Posted by: notdeaddinosaur | November 22, 2015

How Many Patients Do You Have? Who cares!

How many patients do you have?

I’m not sure what you mean. How many patients do I see on average each day? About twelve.

No. How many patients do you have?

Let’s see: Last week I saw about sixty patients altogether. Five of them were new patients.

No, no. How many patients do you have on your panel?

My panel? I don’t know what you mean by that. I don’t work as an employer in a fully prepaid system where patients are specifically assigned to me. I’m down to only two capitated HMOs, insurance plans that pay me a certain amount (not much) each month for each patient on my list. Some people on the list are patients I’ve had for years, while others have never heard of me, since the plan randomly assigns those who don’t choose for themselves. I have about 260 people on one of those lists and about 75 on the other. Is that what you’re asking?

No. Let me put it this way: How many people out there could potentially call you for an appointment at any given point in time?

Gee, I don’t really know that either. Given that I accept most insurances and that I’m open to new patients, I don’t think there’s any way I could possibly come up with a number.

Well, how many patients do you feel you can reasonably take care of? 

About ten to fifteen a day, or about sixty a week. Approximately the number I’m currently seeing. Maybe a little more.

So how many patients are on your panel?

Talk about useless conversations…

When you think about it, a “patient panel” is a meaningless concept in private practice. How many active patients do I have? Depends on precisely what you mean by “active”. Even though it’s usually defined as any patient to whom I’ve provided medical services in the last three years, does it include people who have died? Patients who have asked to have their medical records transferred? What about those people on the insurance capitation lists whom I may not have seen yet but am still getting paid for each month?

Frankly, I wouldn’t even know how to go about figuring out who’s on my panel, much less what the bottom line number may be. More importantly, I have better things to do with my time. Like taking care of patients. However many of them there may be.

There’s a new kind of practice model out there based on the idea of a subscription: in order to see a doctor, you have to sign up ahead of time to be on “the panel,” a privilege for which you often have to pay. Both the Concierge model and the so-called Direct Primary Care model use this principle. The specifics (and the amount of money) vary greatly, but the basic idea is to explicitly define who is on a doctor’s “panel.” Neither one of those models is right for me at this time [more detailed discussions to come] but the idea of managing a panel seems to be way more trouble than it’s worth.

My personal sense of my “active patient panel” is a group of patients that is continually in flux. I have folks in the middle of an acute illness; pneumonia, a flare of diverticulitis, a kidney stone, with whom I expect to have more frequent contact over the next few days or weeks. I have lots of long term patients with well-controlled chronic illnesses: the hypertensives and diabetics I can expect to see two to four times a year. I have the super healthy folks who come in once a year or less; the flu shot groupies; the well babies, who start out getting seen a lot, with lots of phone calls if it’s a first child, and with whom contact tapers off after the first two years. Hospice patients whose needs for my attention increase as the end draws near. Broken bones and other injuries; postoperative, post ER, post-MI followups.

People move in and out of the “active” circle. The kidney stone passes; the cast comes off; the “Okay to return to unrestricted activities” note is written. They’re still considered Active patients to the bean counters, just not as active as before.

It’s called Primary Care, it’s all in a day’s work, an and I love it.

I suppose your definition of my Panel is the grand total of everyone who is or could rotate into that “spotlight” of acutely needing me. But what’s the point of keeping count? The phone rings; I’m able to offer an appointment whenever the caller wants. What more could anyone ask?

Posted by: notdeaddinosaur | November 10, 2015


I still work because I don’t think I could keep up with all the activities in my new Active Adult Community. It’s a development whose initials spell out “RAP” and recently, when my Dearest Darling Spouse had a birthday commemorating six and a half decades on the planet, every single person who heard he was turning 65 said exactly the same thing. So I put it onto the cake I baked (from scratch!) for him:

65 Baby Cake

Happy Birthday, DDS. Many, many more.

Posted by: notdeaddinosaur | November 1, 2015

New Codes for End-of-Life Counseling; Heaven Help Us

Poor bored Government. So much time on their hands; so little real work that needs to get done, all they can do is micromanage poor physicians like me to death. Well, they can try.

For its first forty-five years, Medicare was (in)famous for the very narrow limits on things it covered. It would pay for medical care when you were sick or injured, and that was basically it. No preventive care. No shots. Counseling, coming under the rubric of Psychiatric care, was paid at 65% of the “medical” rate. On the flip side, all you had to do to get paid was bill for it. Somehow way back then, physicians were considered professional enough to be trusted only to bill for what they did.

Of course they gamed the system some. (Some would say a lot.) I remember happily billing for physicals as long as a patient had any possible “medical” diagnosis I could use as a primary code. Hypertension, diabetes; even just “Elevated blood pressure, no diagnosis of hypertension” or “Impaired fasting glucose” would work. “Fatigue” was also a great catchall. Who wasn’t tired all the time? I had no ethical problem with it, because I felt that once a year my hypertension and diabetes patients deserved a longer, more complete evaluation. It was simply a matter of getting paid for doing the right thing for my patients.

Then along came coverage for Preventive Care. Now I could provide that annual Wellness visit without having to fudge a diagnosis. Great, right?

Not so fast. Turns out that once the proposal had made it through the sausage-making machinery of CMS, the only way to get paid was by jumping through a slew of hoops requiring the documentation of all kinds of irrelevant minutiae that converted the visit into nothing even remotely resembling what you or I or any rational being would consider a “Physical.” Then again, because it pays pretty well, and because some of the services waive patient deductibles and co-insurances, I used a template designed to capture all the picayune crap they want, and actually use the codes.

A shining example of getting paid for doing the right thing for my patients.

Next stop on the CMS runaway Medicare train was paying for “chronic care management”. You know; re-capturing at least some of the uncompensated time spent on the phone coordinating care for patients with multiple chronic conditions. Again, something that sounds like a good idea in practice didn’t quite turn out that way. Gee, I wonder why? Because of the micromanagement of required documentation, in short.

And now CMS, the bumbling, fix-what’s-not-broken, Great and Powerful has deigned to begin paying for two new codes (though not until January 1, 2016) specifically for covering discussion of end of life issues. I haven’t yet seen any documentation parameters regarding the codes (99497 for the first 30 minutes; 99498 for subsequent 30 minutes) though if the Wellness Visits and Chronic care management codes are any gauge, I shudder to think what they could come up with.

Unless these new codes pay significantly more than what CMS already pays for a Level 4 visit, I will not be using them. Here’s why:

I already have these conversations with my patients, and have for years. I also get paid for them, and it’s completely legitimate. Quoting myself:

Medicare and other payment systems have a provision for time-based billing. When more than half of the face-to-face time is spent counseling the patient, reviewing treatment options, etc. then the total time spent in the encounter can be used as the determining factor for payment. News flash: the topics discussed are NOT REGULATED. “Death panels” (ie, the proposed payment once every five years to discuss end of life issues) aside, I can and do (and always have) bill specifically for those visits.

That was from a post FIVE YEARS AGO.

I use time-based billing to cover visits for psychiatric problems, chronic care management, end of life discussions, and much more. I document appropriately, sleep soundly, and cannot fathom why the big hullabaloo over this new policy.

People have been dying for years, and I have it on good authority that they will continue to do so. On the one hand, perhaps the existence of these new codes will encourage more doctors and patients to have these difficult conversations. Then again, human nature being what it is, I have my doubts. We need to do much more than just create new medical billing codes in order to overcome our deeply ingrained cultural aversion to all things “death.” This is a good place to start.

