Archive for December, 2012

2012 in review

December 30, 2012

The end of December is near.

The stats can help make things clear

The response is inviting,

I’ll keep up my writing,

You know, it’s been quite a year.

The stats helper monkeys prepared a 2012 annual report for this blog.

Here’s an excerpt:

4,329 films were submitted to the 2012 Cannes Film Festival. This blog had 15,000 views in 2012. If each view were a film, this blog would power 3 Film Festivals

Click here to see the complete report.

Triumphs despite slow computer systems.

December 29, 2012

The computers were running so slow,

Still I managed the good patient flow

Through all the strife,

I saved someone’s life

The satisfaction’s as good as the dough.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

I wish I could give details of the case that made my day, but I didn’t ask for permission, and, under the circumstances, any permission would have been suspect.

The sequence of events unfolded over the course of a morning, and finished with a doctor’s moment.

My medical school class started with a couple of people who had nothing but money in mind.  Half of those dropped out in the first two years, the others dropped out in the third year, when we had to start dealing with real sleep deprivation and patients with genuine bodily fluids.  A mercenary mind-set can’t stand up to that kind of torture.

A lot more of us came to campus with pure idealism, which lasted till we started taking care of patients.  Too many nights without sleep and days without eating robbed us of the urge to save the world without recompense. 

All in all, the medical education process and general maturation brought us to reality.  Yes, the work carries a satisfaction that no other field can provide, but, we realized, no one should work for free.

My career trajectory has brought me full circle. I haven’t decided to volunteer, I still want to be paid, but the real rewards of my job come from professional satisfaction, when I have that moment when my education and my abilities to listen, examine, and think all come together and the patient gets better.

Saving the life of a baby, relieving back pain or a dislocated shoulder before the patient leaves, taking foreign bodies out of places where they don’t belong, all give me a thrill. 

Today the computer system ran with maddening slowness, taking 45 seconds to change the patient on the screen and 40 seconds to access the printer.  The first patient left me frustrated, but the second patient left me alarmed.  When testing confirmed my suspicions an hour later, a pink cloud of clinical satisfaction settled over the rest of the day as I received successive phone reports detailing the saving of a life.

A minor clinical triumph followed in the late morning. 

I talked to three patients who have taken up the good cause of diet and exercise, losing a total of 280 pounds between them, and doing away with a total of 14 medications for five diseases. 

One patient, about whom I’ve written in the past, came in, still a beacon of light and hope to many on the verge of despair.

I still have defeats, the alcoholics who have no insight, the smokers who don’t want to stop and in the next breath talk about their deceased close family members, the obese who refuse to exercise.

And in between I took care of the curable and the treatable.  I finished with patients before the end of the session, and settled down with my computer to finish the documentation for the day, with the system still running at a glacier’s pace.

Originally written mid-December.

Christmas 2012: caution, longer than usual.

December 26, 2012

These things sure shouldn’t come cheap,

The phone, the admit, the beep

One hundred and twenty

Hours seem plenty

To forego quality sleep. 

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

Christmas falls on a Tuesday this year, so that the holiday call includes everything from Friday at 8:00 AM till Wednesday at 8:00AM. 

My share of the dirty job began well on Friday; I started early, moved efficiently and rounded on twelve at the first hospital, discharging 3.  Our hospital nurse greatly boosted my efficiency by entering orders, filling me in on the patients, researching old charts, and placing calls.  We rounded on three more at the second hospital, finishing rounds well before lunch.

I got to eat a festive meal at the clinic, pizza bought by the providers and managers.  A quick nap in my office chair followed by a couple of hours of paperwork, and a hospital admit through the ER rounded out the afternoon.

Friday night I slept poorly, my sleep ruined by vigilance.  Still I got through rounds by 12:30, then napped well into the afternoon.  After dark, the real work started with admission after admission. 

Three different patients couldn’t talk to me for three different reasons.  Still, it makes the drama and the irony more poignant when I carry on a conversation and have to keep redirecting my comments to the patient.  And I don’t know which strikes harder, doing so with a conscious or an unconscious patient but the contrast in itself brings meaning.

Called in at midnight and back home past one, and hammered by the phone every time I got to REM sleep, I dragged myself into rounds on Saturday morning. 

