Posts Tagged ‘surgeon’

Hardware, software, and chairware

June 24, 2018

A problem is found, tell me where?

Is a problem that’s not the software

I said to IT

Perhaps it is me.

Is the answer to be found in the chair?

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission.

Eight years ago I took a course for doctors who want to be writers. Don’t use the word suddenly, they said, and never write, “All hell broke loose.”

I suppose all writing has rules, yet I haven’t figured out all the rules for effective blogging.

But I find myself enjoying this gig. A small hospital is an efficient hospital; one doesn’t waste a lot of steps.  Consider the context:  a functional Iowa town just big enough to have a hospital.  In two weeks I’ve dealt two marijuana users, and no drug seekers.  Every urine drug screen has come back clean.  Fewer than 10% of the patients smoke.

And I have time to spend with the patients. I listen attentively, I don’t interrupt.  I get to dictate my progress notes, and I can enter my hospital inpatient orders on paper.

I haven’t figured out how to use the Emergency Room EMR, not quite the same system as the inpatient program. I just couldn’t get it to turn on.

Today the Information Technology person asked me to show her the problem; I signed on and got a nice border on an otherwise blank screen.

“Is it the hardware?” I asked

She shook her head.

“The software?”


“The chairware?”

She looked at me, left eyebrow crowding the right.

“You know, the person in the chair?”

She burst out laughing, and told me she’d get back to me.

Despite cool, rainy weather, the clinic overheated. We got out the fans.  I sweated.  For the first time I realized that my large flat screen monitor produces a huge amount of heat.

The morning went at a reasonable pace. Online research, signing my dictations, reviewing labs.  Then at 11:00, suddenly, all hell broke loose.  The surgeon and the nephrologist each asked me for consultations.  The radiologist called from Orange City.  The neurologist called from Sioux City.  Two non-English speakers turned out to have a much more complicated clinical picture than we could have imagined.

I worked through lunch; the nurses and I did not get a chance to eat.

In the course of 4 hours I read 4 electrocardiograms, ordered 4 sets of labs and admitted 2 patients. I accommodated a walk-in.

I worked hard to replace my fluids lost to sweat.

And just as suddenly, things went quiet at 4:15PM. I finished with the two hospitalized patients at 5:00PM on the dot.  Food became my next priority.


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.

Fourteen hours of a zoo of a day.

February 17, 2011

I don’t do this because of the pay,

Going straight into the fray

     From eight until ten

     Like the old headless hen,

It’s been a zoo of a day.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  Avoiding burnout, I’m taking a sabbatical while my one-year non-compete clause winds down, having adventures, visiting family and friends, and working in out-of-the-way places.  Currently I’m on assignment at the hospital in Barrow, Alaska, the northernmost point in the United States.

I’m writing this after fourteen continuous hours of caring for sick people trying to get better, sick people trying to stay sick, well people pretending to be sick, and a few well people just wanting to go back to work.

I tried to take care of five people who came out and said they didn’t trust me, then tried to bully me into narcotics prescriptions.  I pointed out to them that if they really didn’t have confidence in my judgment they wouldn’t accept anything I would prescribe, and the only thing they should take from me is an arrangement to see another doctor.

A recurring theme today, just like an episode of a TV doctor show, involved a schizophrenic with a horrendous medical problem that cannot be dealt with on the North Slope.  We discussed the patient at morning rounds, I made several calls to Anchorage and received varying combinations of arrogance and sympathy from the Big City.

I placed a cast with the advice to the patient for prompt follow-up if the cast got too tight.  Which it did.

Influenza and post influenza problems saturated the walk-in clinics.  People slip on the ice and sometimes break things, but mostly just hurt for a couple of weeks.  I explained to a lot of people that if it didn’t hurt bad enough to come in for the first five, six, or eight days that they didn’t narcotics today, and they should expect to be sore for several days.

The Inuit smoke a lot of marijuana, which has marginal legality here.  But they smoke it now like hippies smoked it in the sixties and a lot of folks haven’t been unstoned for decades.  Some of them hunt stoned.  I see health problems related to cannabis abuse.

Instead of eating dinner, I waited twenty minutes to talk to a pediatrician at ANMC (Alaska Native Medical Center) because the phone operator didn’t read the call schedule correctly.

When I finally connected to the surgeon/gynecologist/pediatrician, I received cogent, useful advice in a time efficient fashion.

Seventy percent of my business came from tobacco, alcohol, or marijuana. Twenty percent came from influenza.  Ten percent came from bad luck or overeating or both.

And I saw something I’d never, ever seen before.  I didn’t even ask for permission to write about it, even if the answer had been yes, I wouldn’t have written the details.

Appendicitis on the front lines; drama and irony close to home

December 20, 2010

For the patient who hurts low and right,

And suffers from lost appetite

    Search high and low

    The appendix must go

Would a CAT scan help? Well, it might.

Appendicitis has afflicted so many patients since my arrival that I can write about the disease without identifying anyone in particular.

