Posted by: notdeaddinosaur | February 2, 2016

Back-Dated Travelogue, Day 9: The Golan

The Golan heights, or “up north” to Israelis, is one of the areas of contention between Israel and Syria, with many different types of pros and cons around the issue of “giving back land for peace,” which we went over at some length during our morning study session. Getting out and seeing the land, though, was wonderful:

The first picture is through the mountain passes heading north. The second is from the “heights” looking down across the fields where the Syrians fired pot shots at Israeli farmers working the land. Finally there’s the war memorial to those killed in the 1973 war (the Yom Kippur war.) There were a lot of memorials like that all over the country, though it seemed like we passed more of them in the north.

By midday we headed to a planned city called Katzerin, where we had an amazing lunch and a fascinating discussion with one of its founders. Her take on the Golan, specifically about whether or not it should be returned to Syria, was that whoever made best use of the land had the strongest claim to it. Before the Israelis came, she told us, it wasn’t really used for much; just some disorganized grazing. But under their current stewardship, the industries of farming and tourism were booming. So was this industry, though to be honest, it was the only brewery we saw in the whole country:

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I realized she was essentially articulating the terms of the Organian peace treaty from Star Trek TOS, most famously applied to Sherman’s planet, where the Klingons plan to cheat was foiled by none other than…tribbles. I found it amusing to contemplate.

 

Posted by: notdeaddinosaur | February 1, 2016

Back-Dated Travelogue, Day 8: Tsfat

Imagine a magnificent medieval city high in the mountains, streets terraced into the hillside, stone buildings dating to the 1500s and before, water collected in 45 meter deep cisterns, once the center of Jewish mysticism now known as a thriving artists’ colony. No need to imagine: that’s Tsfat.

Having arrived after dark we had to wait until morning to appreciate the view. But what a view!:

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The hotel used to be a Turkish inn, and the art about town was unbelievable. Something amazing at every turn:

We finally had an opportunity for shopping actually built into the program. The stated aim was to help the struggling economy of Tsfat; all I can say is that we did our part:

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Posted by: notdeaddinosaur | January 31, 2016

Back-Dated Travelogue, Day 7: Caesarea

Travel day, heading north. Of course given that the whole country is about the size of New Jersey, it was kind of like driving up to Hackensack. But this was Israel, and we were traveling back in time…to Caesarea.

Caesarea, the Roman capital of Judea when they ruled, now filled to overflowing with Roman ruins and luxury housing, more like Moorestown than Hackensack. But I fell in love with the ruins, and spent the day happily clicking away:

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There was also the Bird Mosaic, a mosaic floor in remarkable repair that was once the courtyard of a sumptuous, palatial home:

I wrote:

Although the study sessions have been truly fascinating…in a way, I would have loved spending more time in that space. In the rush-rush, look-here, wow-look-at-that, I didn’t feel I had the chance to really absorb the feel of it all. I wanted just to sit quietly, and maybe let the ghost of a little girl who used to play there, back when the house — her house — was still there, come shyly up to me. I’d smile, and she’d smile back, and I’d ask her without words about her life there, and she’d tell me without words (because she’s shy, and not just because she’s a ghost) that the yellow flowers she was picking were for her mother’s hair, because there was a big party tonight, but she couldn’t go because she had to go to bed, because she was just a little girl. And I’d think about how little girls and flowers and ghosts and courtyards with beautiful mosaic floors could all exist in the same space, the space I’m sitting in right now, despite the separation of centuries.

We traveled on, and explored the catacombs and caverns of Beit Sharim. Finally we headed up to our destination for the next day, arriving after dark so that we had to wait until morning to appreciate the unbelievably amazing views.

Posted by: notdeaddinosaur | January 30, 2016

Back-Dated Travelogue, Day 6: Shabbat

Ever have one of those friends where even if you don’t see them for years on end, when you finally get together again, the years fall away and it seems like you saw them just last week?

You meet their kids for the first time, realizing that some of them are older than you were when you first met, and they’re wonderful and amazing, and you wish you lived closer than 3000 miles away so you could spend so much more time with them, but you have to settle for subscribing to their YouTube channel and making them laugh by showing them YouTube videos of your kids, and then watching other videos, and then sitting down to a huge Shabbat lunch together.

And you hug and you talk and you hug some more. Your husbands don’t mind because it turns out they’re in the same industry, so they chat companionably. But you just keep hugging her because you can’t believe you’re finally seeing her again after all these years, to the point where you worry a little that you’re annoying her, but not really.

And you swear to get together again sooner than another twenty years. And you really mean it.

This:

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I wrote:

Although I have every intention of coming back some day, life, as always, is unpredictable. So it is possible that I will never again experience Shabbat in Jerusalem. Yet if that is Gd’s will, at least I’ve done it once, and can be grateful for that.