Posted by: notdeaddinosaur | October 20, 2015

How Pennsylvania is Screwing Radiologists

Here’s something new and different: Dino defending Radiologists. Oh, I’ve lit into them from time to time over the years, but we are colleagues. And a recent ruling by the Pennsylvania Governor’s office mandating that 3D mammograms, also known as tomosynthesis, be treated exactly the same as previous technology for payment purposes (ie “Free” to patients) is patently unfair to radiologists.

Some background: The current technological standard for breast cancer mammography screening consists of taking plain low-dose xray images of compressed (ouch!) breast tissue, either with film or digital technology. Usually they take two views of each breast, resulting in four pictures, which takes an experienced radiologist less than two minutes to read. Tomosynthesis is a process conceptually similar to a CT scan in that it produces a series of images of the breast that can be scrolled through to produce a “3D” mammogram. Trouble is that it takes longer to read, meaning that because time is money, 3D mammograms cost more that the old-fashioned ones. The equipment is hideously expensive as well, so of course they want to recoup those costs.

But is tomosynthesis “better”? It depends. In women with dense breasts, tomosynthesis can do a better job of distinguishing actual masses from shadows formed by overlapping tissue, which lowers the number of patients called back for extra views. This is a good thing. The problem is one of over-marketing: hospitals and medical systems have done a bang-up job selling their new technology as the latest must-have latest and greatest. Everyone’s clamoring for it. How dare anyone suggest pawning off yesterday’s technology on them! After all, “Isn’t your life worth it?” (Never mind the whole “saving your life” thing with mammography is starting to look more and more overrated.)

Now the Commonwealth of Pennsylvania is requiring that all mammograms, 3D as well as 2D, remain “free” to women.They’re not “free”, of course. Mammogram technicians and radiologists aren’t in it just for the money, but they do have bills to pay. “Free” mammograms are paid for by insurance companies, who both pass on the costs in the form of premiums to all their subscribers, and by restricting payments to radiologists and hospitals. You don’t think they’d let their profits take a hit, do you?

Ordinarily I’m a fan of our new Governor, Tom Wolf. But in this case, his new policy is unfair, and ought to be re-visited.

Posted by: notdeaddinosaur | October 19, 2015

“Stop Calling Us Mid-Levels,” Cry the NPs

Nursing is an honorable profession, neither superior nor inferior to medicine, but distinct from it. I learned this from nurses! Then last night I saw a commercial on TV for “Nurse Practitioners,” who are:

…leading the charge and growing the nation’s access to patient-centered, accessible, high-quality health care.

They’ve also got a chip on their collective shoulder over the term “Mid-level” provider. Can’t call them “Physician extenders” or “non-physicians” either. Fine. I’ll just call them “arrogant doctor-wannabes”. I was just being polite with the “mid-level” thing anyway.

Apparently their issue with the term “Mid-level” is the implication that the “mid” means “middling,” or somehow less than “high”, and that it refers to either the quality of their care, or their education, or whatever. I’m not really sure; it seems like such a stretch, trying desperately to find offense where none was ever intended.

It’s as silly as if I were to get all bent out of shape about “Primary” care being somehow inferior to “Tertiary” care, as provided in large downtown institutions, because “Tertiary” means “three”, which is more than “one”, which is “Primary.”

At issue is what kind of care is provided to what kind of patients for what kind of problems. First aid kits are the first line of defense most of the time. Hopefully even Nurse Practitioners can agree that not every little cut and scrape needs professional medical attention. “Mid-level providers,” individuals with approximately 1/3 to 1/2 of the training of a physician, are used in ERs and busy offices to “extend” services to more people than can be covered by physicians. Their care is not inferior to that provided by physicians. It’s just properly provided to care for problems requiring their levels of expertise, which is not the same as that of a physician.

I think that non-physician providers should care for healthy people and doctors should take care of sick people. Let the NPs do well baby and preventive care til the cows come home. Most of it is education anyway, which is their alleged forte. (Spoiler alert: It’s mainly because they have more time to spend with patients.) [plagiarized from myself]

Patients need all of us: Moms and Dads to bandage cuts and kiss skinned knees; mid-levels to stitch up simple lacerations and care for people who didn’t really need to come in, and doctors to figure out whether you’re tired because you have sleep apnea, depression, anemia from colon cancer, or something else.

Don’t try inundating me with stories about noble NPs who rush in to save the day from arrogant doctors. On the one hand, I can match you incident for incident with ignorant NPs and PAs doing harm practicing beyond their abilities. Then again, the plural of “anecdote” is not “data.” Get off your high horse about the term “Mid-level” and let’s join forces against the truly demeaning moniker of “Provider.”

Posted by: notdeaddinosaur | October 18, 2015

Musical Insurances

For the moment, I still take almost all insurances in my practice. And as long as I see enough patients (ie as long as the phone rings) I’m doing okay. I’ve been billing electronically with a free clearinghouse for about five years now, and things are pretty good. (Give it another week to make sure I’m still getting paid using ICD-10 codes, though.)

Over all these years, I’ve only dropped one insurance. It covered a fair number of patients, including many of my favorites. It paid terribly, though I’ve recently realized that there’s another plan that pays even less. So why did I drop that one plan?

It was the hassle factor.

For some outrageously obscure reason, this insurance insisted on using my employer ID on claims instead of the SSN accepted by every other insurance. I had to remember to go in manually every time I created a claim and switch the numbers around. Given how poorly it paid, eventually it got to the point where it wasn’t worth it. I tried calling the plan to see if I could negotiate a better rate. Suffice it to say, they offered only two options: take it, or leave it. Many of the people who already had that plan still come to me and just pay cash, given that my fees aren’t all that high to start with. Others went and found new doctors (and some of them came back again, happily paying for my care.) And when potential new patients call asking if we take that insurance, we have to say, regretfully, no. We’ve moved on.

I mentioned another plan that also pays very poorly. Why do I keep it?

It may not pay much, but it pays promptly and easily. Billing is as easy as point and click. Sure, I need the documentation to back up my services, but it’s not all that hard electronically to edge up the difference between a level 3 office visit and a level 4. Knowing which plans pay less than others, I’m more likely to — not exactly fudge; let’s say — take a little extra time with the patient, then go ahead and be sure to code fully for my services.

What about the better paying plans? Interestingly, if I know I’m going to get all or nearly all of my fee for any given level of service, I’m less likely to try and squeeze out every last nickel from each visit. On balance, it’s probably much more economical for an insurance plan to pay me, and by extension all physicians, reasonable rates for our services instead of trying to ratchet us down so low that we have to game the system in order to make ends meet.

Who’d a thunk it? Doctors leaving money on the table? Not billing for services we apparently are already providing? Surely not us greedy doctors.

But yes:

The CMS says doctors tending to tens of millions of chronically ill Medicare patients aren’t taking advantage of federal dollars aimed at improving care and reducing hospital readmissions and overall costs.

This year, Medicare began paying an average of $42 per patient per month for non-face-to-face chronic-care management services, such as consulting with other doctors caring for the same patient who might be dealing with dementia, heart disease or arthritis.

The CMS estimates 70% of Medicare beneficiaries—roughly 35 million—would be eligible, but CMS has only received reimbursement requests for 100,000 beneficiaries thus far, Kathy Bryant, a senior technical adviser in the Center for Medicare, said last week at an Advisory Panel on Outreach and Education meeting. She added that even that number may be too high as some could be duplicate claims.

Now why wouldn’t I want to collect an extra $500 or so a year per Medicare patient? I mean, I’m already coordinating their care, calling specialists, keeping track of their tests, refilling meds and so forth without seeing a penny. Why not bill for it?