The classic appendicitis patient will complain of abdominal pain starting near the umbilicus (navel), increasing over the course of three days, and moving to the right lower quadrant, aggravated by jarring, and accompanied by loss of appetite.

I always ask the patient what they had for lunch, and whether they enjoyed it.

People with appendicitis come with a back story and a social context.  Some had serious medical problems before their appendix went bad.  They may use illegal or legal things to excess.  They may have good or bad relationships with their family members; they may have no family members at all.  They may not possess the ability to speak for themselves. 

The physician must rely on the information available.

Eighty percent of appendices live near a spot two-thirds of the way along a line from the belly button to the front point of the hip bone, called McBurney’s point; a patient who points there brings immediate suspicion for appendicitis.

If I call a surgeon, he or she will want to know about rebound (increased pain on sudden release of pressure on the abdomen), psoas sign (pain on pulling the right leg back when the patient lies on his or her left side), bunny hop (pain on jumping on the right foot), bowel sounds (presence or absence of normal gurgling in the abdomen), and guarding (tenseness of the abdominal wall muscles).

None of these signs or symptoms makes the diagnosis by itself.  I have had appendicitis patients come with pain low on the right, low on the left, high on the right, and high on the left.  Some had pain in the leg or the back, and a few had no pain at all.

Not one enjoyed their lunch.

When I worked in Navajoland, my appendicitis patients complained of not being able to eat rather than pain.

CT scans help if the history and physical don’t paint a clear picture but characteristic history and physical trump a normal CT scan.  “I operate on patients,” I heard a surgeon say, “Not images.”

Six years ago, while Bethany and I got ready to go out, I told her about the twinge I’d just had at McBurney’s point.  She asked me if I’d enjoyed lunch, which I had, and if I had pain when I hopped on my right foot, which I didn’t.  I ignored the mild zing which came and went over the next six months while my gallbladder went from bad to worse.  I set a convenient date for its removal, and as I walked to the OR with the surgeon, I said, “Listen, Mike, while you’re in there, take out my appendix.  I really don’t want to get back on this table.”

Ten days later, to my unpleasant surprise, the pathology report showed carcinoid, a low-grade cancer.

More things can go wrong with the appendix than just appendicitis.

Mennonites and CT scans

December 14, 2010

For the patient, here is the plan

Forget the equivocal scan

     I don’t need much urgin’

     To call up the surgeon

With the results of the tests that we ran

SYNOPSIS:  I’m a Family Physician from Sioux City, Iowa, making a career transition to avoid burnout.  While my one-year non-compete clause ticks off I’m traveling, doing locum tenens, and having adventures.  Right now I’m working at Van Buren County Hospital in southeast Iowa, where there are no stop lights or fast food.

I’m on call in Keosauqua, Iowa, where the mid-level providers (Physician’s Assistants and Nurse Practitioners) take first ER call, and the MD or DO provides back-up and more definitive care. 

The day till now has run on a low stress level.  As with any other day I care for patients, I came across a physical finding I’d never seen before, a soft lump where I should find hard bone.  The MRI machine comes in a trailer tomorrow and will give me an answer.

I hesitate more about ordering MRIs now than I did when I owned a part-share in a scanner, but I seem to order the same number.  I’m likely to fill out the paperwork and jump through the insurance company hoops when back pain goes down the leg and doesn’t get better, when mysterious physical findings can’t be denied, or when the patient worsens.  I find a lot of occult fractures, that is, broken bones that didn’t show on x-ray.

I remember patients I sent for MRI when I had profit motive to do so; scans showed problems malignant and benign, and surgeons prolonged or saved lives.

Keosauqua has growing Amish and Mennonite populations.  They call us English even if we aren’t English, we call them Pennsylvania Dutch even if they don’t live in Pennsylvania and they aren’t Dutch.  Their economic basis depends on subsistence farming; their agricultural methods qualify for the trendy buzzword sustainable.  I haven’t seen horse-drawn vehicles on the roads here but I have seen traditionally dressed people at the café and in the hospital waiting room.

A call comes from the ER for me to evaluate a Mennonite patient.  I find the family straightforward, respectful, and friendly.  I’ve seen the problem at hand hundreds of times.  The CT scan, ordered before I saw the patient, comes back equivocal, but my exam makes a firm diagnosis requiring a surgeon.

Our surgeon and I have come to similar places in our careers: we want to work but we want to slow down.  His solution to the full-time-means-eighty-hours problem led him to work two weeks out of four, while I intend to go to a forty-hour week when I get back to Sioux City. 

Thus, the patient arrives while our hospital’s surgeon is en route to Florida.

I admit my surprise when the matriarch pulls a cell phone from her skirt pocket.  You should have been there.  The family requests a surgeon across the state line in Missouri.

I make the call requesting a transfer, speaking to the surgeon herself.  My presentation of the patient comes off smooth and articulate.  

The family drives into the night, subsistence farmers with hard copies of lab results and a CD copy of the CT scan.

Contrast is the essence of meaning.