Posted by: notdeaddinosaur | January 29, 2016

Back-Dated Travelogue, Day 5: Jerusalem “Field Study”

I wrote:

Began with a study session on Jerusalem itself; the city. After than came an experience I never would have thought I’d…have (and which may or may not in fact have been all that good an idea): we were sent off to various Jerusalem neighborhoods to find someone — a stranger — and ask them questions about themselves, their opinions about living in Jerusalem and Israel, and various other things. Really? Really.

[DDS] and I chose French Hill, described as “a comfortable upper middle class neighborhood with many academics and Anglos due to its proximity to the University.”

We took the bus. It was about a 30 minute ride through a series of fascinating neighborhoods. Early on we passed the Great Synagogue of Jerusalem…through Mea She’arim, which yielded views of black hats of all descriptions. The people-watching was fabulous. All sizes, shapes, and colors…We heard some English and struck up brief conversations.

Almost no one paid cash for the fare, as we had. Most people seemed to have smart cards, with readers on poles inside the bus. One older lady had trouble with hers, so a little boy, maybe about 10, helped to show her how it worked. A moment later someone else had the same problem. The kid got up again and helped that guy as well. When in doubt about technology, ask a kid.

We actually did manage to find someone to interview, who wasn’t overtly offended by our request, and whose answers were friendly and insightful. An American from an observant family in the states, her reason for moving to Israel boiled down to, “I had a lot of questions about Gd, and it took living here to get comfortable with the idea that there are no answers.”

Our next errand was to pick up assigned snacks for our next group study and schmooze the following day. We had been tasked to procure roasted cashews and milk chocolate. Mission accomplished on Ben Yehuda, a pedestrian shopping mall and tourist heaven.

Although the idea of heading out into a city to interview a stranger was terrifying enough to give one pause, after that part was over it was nice to finally have some time to ourselves to wander around a little, shop, chill, and watch the people.

Posted by: notdeaddinosaur | January 28, 2016

Back-Dated Travelogue, Day 4: Tel Aviv

I wrote:

So it turns out that Tel Aviv is a really cool city. Probably the first “planned community” in the Middle East.

Cool shot of the ancient port city of Jaffa, contiguous with Tel Aviv:

DSCN0098

Several study sessions. Mosaics. Independence Hall (Israeli version.) Falafel. Wandering the shuk (market). Bialek house. Amazing Yemeni restaurant for dinner.

Busy day in a busy, bustling city.

Posted by: notdeaddinosaur | January 27, 2016

Back-Dated Travelogue, Day 3: Dead Sea

Turned out that we couldn’t entirely escape the weather. The first week of the trip was rainy and cold. They said there was a little snow although it didn’t stick around, but compared to what we’d left, we were unimpressed. However today it caught up with us: the road was washed out, so we never made it to Masada. It was okay, though.

We began at Qumran, the site where the Dead Sea Scrolls were discovered in 1947, and within minutes of our arrival I was planning my next novel. Suffice it to say that I listened to the stories of the sect who wrote the scrolls through the lens of a psychological anthropologist, answering for myself the question, “Who would want to live like this?” Now there’s a story puttering around in my brain, yet another one clamoring to get out onto paper. Some day.

The caves:

The archaeological site:

Next we had a study session in a bombed out open air restaurant, and a guy walked in with a camel:

Finally, instead of Masada, we went to Qaser El-Yahud, a baptismal site on the Jordan river right across from Jericho. It’s the site where Joshua led the Jews into the Promised Land after 40 years of not asking directions, and it’s also where John the Baptist did his thing. So it’s an important site for several different religions, for different reasons.

Contrary to all the old spirituals, the river Jordan is muddy and brown. If it weren’t for the historical and religious significance of the site, you might even call it disgusting:

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Then again, the amenities were nice enough, and we even caught sight of a group who’d come for their own religious experience:

 

Posted by: notdeaddinosaur | January 26, 2016

Back-Dated Travelogue, Day 2: Jerusalem

We were based in Jerusalem, which was fabulous. The first morning we were at the Shrine of the Book, home of the Dead Sea Scrolls.

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After driving around the outside of the city to get a sense of the geography, we went in through David’s gate and made our way to what seemed like a perfectly nice little restaurant for lunch and a study session. But when I turned my head, I was startled by the view:

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Yes, that’s the Dome of the Rock, the big golden dome that pretty much defines Jerusalem in terms of images, and yes, it was right there. I kept snapping pictures of all the other gorgeous landmarks, but I kept coming back to it.

After lunch we made our way down to the Kotel (the Western wall, the only remaining part of the original holy Temple Mount).