What would I have to do? (Following info from this CMS Fact Sheet)

First, I have to get the patient’s consent. No biggie. I’m sure most of my patients would be okay with it. Turns out that there’s a little bit more to it than that, though:

Patient consent requirements include:

  • Inform the patient of the availability of the CCM service and obtain written agreement to have the services provided, including authorization for the electronic communication of medical information with other treating practitioners and providers.
  • Explain and offer the CCM service to the patient. In the patient’s medical record, document this discussion and note the patient’s decision to accept or decline the service.
  • Explain how to revoke the service.
  • Inform the patient that only one practitioner can furnish and be paid for the service during a calendar month.
  • How to access the elements of the service;
  • How the patient’s information will be shared among practitioners and providers;
  • How cost-sharing (co-insurance and deductibles) applies to these services

Sure, no problem. I can probably manage to squeeze that discussion in between going over their latest admission for CHF, refilling their COPD meds, reviewing their home glucose readings, updating their pneumococcal vaccine, making sure they got a flu shot, and discussing their wishes for end of life care.

Okay, say I get their consent, what exactly do I have to do? It boils down to creating, implementing, and monitoring a “Comprehensive Care Plan”.

What the hell is that?

You asked:

A comprehensive care plan for all health issues typically includes, but is not limited to [italics mine], the following elements:

  • Problem list;
  • Expected outcome and prognosis;
  • Measurable treatment goals;
  • Symptom management;
  • Planned interventions and identification of the individuals responsible for each intervention;
  • Medication management;
  • Community/social services ordered;
  • A description of how services of agencies and specialists outside the practice will be directed/coordinated
  • Schedule for periodic review and, when applicable, revision of the care plan.

Not only this, but it turns out that Medicare only pays 80% for this “service”, leaving patients footing the bill for things they basically never had to pay for previously.

As my eyes glaze over, I can’t help but wonder: Why is anyone surprised that doctors aren’t rushing to bill for this albatross of a “service”?

Posted by: notdeaddinosaur | October 6, 2015

Where Have All the Bloggers Gone

I started blogging in 2006. That was six iPhones ago. There was no such thing as Twitter or Instagram, and although Facebook was around, it was mainly used by college kids. None of my kids had graduated from college yet. I was still in the same house I’d bought in 1985, right before graduating from medical school. I had four old cats and a paraplegic peke. It was a long time ago.

Blogging was different then as well. At the very beginning, there weren’t as many of us, though our numbers blossomed. For several years there was a fairly steady group making up what we called the Medical Blogosphere. We were pretty active, usually posting several times a week. It was also before the days of the RSS feed, so you had to go clicking down your blogroll to see what everyone had written. None of this “new posts in your email” back then.

Every Tuesday, we’d take turns hosting what we called Grand Rounds. Named after the time-honored medical tradition of a formal presentation by some bigwig, it was a “Weekly roundup of the best of the Medical Blogosphere.” I hosted it a couple of times. Sometimes there was a theme; other times it was just a collection of links. It was a great way to generate traffic, both by having a post linked there, even more so when hosting although it really was a lot of work.

So what happened?

What often happens when a group of people get together, in person or on the web: we moved on. Most of us likely got busy with other things. It happens. Blogging can be hard work, and very time consuming. Did we run out of things to say? In a way, perhaps. I started finding more and more that when I went to write about something, I realized I already had. I found myself quoting myself a lot (since a lot of my writing was pretty damn good.) Gradually, we kind of drifted apart.

Blogging itself changed as well. Twitter came along, with all the pros and cons of its 140 character limit. Instagram arrived as well, in conjunction with the smart phone explosion. Who had time to sit down at a laptop anymore when you could do almost everything on your phone?

The landscape shifted. Many blogs went dark, even as many others popped up. Today we live more by the RSS (and Twitter, and Facebook) feed than by the blogroll, but I did take a quick stroll down memory lane to create a brief “where are they now?” list:

  • Mike Sevilla, originally Dr. Anonymous, is now the king of social media.
  • Kevin Pho became its CEO as his original “aggregator” blog became bigger and more monetized.
  • Sid Schwab (SurgeonsBlog) retired from surgery, had a grandson (cutest kid ever), and continues to write a wonderful flamingly liberal blog.
  • Kim McAllister (EmergiBlog) shuttered her blog, had a grandson (cutest kid ever), and posts regularly on Facebook about NASCAR, among other things.
  • Peggy Polaneczky (The Blog That Ate Manhattan) still blogs from time to time, with awesome pictures of her upstate weekend home and fabulous recipes while also clarifying the increasingly confusing world of mammograms and paps.
  • Wes Fisher (Dr Wes) is still going strong, most recently engaged in exposing the financial shenanigans around the deeply flawed Maintenance of Certification fiasco. (Atta boy, Wes.)
  • Bob Centor (DB’s Medical Rants) is also still plugging away; teaching, running, losing weight, and steadily writing about it all.
  • Shadowfax is still Movin’ Meat, though he’s down to about one post a month.
  • Ramona Bates (Sutured for a Living) retired from surgery, but still blogs her various knitting and stitching projects.
  • Science Based Medicine and Respectful Insolence are also both still going strong, though I confess I don’t head over there nearly as much as I would like. (Yes, David Gorski, you really do get pretty logorrheic.)

As for me, obviously I’ve cut way back over the years. There are several etiologies: a failed foray into long fiction writing, a bout with thyroid cancer, and the process of downsizing both a home and an office. There’s also my adoption of electronic medical records five years ago, which was huge: after sitting at a keyboard all day, the last thing I feel like doing when I get home is boot up yet another computer. The only keyboard I want to play with after hours is my piano (or my new clavichord.)

What of the future of blogging? Who knows? Certainly not I. But I would hazard a guess that public Internet journaling will continue in one form or another. People will always be interested in medicine, because writing is writing, medicine is medicine, and people are people.

See you around the ‘net.

Posted by: notdeaddinosaur | October 5, 2015

Questions, Answers, and Nature

Poster seen in the window of the local LL Bean store:

LLBean image

But the questions are still up to us.


Posted by: notdeaddinosaur | October 3, 2015

In the Trenches: Week One of ICD-10

Welcome back, blog fans. Sorry for the prolonged radio silence, but as some of you may have heard (or not, if you don’t happen to work in the medical field) this past Thursday, October 1, 2015 marked the official switch-over to ICD-10, and to say things have been a little hectic is like saying Congress is a little contentious.

What am I talking about, you say? Diagnosis coding.

At the end of my residency, the program sent the third year residents to a two-day seminar on practice management. Knowing I was about to go out on my own, I paid close attention, and ending up being able to use a great deal of what I learned. When discussing the insurance claim form, the divided it up into sections based on the “Who” (demographics, ID numbers), the “What” (procedure codes, copyrighted by the AMA, known as “Common Procedural Codes” or CPT), the “where” (to send the money: my name and address at the bottom), and of course the “why”, or the diagnosis.

Every possible thing that can conceivably go wrong with the human body can be assigned a code to identify to third payer parties the “why”* of any given medical service. Not just every disease, condition, injury, or complication, but any possible reason to go to the doctor (or in modern parlance, “to encounter the health care system”) must also be coded. Everything from a school physical to a preoperative H&P has its own code. My favorite over the years was V65.5:

Person with feared complaint in whom no diagnosis was made. Feared condition not demonstrated. Problem was normal state. “Worried well”

The system used for diagnosis coding is called the International Classification of Diseases, or ICD. Up until last week we were on version 9, which contained a total of about 14,000 codes. As of October 1, everyone switched wholesale to ICD-10.