About 830AM I had trouble keeping my thoughts in my head long enough to write them on an orders sheet, and I simply had to rest.  In a doctor’s dictation room I leaned my head back against the wall.  I crossed my arms and napped for 9 minutes, exiting the real world directly to dreamland and coming back without going through non-dream sleep.  I awakened euphoric.  I finished my rounds by noon and returned home to try to nap again.

Eleven phone calls shattered my siesta till I went to the ER to admit a patient.  I returned to the same hospital at midnight for another admission, and 8 phone calls followed till 6 on Sunday morning, when I gave up trying to sleep.  Only one phone call interrupted my shower. 

Sunday rounds went well and at 3 I signed off to my partner and went to the gym for a workout.  Bethany and I dined out and I crawled into bed early and out early.

On Christmas Eve morning I went back to the gym.  Rounds on 9 patients (with one discharge) followed breakfast out. 

The hospital’s yearly culinary largesse helped keep the good humor of a good night’s sleep, and I finished rounds before noon.  Preemptive napping alternated with beeper traffic punctuated the afternoon till an admission at 500PM and another at 700PM. 

Christmas Eve found me responsible for 20 hospital patients.  Three narcotics abusers had legitimate medical problems requiring narcotics administration.  Three people had pancreatitis.  Two people lied to me about drug use and four others told the truth.  Terrible infections in various states of healing besieged the immune systems of five patients. 

Five phone calls mangled sleep between midnight and 100AM, mostly concerning a psychiatric patient with no medical diagnosis; the question concerned not patient care but which physician should assume title of attending and which consulting.

The morning darkness of the 25th found me in the doctor’s lounge with a census of 11 in one hospital.  For each patient I reviewed vital signs, labs, x-ray reports, consultants’ dictations and the note for the previous day before I entered the room, washed my hands, greeted all present, sat down, asked about symptoms, stood up, listened to heart and lungs and examined what needed examination, sat down again, went over the case so far, and told a joke.  I spoke directly with consultants regarding three.  Another six required discussion with the nursing staff.

Substance abuse, mostly alcohol, runs rampant in patient populations; today I discussed cocaine with twice as many patients as usual.  A substance that leads people to sex work, it also brings on the death of heart tissue at an incongruous young age, which in turns leads me to look at the poetry of pathology. 

I came home at 1230PM and lunched.  I plugged in my phone and lay down, intending to have my standard 18 minute power nap and awakened two hours later, refreshed in body and battery.

We had a birthday dinner with our neighbor.  Bethany came with me when I left for more hospital work at 700PM. 

Every visit with a patient requires documentation.  I found 64 dictations I had to review and edit; about one-third had laughable typos (for example, I said trophic changes at the ankles, and they typed terrific changes at the ankle). 

Just as I finished, I received a beep from the other hospital’s ER.  A young patient required admission.  As I gathered myself, my beeper sounded its cheerful ring again from the other ER; an adult required admission.

I left Bethany in the doctor’s lounge and set off towards the other end of the hospital, 300 yards away.  Cheerful drama and irony followed, and I returned fifty minutes later.

Tired people make mistakes.  I arrived at the other hospital and realized I’d forgotten to download the history and physical I’d just dictated from my pocket machine.   Having Bethany do that for me without orientation and training did not rate the word feasible.

I took the elevator to the fourth floor.  The patient and the family recognized me from a year ago as the doctor who plays with yoyos. 

At 1010 PM we started the cross town drive.  The process of downloading involved 9 distinct steps and a 3-digit code but lasted less than a minute.

In bed an hour later and promptly asleep, vigilance awakened me at 130AM.  I took my own advice to get out of bed and do Something Else if unable to sleep for more than 10 minutes in bed.  Yawning set in an hour later, and I slept solidly till the alarm went off 15 minutes shy of 600AM.

The beeper and phone both went off at 630AM; a patient needed admission through the ER of one of the hospitals, but I had a commitment to a C-section at the other hospital at 700AM.  When mom and baby checked out normal, I called my partners about the admit.

I can’t give details but the fine points of that last admission’s turf question have huge ramifications.  Things settled, I got back in the car at 800AM.

Thus in 120 hours of holiday call, I put in 28 hours in the hospital, and took 161 phone calls.  I got called back in to admit patients 7 times.  I got 17 hours of payback coverage that included an excellent night’s sleep, otherwise my longest uninterrupted slumber was 5 hours.

I’m napping most of the day, and going deer hunting this afternoon.



