Just for a change of pace, the back:
We have siding (though why they don’t call it “backing” when it’s on the back of the house…)
Plumbing and electrical rough-ins mostly complete. First (formal) walk through is tomorrow.
Windows also now placed in the family room, only visible from the back of the house. Plumbing and electrical mostly done. Ready for “Pre-drywall walk through” next week.
Also coming up next week: see those boxes in the right side of the garage? That’s siding. They should also be delivering a pile of brick sometime soon, so the exterior should really start taking shape quickly.
When last we visited the world of electronic medical records, Dino and Friend were happily puttering along with our freebie EMR and our freebie practice management system (including free electronic claim submissions.) We were hooked up electronically to the lab, so we entered orders and got results through the computer, though we still have to print out requisitions and labels for specimens. But we still had a fax machine.
Until about six months ago, when I splurged on a hideously complex and expensive piece of technology which we plugged into the fax phone line and one of the office computers, and Voila! Faxes on the computer. The fax machine still sits there, seldom utilized (except for outgoing faxes; we could do those electronically as well, but Friend has some techno-timidity), though it comes in handy when the power fails. (It comes back on automatically, whereas the computer does not.)
At last the office utilization of paper has shrunk. Dramatically! Checking faxes is now a matter of point and click instead of risking smeary-inked paper cuts. Best of all, they go directly into the EMR.
The next step — over a chasm still as yawningly huge as ever — is sharing all this information with other doctors. As mentioned above, lab results come directly into the computer as well. Luckily, the lab has this nifty feature allowing me to send duplicate copies to referring physicians. So whenever I draw a test for another doctor, I always make a point of asking the lab to send it along. (Yes, people come to me for blood draws. I have mad phlebotomy skillz).
There’s this one office, though, that always calls and asks us to fax patients’ labs over.
“Didn’t you get it from the lab?” I ask, over and over.
“No,” they claim.
I look at the lab report. Sure enough, it says right there, “DUPLICATE FAXED TO ABC SPECIALISTS.”
“But the lab report says they sent it to your office.”
“Oh, well Dr. A can’t access it through our EMR unless it comes directly to him.”
Only problem with that is that when I put Dr. A’s name into the lab, the program changes it to the practice information.
So I guess we’re not finished killing trees just yet.
Lots has been happening inside (plumbing, wiring, etc.) but nothing much that shows up in a picture Today, though, there was action: cutout done for the window over the garage, of which DSS sent me a picture.
Here’s the thing, though: when I downloaded and opened the image, the way it showed up against my computer desktop cracked me up. So here’s a screenshot instead of just the picture:
Looks like a scary neighborhood we’re moving to, doesn’t it.
We lost a branch off a big old tree a few weeks ago.
“Call the tree guy,” said DSS.
“It’ll cost us a grand,” I muttered.
“No it won’t,” he said, dialing Dan, the tree guy.
$300 later and the branch was gone. Such a deal. But Dan the tree guy discovered that the tree was starting to rot out. Also, without the fallen branch, the tree was now dangerously unbalanced and really should be taken down, as it could present a safety hazard. $700 later and the “big stick” (as he called it) was history.
“Told you so,” I muttered to DSS.
But I had the chance to talk with Dan the tree guy.
“So I guess your dream job would be something in forestry, right?” I asked.
“No. I take care of trees.”
“But isn’t a forest just a whole bunch of trees?”
“Well, yeah. But there’s much more involved in taking care of a forest than just taking care of one tree at a time.”
Hm. Sounds familiar.
I take care of patients. Many patients. But, contrary to the impressions of the medically naive regulators who somehow consider themselves competent to pontificate on health care, a “population” is more than just a collection of “many patients.”
My job is to take the best possible care of the patient in front of me. Then the next, and the next, and the one after that. At the end of the day, however many patients I’ve seen, I still haven’t taken care of a “population.”
Caring for populations is called “Public Health.” It includes such things as access to potable water, food supplies, and schools as well as hospitals, doctors, and medical care. Physicians can be involved in public health, but it really doesn’t have anything to do with “practicing medicine.”