How big a change could it be?

Pretty big.

The new set has about 68,000 codes. The vast majority of ICD-9 codes contained only numbers. Administrative codes began with the letter V, and injury codes began with the letter E. All ICD-10 codes start with a letter. Yes, they include “I”, “O”, and “Z”, which look perilously like 1, 0, and 2. Luckily they are not case sensitive, so the lower case versions may be clearer.

ICD-10 codes are super specific. One of my favorite ICD-9 codes was 729.5: “Pain in limb.” Didn’t matter which part of which limb. It was very useful. Now there are individual codes for pain, stiffness, effusion, instability, and several other derangements of shoulder, elbow, wrist, fingers, hips, knees, ankles, and toes, plus pain in upper arm, lower arm, thigh, and lower leg. AND each of the above has three subsets for right side, left side, and unspecified side.

Please don’t ask “Why?” No, a middle ear infection of the right ear isn’t treated any differently from a middle ear infection of the left ear, nor does a torn meniscus in the left knee carry any significant epidemiological difference from one in the right knee. But I’m just a tiny voice in the wilderness. All I do is actually provide medical care to real life patients, so there’s no reason for the folks on high who make “policy” to, you know, listen to people like me. At this point, if I want to get paid, I have to play along (unless I shift to a cash-only model, which I’ve decided against for the time being.)

Since I’ve always done my own coding, I’ve always had collections of “Cheat sheets”, or handy-dandy lists of frequently used codes. There’s also the Internet, which has pretty much taken the place of the huge, expensive books I had to buy every year to keep up with annual coding changes. Oh, there are books for ICD-10: an alphabetic list runs to over 1200 pages, and a tabular one (all the codes in numeric order) that runs over 1500. Luckily I downloaded them for free from CMS, and believe me, it’s so much easier to work with them as link-infested PDFs than as actual books.

You know that nightmare when you find yourself in school about to take an exam for which you never studied? That’s how I felt on Thursday morning. Actually, it was more like finding myself about to take exam for which I’d made a detailed study plan, and just started to look over the material, but hadn’t gotten around to getting everything done that I’d planned. It was scary, especially since I also had a full schedule of patients to take care of and worry about the coding later, fearing that “later” meant I wouldn’t get home until midnight. It wasn’t quite that bad, though I did find myself coding just the primary diagnosis and not adding all the other ones I usually do (to support the complexity involved in the medical decision making for a given encounter.) Also, given that it’s the start of flu shot season, there were a lot of visits just for that. And miracle of miracles! An ICD-10 simplification: there used to be a specific diagnosis for receiving the flu shot. Medicare also has another one just for receiving a pneumococcal vaccine, and a third code for receiving both. ICD-10 has just one (Z23; learn to love it.)

There’s one thing I did manage to accomplish ahead of time.Of all the various joint complaints, I chose Pain, Stiffness, and Effusion, because those are the main ones I see, and created a graphic version of the codes that roughly correspond to “Pain in Limb”: Limb pain ICD10 cheat map  Feel free to download, use, and disseminate. (Please don’t sell it. I did include a copyright notice, mainly to appease this crotchety old guy in his 80s whom I’ve known for years.)

I also did a similarly styled “Referral Cheat Sheet” for my single staffer with the codes we use most often for that other bane of our existence, insurance referrals: [insert link when I get to the office, as it’s local to that computer] and I’m currently working on a set of master cheat sheets for myself. The main one is going to end up modeled on the old superbill I used before I went electronic, but I think various skin lesions and infections will lend themselves to the mapping format quite nicely. Diabetes, though; that’s going to be a real headache. Or R51, in the new lingo.

Stay tuned, and Gd help us all.

Posted by: notdeaddinosaur | September 13, 2015

Challah for Two (Show Your Work)

First of all, Happy New Year (Jewish, that is; Rosh Hashanah) or L’Shana Tova everyone.

Empty nesthood is nice. One little issue, though, is that after years of scaling up recipes to feed a horde of growing baby dinosaurs, now that there’s just two of us — who are both trying to watch our weight, with varying degrees of success — it’s time to start scaling things down. DSS decided that he wanted to make a special dinner for tonight, the eve (or Erev) of the New Year. He’s using a cobbled-together recipe for a savory kugel, to which I suggested adding chunks of chicken, making it a true one-dish meal. My contribution is the challah.

For anyone who doesn’t already know, challah is an egg bread traditionally made by braiding the dough. On Rosh Hashanah, though, it’s also traditional to make the challah round. Last year my friend SH sent me a link on how to braid a round challah, so I had that part down. Now, about the recipe. Most of mine make way too much for two people. And before you get waxing rhapsodic over leftover challah, let me just say that 1) I like challah french toast as much as the next woman of valor, 2) it has enough calories for a week because 3) I have no self-control when it comes to challah french toast (any french toast, for that matter.) SO the only solution is to make a single, not-too-enormous loaf, so as to pig out once and be done with it.

I probably could have gone to my trusty Betty Crocker recipe and just cut it in half, but I felt like creating my own recipe. I wanted it to be rich, really eggy, and I wanted to include honey. I also didn’t mind doing the math:

Show your work

I used several sources. I started with that old Betty Crocker recipe (calling for 2 packets of yeast and 7+ cups of flour.) Next I turned to my wonderful new book Ratio by Michael Ruhlman. Just from the cover, I learned that the magic ratio for bread is 5:3 flour to liquid. Inside, I also discovered that the relationship between yeast and how much dough it can rise has more to do with time than amount (ie, if I have “too little” yeast, I just have to let it rise longer.) I also have my many years experience with bread baking, plus a few tidbits from the back of the yeast packet. 

Ratios are by weight, not volume. I do have a kitchen scale, but it’s hard to use with a really big bowl. Besides, I don’t like to dump all my flour in at once, as the book suggests, since I like to mix by hand. So I’m going to stick with cups for the flour. Ratio’s chapter on bread also tells me that although flour’s weight varies with humidity, it’s safe to approximate that 1 cup weighs about 5 ounces. It also tells me that one large egg is two ounces.

Somewhere in my last half century I learned that sugar makes the yeast rise and salt slows it down. Betty Crocker tells me that 2 packets of yeast need 1/4 cup of sugar and 1 tbsp of salt. Easy enough to halve those.

The yeast packet, Fleischmans Rapid Rise, tells me that, despite the fact that Betty says I have to dissolve it in warm water, I can just mix the yeast in with the dry ingredients if I make sure the wet ingredients are warm.

And I’m off:


1 packet Rapid Rise yeast
2 tbsp sugar
1/2 tbsp salt
2 eggs + 1 egg yolk (reserve white for egg wash)
1/2 cup milk, microwaved about 45 seconds
2 tbsp melted butter (pareve margarine, if you insist)
Honey (I think I probably added about 2 tbsp)
3 cups flour

Combine sugar, salt and yeast in small prep bowl. Lightly beat eggs and egg yolk in large mixing bowl; add milk and butter. Stir in yeast mixture and honey. Stir in flour one cup at a time. (I usually have to knead the last cup in.) Turn out on floured board; knead until elastic. Let rise 1-2 hours or until doubled in bulk. Punch down; braid; let rise another hour. Brush with reserved egg white. Bake about 25 minutes in pre-heated oven at 350 degrees.


If you’ll excuse me, it’s time for dinner.

Posted by: notdeaddinosaur | September 5, 2015

Caution: Groaner Ahead

Why doesn’t alternative medicine work very well for vaginitis?


Yeast is yeast,

and est is est

And never the two shall meet.

Posted by: notdeaddinosaur | August 20, 2015

Finding Doctor Right

Proudly Co-Authored with the NinjaBaker, Cross-posted at his group blog, Science ACEs


Finding the right primary care physician for you and your family is a lot like dating. You can swipe right at the first doctor who takes your insurance, then find out he’s a complete jerk when you meet him. Maybe you’ve looked at his medical profile in great detail, then you go for your first check-up and just don’t feel that spark. That’s fine. It’s okay to be picky, and to keep looking for the right person who will take you as their patient, to have and to hold, for better or worse, in sickness and in health, as long as you both shall live. Well, you, at any rate.

We’re here to help you with several “dating” tips on finding Dr. Right.

Find someone you can trust

Why do you go to the doctor at all? Same reason you hire a plumber or a mechanic: because they have special training and knowledge about something you don’t.If a doctor tells you things you either know are wrong or that don’t make sense (and that they can’t explain to your satisfaction), steer clear.

Don’t be afraid to put yourself out there

Just because you have a bad experience with one doctor doesn’t mean you’re destined to never have a rewarding relationship. Be careful about insisting on the “best” doctor, endlessly perusing “Best Of” lists in magazines (which are generally compiled by asking other doctors who they like best, not patients.) The best doctor for you may not be best for your BFF, your neighbor, or even your spouse. You may like the idea of a doctor who’s willing to spend time discussing every detail of your condition at length, while someone else wants “just the facts,” enough information to make a decision, but no dilly-dallying with endless small talk.

Google them first

Looking up your doctor online can be a great way to get information. Are they board certified? Where did they go to medical school? Where is the office? What are their hours and what insurances do they accept? Be careful about reading patient reviews, though. As with all online reviews, remember that they are generally submitted by people who are very pleased or very displeased.

Communication is key

As in every good relationship, appropriate communication is important. A good doctor should be able to explain everything at your level of understanding without being patronizing. A pediatrician will tell you that “boo-boo” is perfectly acceptable medical jargon, whereas a neurosurgeon should be able to explain brain surgery to you in a way that isn’t rocket science.

R-E-S-P-E-C-T (find out what it means to me)

Doctors’ schedules can get busy, but if they show up an hour late to your appointment without any apology or explanation, they are not respecting you or your time. While no office can run smoothly 100% of the time, a small gesture like an apology can show the difference between a doctor who respects you and one who is trying to crank out as many appointments in the day as possible. Be patient and respectful of the doctor’s time as well (i.e. don’t show up late yourself, call if you need to cancel, etc.). Respect from both sides will help build a meaningful relationship.

Get along with their friends

It’s important that your “friend with health benefits” has friends who are a good influence on them. Your Primary Care Physician will often refer you to specialists in certain situations. It’s important that these specialists fit you as well. Just because they are a friend of a friend doesn’t mean they need to be your friend. Some doctors are paid by drug companies to prescribe their drugs. You don’t want a doctor who has anything to do with people like that.

Be (a) patient

This whole process is so exasperating! Why do you need a doctor at all? Just use one of the gazillions of symptom checkers online and make your own diagnosis. If only. The problem with the Internet is that there’s too much information. Whatever you plug in, some online resource is going to say that it’s cancer or AIDS. It’s the doctor’s job to know which of that information does NOT apply to you. It’s not as easy as it looks. So hang in there and keep plugging away until you find the perfect doctor for you.

Know when it’s not working

You’ve done everything right: google references were stellar, hanging with all the right specialists, and the office is wonderful about communication. But after a few visits, you’re just not happy. You may not be able to put your finger on it. Was that remark he made meant to be funny when it sounded condescending to you? Was she just a little too brusque? Doesn’t matter. You’re the one who needs to be satisfied, and you’re the one who gets to decide what that means. Like any other relationship, if it’s not working for you then it’s not working. Breaking up doesn’t have to be hard either. When you find a new doctor, send the old one a request to transfer your records. Don’t worry about the request being taken personally. Doctors are professionals and patients transfer in and out all the time, for all kinds of reasons. Your doctor wants you to be happy, and if another doctor is better able to do that, then that’s what they want for you. (More on that here.)

If they try to touch your genitals the first time you meet, run.

Actually, this one doesn’t always apply to doctors, especially urologists and gynecologists. Just make sure they wear protection, but do tell them if you have a latex allergy.

Posted by: notdeaddinosaur | August 18, 2015

How Dare the FDA Approve Pain Relief for Kids

How dare they!

This senator is disgusted — DISGUSTED — with the FDA’s recent decision to approve the long-acting opiate pain medication OxyContin for children as young as 11.

“An 11 year old’s brain has another 14 years before it is fully developed. We have years of evidence that shows that drug use at an early age makes a child more likely to abuse drugs later in life,” he said in his letter to the FDA. “You have ignored all of this. Instead, under your new guidance, we are literally poisoning our children’s brains and setting them up for future drug abuse.”

Excuse me, Senator, but this kind of pain medication is much more likely to be used by terminally ill children in hospice care. How dare the FDA broaden the armamentarium for compassionate care at the end of life! How DARE they!

See, the 11-year-olds for whom OxyContin is appropriate don’t have another 14 years of brain development. They’re probably lucky if they have 14 weeks. So get off your high horse and STFU. If your grandkid were suffering with a painful terminal illness, I’ll bet you’d be a lot less disgusted and a little more grateful to have every option at the doctor’s disposal.

Posted by: notdeaddinosaur | August 17, 2015

Building a Clavichord – 6 & 7

I’ve been so busy building, I haven’t gotten around to writing. Or doing anything else.

The listing cloth, a long ribbon of red felt, has been woven between the strings:

Clavichord - with listing cloth

It pulls together the pairs of strings struck by each tangent, and it stops the string from vibrating once the key is released.

I managed to “chip” it to tune; ie pull it very roughly into something vaguely resembling “in tune.” But I still have to set the temperament and do the actual first tuning.

In the meantime, I went ahead and finished the stand:

Clavichord with stand

It’s also made of cherry, finished the same way the case is (two coats of tung oil, followed by a light coat of paste wax). The cover and fallboard are also back in place, as is the cord supporting the lid. I’m not sure I’ve tied it correctly, but it doesn’t matter since it’s against the wall, which keeps the lid from falling backward. Still, I’d like to try finding some fine brass chain to replace it.

From a visual standpoint, it’s finished. Huzzah! I suppose all that’s left is to post a video, or at least an audio file, once the tuning is complete.

Posted by: notdeaddinosaur | July 20, 2015

Building a Clavichord – 5

The case has been finished, as have the keys, including gluing on the sharps:

Clavichord - keys finished

If you look carefully, you can see that I’ve already started installing the strings. Just two so far in this picture, but I’ve been working on it. (Obviously, instead of writing.) I’m also putting the tangents in as I go. They’re the little brass wedges that actually strike the strings.

I’ve made the executive decision to omit the “roof carvings.” The keys are supposed to be carved to a sharp point between the two bends, or knuckles. If you look at the two lowest keys, you can see where I tried my best. They looked so terrible, I decided to quit while I was ahead.

Posted by: notdeaddinosaur | July 9, 2015

Building a Clavichord – 4

The lid is on. So is the fallboard, though it wasn’t at the time of the picture:


Don’t worry: the lid is straight. It’s the optical illusion of photographing it against the full scale drawing with so many parallel diagonal lines.

Immediately after this, I was instructed to remove the screw eyes for the lid cord and the lid hinges, and put them all back in their envelopes. I get to put them back on at the very end when everything else is done, but between now and then they’ll just get in the way.

Next up: finishing the case.

Posted by: notdeaddinosaur | July 7, 2015

Mammography Doesn’t Save Lives

Preventive care doesn’t save money and now it turns out mammograms don’t even save lives.

After sitting through a presentation by a general surgeon about treatment of small breast cancers (the vast majority of his patients do great), I was stunned to hear him opine, “Every woman needs a mammogram every year starting at age 40.” Really. That’s what he said.

I’ve had my doubts. I’ve diagnosed women with breast cancers less than a year after their last mammogram because the tumors grew so damn quickly. Mammography didn’t save them.

Now we have new research (linked above) looking at 16 million women (a pretty decent sample size by any reckoning) showing that the more you screen, the more cancers you find WITH NO DIFFERENCE IN HOW MANY WOMEN DIE of their disease.

To put it into the vernacular, overdiagnosis is a thing.

A real thing, with real drawbacks. Time; money; pain; anxiety. I steamed when the surgeon mentioned above responded to my concerns with the definitive statement, “There is no downside to mammography.” Wrong in so many ways.

Ah, but what to do about it? Especially with the juggernaut already running full speed ahead, fueled by millions of pink ribbons and tacky tee shirts. It’s now a performance measure. Women without mammograms are costing me money. So far I’ve been able to take a deep breath and ignore the increasingly strident calls from various insurance companies crying, “Screen! Screen! Screen!”

Why is this drive so powerful?

There’s the default assumption that knowledge is power. Sometimes it is, but sometimes it isn’t. Despite the reality of fast-growing fatal cancers, the normal mammogram (or breast MRI for the “high risk”, a designation surprisingly easy to fudge) provides reassurance. For now. Year after year we irradiate breasts looking for ever tinier lesions, every last one of which must be treated because “cancer!”

Then there’s the cognitive error which blocks women who have been successfully treated for a small cancer from believing this research. The cognitive dissonance created by, “I went through hell getting treated for breast cancer, and you’re telling me it didn’t make any difference!?!” is strong indeed.

I wonder if we are perhaps one step closer to being able to do a truly randomized breast cancer study: enroll a series of women with small (< 1 cm) breast cancers and randomize them to standard treatment (surgery, radiation, adjuvant chemo) or observation only. Maybe we’re ready to look at the biology of breast cancer more closely. Maybe all breast cancer, like most prostate cancer, isn’t fatal after all.

If we really want to lower deaths from breast cancer, how about re-directing the massive time, effort, and funding away from “mammograms for everyone” toward developing better treatments for those wickedly fast-growing tumors that actually kill.

Think about it.

Posted by: notdeaddinosaur | June 27, 2015

Building a Clavichord – 3

Part way through “Finishing the Case”:

Clavichord with soundboard

Sound board now built and installed, surrounded by its tiny cute little moldings. Holes drilled for tuning pins (on the right), marked for the hitchpins (on the left and back.) Next steps include dressing the sound board with two thin coats of shellac, drilling for the hitchpins, and adding moldings to the outside bottom edges. Can’t even think about getting started on the action (the keys) until after the lid and fallboard (the little section that will cover the front of the keys when its closed) are done.

Long way to go. But it is looking pretty.

Posted by: notdeaddinosaur | June 21, 2015

Best License Plate Ever

Pulling out of a parking space, I noticed this license plate behind me and truly LOL’d:


You’ll have to check it out in a mirror to see what I saw.

Posted by: notdeaddinosaur | June 19, 2015

Building a Clavichord – 2

Section 1 in the instruction manual, titled “Building the Case” completed:


Next up is the soundboard. Stay tuned.

Posted by: notdeaddinosaur | June 16, 2015

Emotions and Memories

I couldn’t sleep last night.

I have no idea why. I played tennis for over an hour in the late afternoon’s sweltering heat, but it felt good. I had a good dinner; not too much, not too late. I even remembered to take some naproxen before I went to bed to combat the beginning stiffness.

But then I just couldn’t get to sleep.

My mind wasn’t racing exactly. I wasn’t thinking of anything in particular. I just wasn’t the least bit sleepy. I thought I felt my heart pounding. Tachycardia? Afib? I checked my pulse; 72 and regular. No pain; breathing was fine. I did have a little tremor though. Not really enough to alarm me medically, but definitely not conducive to sleep.

I wondered if I had somehow gotten some caffeine into my system. As a slow metabolizer, caffeine will keep me awake without fail. But dinner had been chicken and rice, and I seriously doubted that DS had snuck some coffee into the barbecue sauce. I even went so far as to consider whether the naproxen had been contaminated or adulterated. It had been a new bottle. But that seemed unlikely. And I really couldn’t attribute any of it to the NSAID itself.

Eventually I took my own advice and got out of bed, turned on a soft light and read for a while. Finally, after another hour, I got back into bed, and eventually managed to get to sleep.

Not for long, though. Before I knew it, it was 5:30. I dragged myself out of bed and forced myself into the shower, then off to work a regular schedule. A heavy-lidded fatigue stuck with me all day. That draggy dullness with its insidious mental fog I recognized from decades ago. We called it PCPC: post-call pseudo catatonia.

I had a meeting beginning at 3:30 that dragged on til 5:00, when all I wanted to do was get home and pass out. Sleep deprivation is cumulative. Extra hours in bed following the night I’d had was just what the doctor ordered.

Then I noticed the date, and a wave of emotional deja vu washed over me.

29 years ago, more than half my life. It was a Monday instead of a Tuesday, and I was post call toward the end of my internship year. Only this day had begun with a 7:00 am phone call both dreaded and expected. Too bull-headed to ask for the day off, I soldiered through. Draggy; exhausted; brittle emotions firmly bottled up until I could get home — my ancestral home a two-and-a-half hour drive away, that is. At 3:30, my residency director insisted that I review the pathophysiology of congestive heart failure with a bunch of medical students. To this day, I don’t know how I got through it. But I did.

Two days later, I don’t know how I got through my mother’s funeral. But I did.

But the draggy, depressed foggy fatigue that clung to me today reminded me of that day far more viscerally than the mere realization of the date, the lighting of the candle, the ritual emails with so few words that say so much.

I can’t help but wonder if that’s why I couldn’t sleep last night.

Funny about that.

Posted by: notdeaddinosaur | June 10, 2015

Building a Clavichord – 1

So it looks like building a house wasn’t good enough. Now I’ve somehow gotten it into my head that I want to build an early keyboard instrument called a clavichord. I have no idea why. Something to go along with this in the Music Room?:

Piano Room

At any rate, I have purchased a kit for building a clavichord modeled after one found in the collection of the King of Sweden — which is why they call it the King of Sweden clavichord — from a lovely outfit in Stonington, Connecticut known as Zuckermann Harpsichords International. The second video down on the first page is of the instrument I’m going to (try and) build.

I have a brand new workshop. So new I don’t even have much in the way of wood scraps. Then again, I do live in the midst of multiple building sites, so I should be okay.

So here we go:

The plan: The Plan

The parts: Clavichord - some assembly required

Updates as it progresses. Don’t hold your breath. I anticipate anywhere from 6 to 12 months for completion.

Posted by: notdeaddinosaur | June 6, 2015

Breaking Up is Hard to Do; Or Not

Question from a reader:

What are your feelings about when a patient breaks up with you? I love love love my doc, but…

Patients “break up” with me all the time. Well, not “all” the time, but it’s not uncommon. There are many reasons, some of which are under the patient’s control, and some which are not. Moving across the country is a good reason to look for a new doctor. (Seriously. When you move several states away, please find a new doctor. I’ll refill your prescriptions long enough for you to get settled, but I have some people still calling me years later “just to keep you in the loop.” I appreciate the love, but come on already.)

Even if you haven’t moved that far, but just far enough that driving to my office is now inconvenient is an understandable reason for a change. It happens.

Some people switch because of their insurance. I’ve done my best to participate with most of the major players in my area, but there are some I don’t take. That said, many people have chosen to continue seeing me, paying out of pocket. I offer a nice cash discount (legal with Medicare and virtually all other insurances), so I’m not break-the-bank expensive if you want to go that route.

There are people I’ve misdiagnosed who make no secret about why they want someone else. Sometimes there are people who think I’ve misdiagnosed them who write me scathing letters when requesting their records. Only once has someone been upset enough to sue. Others decide that for whatever reason, I’m not the right doctor for them.

I’m okay with that.

Then there are the folks like my questioner, who goes on about how she’s been through a lot with her doc, but that things have changed. She’s lost that lovin’ feeling, if you will, and she’s asking about breaking up, but in a way that acknowledges the good care she’s received in the past. She’s also asking specifically about my feelings, so here goes — with the caveat that I’m just one doctor, and that others are certain to feel differently.

Many doctors have forms you can use to transfer records. No problem using any of these (I have them too), but without any further context, I’m left to wonder a little. If the new doctor is in another state, the situation is self-explanatory. Otherwise, it may give me pause. But not for too long. Over the decades, I’ve learned not to take it personally when patients transfer. Unlike other relationships, I still have hundreds of other patients who still like me if you want to break up. So while I may be momentarily bummed, I’m seldom devastated.

All you need to to is send me a simple note telling me where to send your medical records. Like other kinds of breakups, you don’t need to give a reason. As in other relationships, I’ll probably have had at least a hint that you’re not happy. If you want to specifically convey that you’re not angry or upset with me, adding a line like, “Thank you for all your good care over the years” is good enough. Also like in other relationships, there is seldom anything to be added by including a long explicit list of all my shortcomings that led you to the decision. In general, I would like to know if I pissed you off — mainly so I can potentially avoid doing the same to other patients — but it doesn’t need to be an essay. It’s always a good idea in general to avoid burning your bridges, especially if other family members are going to continue seeing me. Also, you never know: you may yet change your mind and want to come back. I just had a family of six move about half an hour away and asked me to transfer all their records. They called last week for an appointment. Seems they just didn’t like the new guy, and they figured half an hour wasn’t that far after all.

Again as in other relationships, the best way to convey your appreciation for good times in the past is to do it in person. A heartfelt “Thank you” in conjunction with a handshake or hug means the world to me.

Posted by: notdeaddinosaur | June 2, 2015

When Turnabout is Effective as Well as Fair

I’ve written before about transforming my own preventive care needs (and failings) into an opportunity to help my patients get things done even when their first instinct is avoidance. It happened again the other day.

I’m not good about going to the dentist. Even though they want me there every six months, they’re lucky when it’s once a year. Every now and then, it stretches out even farther. Now is one of those times.

I’m sure many others share my feelings about the dentist. I also know those feelings extend to other preventive services…like pap tests. I’ve had women in the midst of a pelvic exam tell me they’d rather be at the dentist. Can’t say I blame them.

So when I was seeing a lady for a physical the other day, I noticed it had been a long time since her last pap. More than five years, which is the outer limit of the most liberal of the new guidelines for women over 30 with no history of abnormal paps or evidence of HPV on testing. However I tried to slice it, she was due. But she really didn’t want it. Not today.

As it happens, she’s my dentist’s receptionist. So I came up with the following deal:

I told her that when I called her back with her blood test results, I would go ahead and schedule my dental checkup if she would agree to then schedule her pap. She agreed enthusiastically.

I called with her perfect labs. Then at the same time, I scheduled my checkup. And then she scheduled hers.

I guess I’m not the only one not above using the personal in pursuit of the professional.

Posted by: notdeaddinosaur | May 17, 2015

Circle of Life

Life is all about beginnings and endings. One of the biggest draws of Obstetrics as a medical specialty is the fascination with the birth process as the beginning of life. The other extreme…well, let’s say in this particular place and time in history, it’s still something that catches people unawares. Too often filled with dread and loathing, we approach the death of patients as a foreshadowing of our own. Why else have we as doctors developed the reputation of squaring off with Death? Beating Him off with tubes and drugs and electricity, “No!” we shriek. “You can’t have this one yet!”

Let me share a secret with you: in spite of EMRs, PBMs, PQRSs, insurance companies, malpractice, legislation, and everything else you hear us bitch and moan about, we doctors care for our patients. And I don’t mean just in the sense of providing them with medical services. We care.

Over the decades, we come to know these people who have entrusted us with their lives. Some of them…many of them, for those of us who are especially lucky…we come to think of as friends. Friends who allow us the privilege of joining with them along this journey we call life; friends who trust us to do everything we can to keep them plodding along when its not yet their time, and those who trust us to ease their suffering at the end.

It’s been an interesting few weeks.

Two weeks ago I got one of the most dreaded calls a doctor can get: my patient had come into the ER as a cardiac arrest. He was the same age as me, and he had simply dropped. No pulse; not breathing. No cardiac history; no medications; no chronic illnesses; no risk factors. Nothing. But his gym had an Automatic External Defibrillator (AED), a magical machine that delivered jolts of electricity to get his heart started again on the spot. Once. Twice. Five shocks from the AED. Two more from the paramedics, and another in the ER. Clear coronaries on catheterization; but progressed to cardiogenic shock; hypothermia protocol; aspiration pneumonia; transfer to tertiary center; left ventricular assist device. Suffice it to say, things didn’t look good.

But it worked.

For all the futile aggressive care we mete out to seemingly hopeless cases, this time it worked. After 10 days, I was talking with him on the phone in a regular hospital room. He was still pretty fuzzy on the details, as you can imagine; try freezing and thawing your brain and see how well it works right away. But it was him. And he’s going to be okay.

At the same time, there’s another patient. (There’s always another patient. No sooner do you hang up the phone and breathe a sigh of relief than there’s another patient.) Nearing the century mark, he’d begun the revolving-door process of in-and-out hospitalizations for the last several months. CHF, pneumonia, NSTEMI, high-output cardiac failure from anemia; one thing after another. I’d been trying to broach the idea of hospice all along, but now he was wearying. This time he said yes.

I went to see him last week at home. He was having some pain and a little trouble breathing. He was reluctant to use the morphine on hand. I tried to reassure him.

This morning I took several calls from the hospice nurse as she struggled to keep him comfortable. It worked. Later this afternoon, I got the other call.

I’ve spoken before about the futility of discussing “outcomes” in Primary Care. Yet this should count as a good one. Passing peacefully without pain or suffering, with loved ones present. In its own way, as miraculous as birth. All that begins must end. A life well-lived; what more can any of us ask?

Posted by: notdeaddinosaur | May 6, 2015

Two Little Words

I’m frequently reminded of the power of words. Especially small words added to other small words.

Consider the difference between two states of being reflected in a conversation a while back with this crotchety old guy in his 80s whom I’ve known for years. I was telling him about a mutual friend who happened to be ill. I said that the individual in question was “Not well.”

The crotchety old guy’s response:

Is he “not well,” or “not well at all”?

“At all.” Two little words adding a dire new dimension.

They can also add emphasis. Hear the difference:

  1. If you need me for anything, please call.
  2. If you need me for anything at all, please call.

Nice little quirk of language.

Posted by: notdeaddinosaur | April 27, 2015

Talk About “Manipulation”

I generally enjoy reading my Philadelphia Inquirer’s Health section each Sunday. In fact, for several weeks (beginning in February) I contributed to their Medical Mystery feature. Most of their stuff is generally spot on, providing good, solid information. Other times, not so much. I guess this was a slow week:

Question: How can osteopathic [manipulation] help my cold and sinus symptoms?

The correct answer is, “It can’t.”

But no. That doesn’t stop our friendly neighborhood Osteopath (excuse me: she’s also an assistant professor of osteopathic manipulation at the Philadelphia College of Osteopathic Medicine) from chiming in. After correctly informing us that MDs and DOs get the same general training in school, she segues right into the old (discredited) idea that anything and everything wrong with the human body can be attributed to “blockages” of one variety or another. This is especially seductive when talking about upper respiratory symptoms, when subjectively one’s entire head feels nothing if not completely blocked.

But this:

An osteopath might use [osteopathic manipulative treatment] to gently contact the structures of the upper back, neck, and face and move them so deeper structures are affected, especially if they are blocking drainage paths.Freeing those deeper structures can help thin out mucus, loosen congestion, and ultimately make the patient more comfortable.

This is about as bogus as it comes.

There is no physical manipulation that can “thin out mucus” (pushing fluids does that) or “loosen congestion,” and given the self-limiting nature of cold symptoms, the patient is “ultimately” going to become more comfortable whatever anyone does.

At this point in time, Schools of Medicine and Schools of Osteopathy are parallel tracks providing essentially the same education and training. The reason many DO’s have abandoned osteopathic manipulative therapy (OMT) is because they recognize it as a vestige of philosophical differences from a bygone era predating our current understanding of medical science. Those who continue the practice are no better than MDs who have given up practicing actual medicine for the more superficially satisfying (and eminently more lucrative) practice of “alternative”, or “complementary”, or “integrative” quackery (despite the fact that they still use the M-word. What they practice is not medicine.)

Come on, Philadelphia Inquirer. I expect better from you.

Posted by: notdeaddinosaur | April 12, 2015

Drawing Lines

Who is a Family Physician?

Who is a PCP? (And does that second “P” stand for “physician” or “provider”?)

Who gets to say? Does it matter?

Perhaps we should start with some basic qualifications: the degree of MD or DO, the satisfactory completion of an accredited residency in Family Medicine, and successfully passing the written examination of the American Board of Family Medicine (ABFP, an organization distinct and independent of the AAFP). Hard to argue with those.

How about going by what we do: Primary Care medicine consists of caring for patients as their first contact with the health care system, regardless of age, gender, organ system, or disease process. Also pretty straightforward.

But what about hospitalists? Family physicians trained and board certified who choose to limit their practice to caring for patients in a hospital setting; are they still “real” family doctors? What about those who go into Occupational Health? Academic medicine? Exclusively caring for patients in nursing homes? Do you have to even see patients? What about administration?

Wanda Filer MD, president-elect of the American Academy of Family Physicians (AAFP) and my new BFF, has come out in favor of an inclusive definition, at least regarding AAFP membership. Her position, and it’s a valid one, is that Family Physicians are under attack by enough non-Family Physicians (both inside and outside Medicine) that we should stick together. Her big tent says that we shouldn’t be fighting among ourselves about defining Family Doctor-hood by whether or not we deliver babies, care for children, perform surgery, or do house calls. Meeting the criteria for AAFP membership (completion of accredited residency, state licensure, ongoing Continuing Medical Education, and of course up-to-date dues payments) is what makes us Family Physicians.

Sounds good. But what about Internists who advertise as Family Physicians because it’s “better marketing”? I’ve seen this, and it pisses me off. Do we have any recourse?

Is it self-defined? Can anyone who wants to call themselves a Family Physician? This of course gets into the whole debate over Primary Care. To most in Health Administration, “Family Physicians” and “PCPs” are synonymous. They’re not, of course. NPs who want to practice the full scope of primary care (few and far between, actually; they have the same payment and administrative hurdles as we do), chiropractors and naturopaths; all claim the title for themselves. This is scary. As soon as someone drops dead of hypertrophic cradiomyopathy undiagnosed by a chiropractor who doesn’t even own a stethoscope, watch the fur fly.

What about conventionally trained Family Physician who turn their backs on the scientific basis of medicine and become proponents of “alternative”, “complementary”, and “integrative” modalities? I believe they have effectively repudiated the right to call themselves Physicians at all. They disagree.

Who’s going to draw the lines that say no, you are not qualified, and you may not hold yourself out to the public as a Family Physician, practitioner of primary care? Ultimately I think it needs to be the general public; the patients we care for who use, and ultimately pay for our services. The charlatans (the alties, the chiropractors, the reality-challenged naturopaths) and the wannabes (the PAs and NPs) make their case with wishful thinking and self-serving data.

The bottom line, the one drawn in the sand, is that however difficult it may be to define who is a Family Physician, you know it when you see it.

Posted by: notdeaddinosaur | April 5, 2015

On Shame

Monica Lewinsky has re-emerged, and I say good for her! Please take the 20-something minutes out of your life to watch the video. It’s well worth it. 

I agree completely that “Internet shaming as a blood sport has got to stop,” and I applaud her call for a more compassionate culture, both off and online. Nothing good comes from public shaming of private indiviuduals, usually women, usually over sexual misconduct. Innocent lives have been ruined — even lost — by the vicious words of anonymous haters spewed for no legitimate reasons.

There is another consequence of this cultural coarsening, in which the whole concept of “shame” has been so perverted that its true purpose — yes, shame has a purpose — has been lost. 

Shame is the feeling of distress or humiliation caused by the awareness of having done something wrong or foolish. Note that it requires two separate components: both the action, and the awareness that the action is wrong or foolish. In verb form, it means inflicting the emotion on someone else by making them aware that their actions are shameful. This presumes that the individual is not already aware of it him or herself. 

So how can shame be good? Simple. Fear of shame, and therefore its avoidance, is a powerful motivation to refrain from wrong or foolish behavior, be it words or actions. 

Remember when the expression, “You ought to be ashamed of yourself” actually had an effect on behavior? One of the darkest episodes in twentieth century American history, the reign of reputational terror known as McCarthyism, was finally brought to an end by a courageous lawyer name Joseph Welch who basically told Joseph McCarthy that he ought to be ashamed of himself. (His actual words were, “Have you no sense of decency, sir?”)

There was a time when shame, specifically public shaming of public figures, served to hold those public figures in check. Nowadays, I can’t help but think that the relative explosion of shaming has served to dull the responses to it of those who really should be ashamed. The O’Reillys, Limbaughs, Palins, Cruz’s,  Tea Party folk and their predominantly Republican Congressional ilk who lie, slander, and hypocritize (is that a verb? If not, it should be) their way into our lives trumpeting the evils of “big government” all the while pure and simply ought to be ashamed of themselves. “Ought to” being the operative words. 

Perhaps when the poor choices of young people, troubled gay and questioning teens, and of course women of any age who dare to buck so-called societal “norms” of occupation, appearance, or sexuality cease to be fodder for relentless Internet shaming — what Lewinsky calls the “culture of humiliation” — then those who ought to be ashamed will no longer be able to hide behind the ho-hum numbness of “everyone does it.”

If nothing else, it can’t help but improve our civic discourse.

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