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I wrote:

I found myself approaching slowly, not quite sure what to think. Certainly didn’t have any specific prayer in mind. I just tried to keep myself open to the place and the moment…I let thoughts of my patients flow through me, offering up generic prayers for health and healing. Above all, I just thought, “Peace.”

I stepped all the way up. Next to me was a slightly older woman, both hands and one cheek flat against the cold stones, sobbing softly. Without quite understanding why, I teared up as well. It’s a powerful place.

Later, after I backed away slowly, reluctantly, we noticed a group of Korean girls clustered beneath the flagpole in the middle of the plaza. To our amazement, they began singing Hatikvah. Turns out they were a choir group on tour. Talk about magical.

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But in a way, the magic was just beginning. Archaeologists have excavated along the Western wall all the way to the end of the Temple Mount, and we got to go in and see. The most amazing part was our guide, an ex-pat whose English was perfect, and who literally acted out the history of the Temple Mount for us. Her name was Batya Davis, and you don’t just listen to her, you experience her.

All in all, a powerful, packed first day.

Posted by: notdeaddinosaur | January 25, 2016

Back-Dated Travelogue, Day 1: Departure

We were so smart.

To get ahead of the monster storm forecast for the day of our departure, we decided to drive up to Newark NJ the day before and stay in a hotel. It worked like a charm: we were comfortably ensconced at the Holiday Inn before a single flake fell. The joke was on us, though, as well over two feet of snow proceeded to bury us, dashing our hopes of a departure that would have allowed us to arrive in Israel a day before the beginning of the formal program. So we stayed in the hotel an extra night, and arrived at our destination with a mere 25 hour delay, leaving our car pretty much buried in snow:

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The flight itself was dull, boring, and uneventful. Just kidding! I made the mistake of heeding the call, “Is there a doctor aboard?” and wound up nursing a passenger who had fainted. He was fine, although while trying to take care of him we hit a nasty pocket of clear air turbulence, which only bothered me because I ended up strapped into a rear-facing jumpseat. Everything came out okay, though, and I was rewarded with a bottle of wine from the grateful crew.

DSCN0011

 

Posted by: notdeaddinosaur | January 23, 2016

Travelogue (Back Dated)

So it turns out you change the date and time settings on a blog post willy-nilly. So even though it looks like I’ve gone dark and silent for a month, it was only because I was traveling. And what a trip I took!

I was out of the office for two weeks — the longest time I’ve every been away from the practice — encompassing an 11-day trip to Israel. And what a trip it was. To study biblical texts while actually at the site those texts either occurred or were written, well, to say it adds another dimension to bible study in quite the understatement.

I took a ton of pictures, of course, and have already posted several on Facebook. I therefore apologize to the overlapping readers who may already have seen them. I also kept a journal, so I have a record of contemporaneous reflections. One day I wrote a poem.

It’s nice to be back, and yes, there are several blog topics itching to get out of my head onto the screen, but it’s been hard to stop thinking about this trip. So please forgive the indulgence of nearly two weeks of back-dated blogging. (For the record, I’m writing this on February 15th.)

Here we go…

Posted by: notdeaddinosaur | January 14, 2016

Do I Have Plague?

Another email from the patient who did not have tuberculosis (lightly edited):

I did something stupid. Last night I woke up at 2:00 am to my cats hissing. I turn on the light and they have successfully surrounded a sock. So, I pick up the sock nervously expecting a spider or something but there is nothing. So, I put the sock down and an itty bitty mouse runs out of the sock and all the cats leap for it. I grab a shoe box and after about an hour, trap it. My plan was to put it outside. But I then realize this isn’t [Florida (from where the patient had recently moved)] and it is freezing outside. So I sequester the cats in my room, and explain to the mouse he has 60 seconds to beat it to wherever he lives in the house and he should remember how dangerous it is out here and I let him run off. So I guess someone can say at my funeral that [I] wouldn’t hurt a mouse, but my worry is that said funeral will be soon because [I’m afraid] I may get plague now from messing with the mouse.  Are there any symptoms from mouse exposure I should look for?

My response:

Given that plague is spread by fleas on rats, rather than mice per se, no, you do not have to worry about plague. I think you need to be more concerned about your cats taking out their frustration on you for having absconded with their plaything.

Gawd, I love my patients.

Posted by: notdeaddinosaur | January 6, 2016

Things I Wish I’d Said

On the phone with an older doc, who keeps saying, “What can I do for you, young lady?” and “Yes indeed, young lady.”

I fought the urge — oh I fought so hard — to say, “Wow, you must be really old if you think I’m young.” Sadly, I succeeded. I was polite throughout the encounter.