If the patient in front of me needs an MRI, I cannot in good conscience tell him that he can’t have it because someone else may need it more. That’s a population calculation, and it falls into the realm of public health. If you don’t need whatever it is you’re asking for, it’s my job to explain to you why you don’t need it. It has nothing to do with “good stewardship of scarce resources.” If you need an MRI, a consultation, or a procedure, my job is to do everything in my power to see that you get it. Period.
All these calls for Primary physicians (in Orwellianly named “Patient Centered Medical Homes“) to “manage populations” are disingenuous at best, and counterproductive at worst. We don’t manage populations. We take care of patients. One at a time. Each to the very best of our ability, with the help of the best possible evidence, but still one at a time.
And then the next.
Several more things have happened that aren’t visible from the outside. We now have cement floors on the front porch, patio, garage and basement, plus stairs down to the basement. The half-wall that will eventually be the larger of our two kitchen islands is in place.
Still a ways to go, but getting there.
The topic for today is In-Home Assessments by insurers masquerading as “useful.” I’ve previously discussed my observation that only patients with few or no actual medical problems seem to be chosen for these assessments. What happens when someone with multiple, complex, longstanding problems is selected?
Um, okay then.
PAIN TREATMENT PLAN: Follow up with doctor
Always a great default response. Since you home-assessment folks are right on top of things, what else do you suggest?
Member is recommended for reassessment of pain in: 6 weeks
Right. Because at that point it will have been there for 42 years and 6 weeks.
Good for a laugh, even though there’s nothing funny about it at all.
Did you know that Google will display a special birthday doodle for you on your birthday?
I didn’t. Until today, when I saw this:
Oh, I thought. That looks like a doodle for someone’s birthday. Let me mouse over and see who…turns out that the alt-text mouseover message says, “Happy Birthday, Dino.”
Udon Noodles with Doctored Peanut Sauce.
Some assembly required:
I just didn’t like the looks of him.
It was the way he was breathing. I counted for a full minute: 24 breaths. (The ER would later document 40.) No accessory muscle use. Not even much coughing. He didn’t look overly anxious or uncomfortable, though he said he couldn’t breathe. No fever. No wheezing or other abnormal lung sounds on exam. No leg swelling or tenderness. Pulse ox 95% on room air. (97% in the ER.) Not terrible for a non-smoker in his 60s. Not much to go on.
I was afraid he had a blood clot in his lungs. Pulmonary embolism; PE, for short. Life-threatening if not caught. Fever, cough, chest pain, anxiety, and leg pain (clots in the leg can break off and go to the lungs) would have been suggestive signs. Then again, their absence didn’t rule it out by any means.
Here’s the kicker: He was already on coumadin, a blood thinner, and his INR was 2.9 the week before. He was therapeutically anticoagulated. Blood thinners are supposed to prevent blood clots. He couldn’t have a blood clot in his lungs if he was already on blood thinners, could he? What was going on?
Pneumonia? Possibly, but with no cough, fever, chest pain, or abnormal lung exam, it seemed less likely. Asthma? Even less likely with a normal exam.
I just didn’t like the looks of him.
So I called the ER and told them I was sending him over.
“Already on coumadin?” asked the nurse.
“Hmph. Probably not a PE. But send him over; we’ll take care of him.”
Later that afternoon, the patient called me.
“I just wanted to say thank you,” he began.
He had been admitted to the ICU with numerous blood clots in both lungs. The only other thing they could find was a little non-occlusive deep vein thrombosis in one of his popliteal veins; the kind that don’t typically break off and to to the lungs (especially when already on blood thinners.) The hematologist was stumped.
But he was alive. Which he probably would not have been if he had continued sitting at home, hoping to feel better, as he had told me he was his original plan.
That was a save. Based primarily on that sixth sense of the experienced clinician: I just didn’t like the looks of him.
[By the way, if there are any coagulation gurus reading this with any ideas for taking care of this guy other than an IVC filter, please feel free to shoot me an email. We really are stumped.]
All hail “The Oatmeal,” the source of all truth in the universe.
So how do you know your cat is planning to kill you? Answers here, but not the fully correct one. The real answer to the question, “How do you know your cat is planning to kill you?” is this:
You have a cat.
I was reminded of this the other day by a comment on a post by Rob Lamberts on KevinMD which began:
As an incurable compulsive introspect, I tend to brood, ponder, contemplate, and (of course) muse on “big ideas,” such as:
- What makes people choose things which cause themselves harm?
- Are some people better people than others, or are they just more skilled at hiding their problems?
- Is pain really a bad thing, or is our aversion to it a sign of human weakness?
- Does God ever wear a hat?
- Do dogs watch Oprah?
- Why did I put “big ideas” in quotes?
I love Rob.
One of his commenters, Eqvet215, added this at the end of a thoughtful response:
By the way, most tasteful dogs watch Ellen; Pugs watch Maury or Jerry Springer Spaniel. Cats watch Dexter.
Of course cats would watch Dexter; makes perfect sense.
Which led me to think of my little Bootsie; my BooBoo Bear; my sweet little 14-year-old tabby with no front claws (rescued that way) who sleeps between me and DDS each and every night. Planning to kill us? Not my darling kitty.
But he is a cat. And suddenly I realized what was going on.
He’s paralyzed by indecision. Every night he jumps up on the bed and tries to decide which one of us to smother first. And every night he lies there, torn: her? Him? Her? Him? All night long. Poor thing just can’t make up his mind. Then before he knows it, the sun is up and we’re gone. Another day to plot and ponder (and poop and barf; he’s nothing if not versatile in his talents), until tonight…
The guy was a curmudgeon. That’s all you could say about him. His blood pressure and diabetes were dreadful, and he insisted there wasn’t anything he could do about it. The meds were too expensive; the diet was far too limiting; he had no pleasures in life other than food. He lived alone, hated his job, saw few people, had no friends; so he told me at every visit. His visits were unpleasant in other ways as well. He didn’t bathe often, nor did he appear to believe in doing laundry.
He sent me emails from time to time. Funny pictures of cats; sentimental powerpoint presentations on the changing of the seasons; the usual. Sometimes I read them, sometimes not; depended on how busy I happened to be at the time. Mine was just one in a long list of names in the header.
Then one night, everything changed.
I got a call from the emergency room. My patient had had a heart attack, found slumped next to his car. They’d been able to get a rhythm back, but not before he’d sustained some mild anoxic brain injury. I’m not sure how they figured out he was mine, because he really wasn’t able to communicate at all. I got to show off my spiffy EMR, rattling off his meds to the ER doc. (“Are you in the office at this hour?” “Nope. I’m logged onto my EMR from home.”) but not much else.
There wasn’t much they could do for him. Just wait for his brain to improve to whatever degree it could, helped along with intensive physical and occupational therapy. Frankly, I didn’t think he had much chance for any meaningful recovery, and would likely be bed-bound and completely dependent for whatever remained of his life.
Later that night, I saw an email. The header indicated it had been sent to everyone on the curmudgeon’s contact list. It read:
Does anyone on this list have Mr. C’s daughter’s phone number? VERY IMPORTANT.
I know what that’s about, I thought, though of course I couldn’t say anything. Confidentiality and all that. Besides, I had no idea how to get ahold of his daughter.
The next day, there was another email from someone with the same last name as the curmudgeon. It relayed what had happened to him and his current condition in far more detail than any other correspondence I’d gotten from the hospital (ie, none). Followup emails from others on the list relayed thanks for the info, good wishes, and prayers. When he was ready for visitors, it was announced through the list. News of his transfer to a rehab facility was next (again, before I’d received any official notice from the hospital), followed by continued improvement and transfer to a stepdown rehab. Finally came word that he was going to live with his daughter to continue his recovery.
Around that time, the daughter also called the office to make an appointment for a followup visit. I was as thrilled as I was surprised to see him walk into my office, unassisted except for a walker.
He smiled when he saw me; a surprisingly symmetrical smile. His neurological recovery wasn’t complete, but it was remarkable. So was his attitude. I’m not sure if the brain injury had caused a change in his personality, or if it was as simple as having nearly died, but he was a different man. Smiling, friendly, pleasant, and optimistic. Everything he hadn’t been before. And with a very long list of people who cared very much about him, that he either never before admitted, or had never believed.
As with everything else in life, there is a time and a place for “Reply All.”
I’m going to let you in on a little secret: not all doctors “save lives” every time they see a patient. Emergency medicine physicians, trauma surgeons, oncologists can all rightfully brag about “saving lives.” Hell, even paramedics probably save more lives than I do over the course of a year. I admit it: more of my time is spent either relieving suffering (diagnosing and treating acute but self-limiting illnesses) or trying to prevent it down the road. Trust me: it doesn’t feel the least bit heroic to discuss diabetic diets, recommend weight loss, prescribe blood pressure medicines, and advise people to quit smoking over and over again, day in and day out.
Also, because primary care is an ongoing endeavor, there will always come a time when “saving a life” is not the goal. Helping patients with terminal conditions to remain comfortable — physcially, emotionally, and spiritutally — through the last stages of their lives is an important facet of our job. It just doesn’t make for compelling cocktail party conversation or blog fodder.
But I still have my moments.
A patient* came in for followup after a protracted hospitalization for sepsis, weak but well on the road to recovery.
“You saved my life, Dr. Dino.”
Those were her exact words.
She said it again: “You saved my life.”
“I give you credit: all those times I came in asking for antibiotics that you wouldn’t give them to me. If you had, I would have died.”
She was quite sure of it.
Who was I to argue?
She was probably right. If I had given in and prescribed antibiotics for previous conditions when they were clearly not needed, I would have killed off the susceptible portion of her microbiome and allowed the smaller population of resistant organisms to prevail. Had those resistant bacteria been the ones to invade her blood stream, she very likely would have succumbed.
We doctors may have “The power of the prescription pad.” But there are still plenty of times when we just need the power of “No.”
*Blogged not just with permission, but by request. h/t TC
In the news this morning, there’s the story of an Ethiopian co-pilot “hijacking” his plane to Switzerland.
I’ll bet that if this had been, say, a Russian plane, perhaps at the height of the cold war, and a white pilot, given exactly the same circumstances (asylum requested, no gun), the media reporting the event would have used the word “commandeered” instead of “hijacked”. But since it was a black man from Africa (albeit from a country with a history of violence in the air) the more emotion-laden term was used.
Sounds racist to me.
Once again my trusty Ratio cookbook comes through on a cold, snowed-in morning: Popovers! Surprisingly simple; amazingly delicious with just honey:
And voila: breakfast as elegant as it is yummy:
Apparently they would have popped even higher if I’d put them in smaller tins. But all I have in this hypoplastic kitchen of mine is this new large muffin tin. I can’t bear the thought of buying more of what I already have, even though it’s in storage and I won’t be able to use it until summer. The popovers turned out fine, though.
The term “Open Access” in the context of Primary Care means that patients are able to get an appointment whenever they wish.
The ultimate in open access is 24/7 availability. No, I don’t offer this, although I come pretty close. I’m available by cell phone virtually 24/7 (I rarely go away; too rarely…sigh) and I’m also almost always willing to come in and see someone if they really need to be seen. This seldom happens. Most of the problems that arise after office hours are acute enough to require a higher level of care than I can provide in the office; hence, I recommend evaluation in the ED. Most other issues can wait until the office is open. For things like colds, flu, and other self-limiting conditions, patients are often satisfied with advice over the phone. Still, I am always willing to meet them at the office for ear infections, UTIs, and the like. No muss, no fuss, and boy are they grateful.
Over my 20+ years in practice, I’ve done a fairly decent job of training my patients to call during regular hours for things like refills of ongoing prescriptions. They’re usually due for an office visit, though, as that’s how I’ve set up my refill policy (once or twice a year for hypertensives, two to four times a year for diabetics depending on their numbers) and I let patients know this. Therefore a refill request also means making an appointment. All of this is a piece of cake with my electronic medical record. I can log on from home or anywhere else and crank out those refills with three clicks. I can also tab over to the Schedule and make an appointment for them.
The primary focus of Open Access is on offering same day, next day, or short term appointments to anyone who wants them. When doctors first contemplate the concept, they freak out: essentially, it means seeing all the add-on patients who call in addition to those on their already full schedule. The best way to start is by not filling up the schedule in the first place. Most offices do this anyway, intentionally leaving room for those add-ons. The trick is to leave more and more space for them until you’ve caught up with your already-scheduled appointments.
Open access in its purest form means not having any appointments scheduled in advance. This doesn’t really work, as many people like to schedule their followup appointments at the end of their visits. Once you’ve gotten to full implementation, it’s not really a problem. Three months out, the schedule is usually completely blank. Even a few weeks tends to be quite open.
So here we are. We’ve worked down the backlog. We are an office with full Open Access. You call; we offer an appointment whenever you want. Today; tomorrow; no problem.
Here’s the problem: what happens when the phone doesn’t ring?
First we agonize. What are we doing wrong? Why aren’t people calling? Is the practice going to go bankrupt? Why aren’t they calling? Is it Obamacare?
It helps to flip back to the same month last year and see almost exactly the same numbers for visits, charges, and collections. It tends to be cyclical, but it’s still scary.
And yet we sit. Twiddling our thumbs. Consider getting into marketing.
What do we do when the phone doesn’t ring?
The phone always starts ringing again. Once the weather warms up (cools down/dries up). It will pick up again.
It always has.
On a cold winter’s night, I find myself craving something sweet. Just a little; on a diet, you know. And not too hard to make; I am working with an abbreviated kitchen. I’ve always loved cake batter. Not just licking it off the beaters, but actually eating it by the spoonful. Easy enough to mix up a concoction of flour, sugar, and milk to hit that tiny sweet spot. I’ve even taken to adding a pinch of baking powder to give it that nice zing.
Tonight, though, I tried baking it. With the help of a really cool cookbook called Ratio (actually just the cover) and my latest kitchen toy, a $25 electronic scale with “tare” feature, I can provide an actual recipe for an adorable little cake that just hits the spot. I know, I know; the Internet is replete with recipes for Mug Cakes. I’ve looked at them: they’re bigger, usually include an egg, and tend to weigh in at well over a thousand calories. This one is much smaller, and adds up to a not inconsiderable 344 calories. But hey, if you’re careful the rest of the day (or week) you can still swing it once in a while.
- 1/2 oz peanut oil (what can I say, I like the flavor)
- 1 oz sugar (I use vanilla sugar, which I suspect is why I can get away without any other flavorings)
- 1 oz flour
- 1 oz milk
- 1/4 tsp baking powder (I probably should have added a similar quantity of salt)
Put a small mug or glass custard cup on your kitchen scale and zero it out. Using the “tare” feature between ingredients, measure them out into the container in order. Stir until blended. Bake in microwave on high for 1 minute. Will be very hot, with soft coarse crumb. May be moist/slightly underdone at the very bottom (just how I like it.)
Optional (today only): Place candle in center of cake, light it, and sing Happy Birthday in absentia to DinoDaughter and the Jock.
Wait a minute. I think my head hurts.
This is from The Weather Channel:
in which the future King of England strongly condemns as misguided those who deny the accepted science of climate change.
Excuse me, but isn’t this the same Prince Charles who continues to embrace homeopathy (full article here):
In the video, Charles finds it baffling that “…we have such blind trust in science and technology that we all accept what science tells us about everything — until, that is, it comes to climate science.” And homeopathy. Just as baffling.
Supporters of homeopathy can legitimately be called “Chemistry Deniers,” and can also accurately be described as members of the aforementioned “Headless Chicken Brigade.” Talk about “…abandon[ing] all our faith in so much overwhelming scientific evidence.” I for one would love to hear that same speech by the good Prince, but with the word “homeopathy” substituted for “climate science.” I’m not holding my breath.