Avoiding liquids you can light

December 18, 2012

With alcohol, here is the gist,

For the drink that you hold in your fist

When combined with a virus

It just might require us

To name you on our transplant list.        

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

The patient gave me permission to include more information than I have.

A remarkable organ, the liver can bounce back from terrible damage in the absence of diffuse scarring.  Capable of detoxifying a large number of poisons, it regulates carbohydrate, fat, and protein metabolism. 

When I started into medical school, we knew about infectious hepatitis (now hepatitis A) and serum hepatitis (hepatitis B). By the time I finished residency we had named a third virus non-A, non-B hepatitis, but this creative moniker didn’t last long and we now know it as hepatitis C.   Others exist, but these three very different diseases occupy most of our concerns for viral hepatitis. 

The last hepatitis A outbreak I saw happened in 1986 in on the Winnebago Reservation; the Tribal Health Department rose to the challenge and vaccinated all the contacts in less than 48 hours. 

The vaccines for hepatitis A and B stand as our first line of defense, and we don’t see much of either any more. 

Nobody dies from hepatitis A but people get awfully sick with it. 

Hepatitis B remains the most infectious particle known; a teaspoon of blood infected with it stirred into a swimming pool full of water would still transmit the virus.  Contracted in childhood it can lead to chronic active hepatitis, thence to cirrhosis and cancer; contracted in adulthood, the body generally clears the virus from circulation.

We have no good vaccine for hepatitis C, but in the last ten years I have seen treatment go from 10% curative to 60% curative (but it lasts 9 months and costs hundreds of thousands of dollars).  Better treatments loom on the horizon.

Hepatitis C multiplies the effect of alcohol on the liver by a factor of 20, and if a person can’t stop drinking during treatment, the treatment does no good.  Thus hepatitis C remains America’s leading cause of cirrhosis requiring liver transplant. 

I recently spoke with a newly diagnosed hepatitis C patient, who, to my surprise, has no interest in alcohol, wants to take the treatment, and has insurance to cover it.  At the very end of the interview I asked about Lysol Spray.  It contains 96% ethyl alcohol, which makes it twice the strength of whiskey.  (It also has a small amount of phenol to make it taste bad and destroy the liver even faster.)

The patient in fact weekly used several cans of Lysol Spray cleaning at home and at work.  I talked about its alcohol content for a few minutes.  Then we sat in stunned silence.  I followed with advice to stay away from volatile solvents in general; the term drew puzzlement from the patient.  After an explanation, the patient said, “Ok, then I need to keep away from any liquid you can light.”

I nodded.  “Well said.  Any objections if I hijack your phrase?”

The patient had none.

I was just doing my job.

No illusions: lies and drugs.

December 15, 2012

This rule I won’t even bend,

I no longer even pretend

I see no excuse

For those drugs of abuse

That make up a frightening trend.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

Last year legally prescribed narcotics killed more Americans than the bullets or the cars.  This frightening statistic comes after a four-year near-logarithmic increase and matches the same trend in the number of narcotic pills prescribed.

Several layers of government keep track of the use of certain medications, the ones most susceptible to abuse, now referred to as controlled or scheduled drugs.  I have to have a slip of paper from any state government where I practice and the federal government to prescribe any narcotic, also addictive tranquilizers, most sleeping pills, and testosterone.

I tend to reach for those drugs as a last resort.  We have a lot of other things to treat pain and anxiety and sleeplessness; nonetheless controlled medications have their place in the work I do.

Of course a lot of patients disagree with me as to how big that place needs to be.

As required by my state licensing board, I took a two hour video course in the proper prescribing of pain medications, exhorting me to watch out for personal and family history of crime or substance abuse, past incarcerations, or frequent missed appointments.

More than half of my new patients don’t show for their first appointment, which leads me to wonder about substance abuse even before I see them.

Our practice includes a large number of people who have done significant time behind bars; I don’t want to know their crimes.  Everywhere I’ve practiced, abuse of alcohol and other substances runs rampant.

So, all in all, I keep my suspicions high, particularly when a new patient comes in with a long med list including tranquilizers and narcotics.

The number of good reasons to prescribe long-term narcotics continues to dwindle; for example, evidence-based medicine shows the opiates lose their effectiveness for back pain after 8 weeks.  I never prescribe large numbers of the two most popular short acting tranquilizers, alprazolam and lorazepam; if the person really has that much anxiety I recommend the long-acting but less marketable cousin, clonazepam.

Really, the problem comes down to diversion: someone other than the patient taking the prescribed drug.   

Thus, for those patients on long term controlled medications, we make sure they sign an agreement that says they won’t share those drugs, and that they’ll come in, when asked, for a urine drug screen and pill count.  And that they won’t seek controlled substances from more than one provider. 

I used to believe people who would tell me they used to abuse drugs but named a date when they quit.  Most can tell twelve-step stories. 

Two of my patients flunked the urine test this last week. 

I’ve asked our case manager to contact them, to see if they’ll come in to get counseling.

I don’t hold high hopes.

Pills and skills: you need a tool set to deal with chronic pain. (Caution: longer than average.)

December 9, 2012

This post is far from laconic

On a subject that’s close to demonic

I don’t think it’s wrong

To write twice as long

On pain, not acute, that is chronic.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

A lot of people deal with a lot of pain in this world.  I’m one of them.

Acute pain, short term in duration and a useful signal to avoid destructive situations, distinguishes itself from chronic not only in terms of duration but in neurophysiology.

My back started to hurt at age 13; my pediatrician initially attributed the problem to growing pains.  Worsening symptoms brought me to the orthopedist at age 17; he proposed surgery and I declined.  By the time I came up for my draft physical during the height of the Viet Nam war, I had a solid 7 year history of back problems well documented.  But the x-ray of my low back gets more credit for keeping me out of a stupid war and saving my life than the pain.

Normal people have five vertebrae between the last rib and the top of the pelvis.  I have four; what should be the bottommost one, the fifth, is fixed to the pelvis on one side but not the other, giving me a mechanically unsound low back. 

So I survived when 50,000 of my generation did not, and my back hasn’t stop hurting.

By the time I hit age 30 I had seen seven different doctors; in their aggregate they convinced me that the pain was in my head.  In so doing, they taught me the most important part of learning to live with the pain.  In a shared triumph of therapeutic decision making, they hadn’t started me on narcotics.

In fact I owe my life to a disease called ankylosing spondylitis, which hits the spine in much the same way that its cousin, rheumatoid arthritis, hits the joints of the arms, hands, legs, and feet.

In the intervening years I had a disc go bad.  One of my low back vertebrae has slid forward on the one below up (spondylosis and spondylolisthesis), and I have developed a worrisome curvature (scoliosis) in the same region.  All in all, I have five bad diagnoses between my ribs and my pelvis.  I’ve only met three people who have worse backs than mine.

When I finally got the right diagnosis of my main back problem, I got a prescription for indomethacin, a very powerful anti-inflammatory drug.  I took it for a decade and I paid for pain relief with loss of kidney function.

I have learned a great deal about chronic pain management on a personal basis.  As with most other problems in medicine, successful management includes both pharmacologic and non-pharmacologic approaches (pills and skills).

We currently measure pain on a ten-point scale; zero being no pain at all and 10 being the worst pain of a person’s life.  When thinking about my pain, I think about the hours after abdominal surgery when I refused narcotic pain relief; it hurt about as bad as when my disc broke open and pushed against the nerve that goes to my shin muscles. 

Life, just the ordinary course of living, includes pain, on the ten-point scale, up to level 4.  At level 6, I start to withdraw socially, and at level 8 I cannot acquire new information or learn. 

As the years went by, I put together a skill set, much like a set of tools, to deal with the pain.  None of the tools would take away all the pain, but each could take away at least a half point.  I recommend my chronic pain patients put together their own tool kit to learn to live with pain.

Indomethacin helped me by at least 3 points; its close relative, naproxen (the active ingredient in Alleve) helped by 2 points but also hurt my kidneys, and now I’m permanently off the entire class of drugs.

Acetaminophen (Tylenol) takes two points off my pain and deserves a Personal Favorite Drug designation.

A 6 level of pain turns into a 4 with a good night’s sleep and into an 8 after a night with poor sleep, and everyone knows it; much of the time and energy I put into pain management goes into sleep management. 

Skelaxin, a muscle relaxant, takes two points off pain caused by spasm.

Enbrel, a drug that costs $1500 a month, takes 4 or 5 points off my pain because it quells the root cause of my ankylosing spondylitis pain, inflammation.

Acupuncture can take two points off.

Massage or a long hot shower is each good for a point.

I can lose between a half point and a point of my pain by socializing, just getting out and talking with other people.

A good, long aerobic work-out can drop a point or two.

A person becomes completely insensitive to pain during orgasm; and relatively insensitive to pain during foreplay and afterglow; how much the activity reduces pain and how long the reduction lasts varies from person to person. 

Good footwear, including shoes, orthotics, and socks, can take off a half point each if I have been ignoring their importance.

Capsaicin cream helps me more in the winter months than in the summer months.  The active ingredient in jalapenos interferes with the dorsal root ganglion’s ability to transmit the signals of chronic pain.  I have no problem slathering it on whenever I need it.  However, most people need to start with a small area, the size of a quarter or half-dollar, apply it three times a day, and not enlarge the area for three days.  And everyone needs to wash their hands with soap and water twice after applying it.

Fish oil capsules, from 2 to 6 grams a day, can reduce inflammatory pain by up to a point (I get about half a point) if used conscientiously for six weeks, but fish oil that sat too long on the shelf (more than six months) can make things worse.

Transcutaneous electrical nerve stimulator (TENS) units bring me about a point of pain relief, but only during certain parts of the flare cycle; they are much more effective for the pain that follows shingles.

I haven’t mentioned the anti-depressants like Cymbalta, trazodone, or nortryptylline.  Good agents all, a doctor in a call rotation can’t take them regularly because of sleepiness.

Study after study has shown oral narcotics capable of reducing chronic pain by 2.7 points, placebo by 2.1 points, and lowly Tylenol by 2.4.

Coding, more complicated than da Vinci

December 2, 2012

I’m not in the overcharge mode

But adequate coin I have stowed

It just seems to me

I shouldn’t need a degree

To figure out the right code.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

In residency, I worked for a month in Thermopolis, Wyoming; the title of the rotation was Supervised Rural Practice Elective.  I had my entry into the idea that I might receive money for my work.  My preceptor, a surgeon, charged $15 for an office call, and felt that I should, as well.  Of that amount, $5 would cover overhead, $5 would go to the preceptor, and $5 would end up in my pocket.

Shocked and horrified that I’d make more money than I had intended, I protested that my $1,300 per month salary covered me.

The preceptor wouldn’t hear of it, and insisted I get my share of the proceeds.  In the end, I caved.

I had a great time and met some wonderful people, including a real author, Win Blevins.  I felt funny about taking money for my services.

From that time in 1981 till I left the Indian Health Service in 1987, I didn’t worry about billing—I was on salary.

By 1987, faceless sectors of the government had decided that cognitive medical services could be stratified into six levels, excluding procedures. 

The Omnibus Budget and Reconciliation Act (OBRA) passed in careless haste in 1989, declared six levels excessive, and consolidated things into five, partly in a move to decrease Medicare/Medicaid spending.  But the same act greatly increased the difficulty of deciding the complexity of a medical visit by declaring the existence of a code for every medical service.

(CPT or Current Procedural Terminology codes have to do with what the physician did; ICD codes refer to with diagnoses; the government proposes that in 18 months those codes attain a level of complexity literally 10 times greater than current.  Most docs do not know that ICD stands for International Causes of Death.)

I attended lecture after lecture, trying to understand how to code.  Eventually, the (then) six docs at the Practice Formerly Known As Mine, hired a professional coder.  She tried to start by giving us the essential theory of coding.  We stopped her.  Each of us had been through a minimum of 8 hours of instruction, we said, and none of us understood, and could you please go over some charts with us?

We recouped the price we paid the coder before the sun set; we had undercoded everything up till then.  We brought the same coder back every 6 months to do chart audits.  We continued to undercode but we made improvements.

I left private practice, but even in a salaried position in a Community Health Center, coding has raised its ugly head, now much more complicated than ever before.  The Coding Consultant came on Friday.

She gave a general lecture for an hour, went into some specifics for the practice for an hour, than six of us got one-on-one sessions. 

I started my half-hour with observing that coding has attained layers of complexity resulting in an academic discipline in which one may now earn a 4 year degree, and, at this phase of my career, I wasn’t about to start that course of study.

I still undercode, but not as badly as I once did; I could have billed approximately twice as much for hospital charges as I did for more than 15 years. 

Sure I feel stupid, but those mistakes have passed, and, having learned from them, I move on.