Even at the end, when he said, “Happy holidays to you, young lady,” and I managed not to say, “And to you as well, old man.”

Posted by: notdeaddinosaur | December 29, 2015

“Do I Have Tuberculosis?”

This is why I love my patients.

Actual email exchange with an actual patient:

SUBJECT: Do I have Tuberculosis?

I had a cold like a week ago and I am better now but I still have a cough that wakes me during the night and produces gross phlegm in the morning. But it is mostly just snot by late morning. It sounds like Keats’ description of his tubercular cough except he thought it was blood instead of phlegm because in the 19th century he probably did not know the difference. Do I need to come in to see you?

My response:

>RE: Do I have tuberculosis?
No.
>>Do I need to come in to see you?
Only if the cough lasts more than 3 weeks, or you start coughing up blood, or if you want to.

Patient:

I suspected that was the case when I failed to write a single poem nor turn pale and thin with that late Romantic wasting away quality and did I mention thin. Sigh. Days of only soup while I was sick and no weight lost.

Are sonnets the equivalent of a tumor marker for TB? Does this mean we can scrap the PPD and all those newer, more expensive proprietary TB tests, and just monitor our patients’ poetic output along with weight and degree of pallor?

 

Posted by: notdeaddinosaur | December 27, 2015

Why I Will Never Close to New Patients

Closing a medical practice to new patients is like cutting off the very top of a tree. It’s the beginning of the end.

The top of the tree, the crown, is where the newest leaves are. It’s also the part that continues growing ever upward, at least until it reaches it’s maximal genetic height, depending on environmental factors like the availability of water and sunlight (both of which also depend on how many other trees are competing for them nearby.)

When you cut the top off a tree, the tree will die. Not right away. Sometimes not for many years. But its death is now inevitable. (By the way, see here for a discussion of why “topping” — basically killing your trees — is never a good idea, despite being widely practiced.)

I don’t believe in a “closed panel” of patients. (I don’t even really know what that is.) Patient populations ebb and flow. No matter how good I try to be, there are a certain number of patients who, due to circumstances beyond my control (and often beyond theirs) leave the practice. Whether moving away, transferring for work, switching insurance plans, getting pissed at me, or even, yes, dying, there is always going to be attrition. New patients are the lifeblood that keep those numbers up. Active patients generate the office visits, which produce the billings that brings in the money.

I know some people with a subscription-type practice model who have a “full practice” and a “waiting list.” Frankly, managing those kinds of lists feels like so much more trouble than it’s worth. If someone calls for an appointment, I’d rather just give it to them instead of trying to figure out if they’re “on the list.”

Some people think that Closing to New Patients can be a temporary thing. They’ll just close for a while until the list shrinks a bit, then open up again. Most of them learn the hard way that once word gets out that you’re “closed” it’s not that easy to open the spigot again. Besides, what if you do, and patients come flooding back, and you’re stuck closing again? Most practices have a variety of referral sources, and it can be really hard both to keep up with them all, and for them to keep up with whether you’re open or closed this month.

There’s also the question of how “closed” is Closed?

“Doc, my mother-in-law is in town for the week and she forgot her blood pressure pills. I know you’re not supposed to prescribe without seeing her, so can we just bring her in for an appointment? I know you’re “closed” to new patients, but she’s family.”

Hard not to make the exception without seeming like a jerk. But then there’s:

“Doc, my mother-in-law is coming to live with us. I know you’re “closed,” but she’s family, and we’ve been your patients for twenty years. How about it?”

I’ve seen practices describe their status as, “Open to families of existing patients only.” What about dear family friends? Will you make that exception too? Doesn’t that mean you’re basically open to anyone referred by current patients? How are you going to work that? When a new patient calls for an appointment, do they need to give the name of your current patient who referred them? What if it’s someone who’s moved away and isn’t technically a “current patient”? What if it’s someone you may not have seen for a while and the person answering the phone doesn’t recognize the name? Can’t someone who really wants to become your patient lie about being referred? How are you going to police that? Like the waiting lists, it all seems so much more trouble than it’s worth.

Another solo physician in my town recently retired and I’m enjoying a nice little uptick in new patient calls as her former patients try to find a new doctor. Obamacare has also produced a nice little pool of the newly insured who are lighting up my appointment book.

I have no problem “closing” to certain insurances. Been there; done that; may do it again. In fact, if your hidden agenda is to prune your populations, that may be a pretty good way to go. Just don’t say you’re “Closed to new patients.” Unless you’re looking to retire. Because closing to new patients is the best way to slowly kill a practice. Which is why I have no intention of doing it.

 

Posted by: notdeaddinosaur | December 23, 2015

Balancing Between Hubris and Despair

Dr. