug calculators to ensure proper dosing.

I think this is a major advantage to the patient in putting this wealth of knowledge at the hands of the physician. In addition, I consider it to be a major time saver, as the physician doesn't have to dig through several books to get info. I have a concern that a physician in a busy clinic might not use the most up to date info because of the time constraints involved in accessing this info.
Medpundit has been blogging her experiences in switching to EMR. One of her concerns regarding prescriptions is that although EMR's will prevent errors due to bad handwriting, there will be errors due to typos.

In my recent experience helping set up a new clinic that was going to be EMR from the start, I researched several EMR software packages.

Sof the EMR packages I reviewed used picklists or pulldown menus for prescription choices. The best system I saw was based on the dx entered. After entering the dx, the software gave you a list (that you had previously designated or was based on various recommendation sources such as Sanford's (or both)) and you just clicked on the one you wanted. No typos. Of course, you have to make sure you clicked on the one you intended.

In addition, the software would calculate the dose for kiddies based on the weight entered by the screening nurse. No calculation errors!

I appreciated the time savings that just clicking on a choice offered over having to look something up in a drug reference, calculate the dose and write a prescription.

Thursday, February 03, 2005

Dr. Bernstein, of Bioethics Discussion Blog, requested, "Are you aware of any issues in medicine or biologic science which are being done right, could be improved or in fact represent totally unethical behavior?" As my introduction above indicates, I review medical records in connection with disability claims.

I see quite a few claims that are supported by attending physicians (AP) who view supporting the claim as "advocating for my patient." After I get a chance to discuss the claim with the AP, she will usually agree with my interpretation of the medical records in terms of specific restrictions and limitations, but sometimes will continue to advocate the patient's desire not to return to work.

However, I don't agree that not returning to work is always the best for the patient. It may be what the patient wants, but not necessarily in the patient's best interests. Frequently, the physical and psychological discipline associated with the workplace is beneficial to the patient.

Since when is it our responsibility to give the patient what they want, in the interest of advocacy, as opposed to standing firm for what is in the patient's best interest? If the patient wants antibiotics, yet we are confident she only has a viral URI, what do we tell her?

I believe a true advocate for the patient recommends and provides what is best for the patient, even if it isn't what the patient wants. We may lose some patients if we do this, but this particular post is about ethics.
Absolutely incredible news. Thanks to Medpundit.

I don't think anyone in medicine doubt's that we will eventually control/cure/eradicate HIV, or any other disease. However, we don't always expect to see these things in our lifetime. To see something like this is very exciting.

Wednesday, February 02, 2005

DrTony

RangelMD is introducing several new medbloggers, including me, to the blogosphere.

Thanks, Doc.
I am currently reading Blogging, Genius Strategies for Instant Web Content, by Biz Stone. I recommend it for anyone new to blogging.
Andrea asked me today about pepper spray for self-defense. I think this is a great idea. I would recommend a key-chain type for carry-around defense and a larger canister for your home and car.

At these prices, from Amazon, why not have several?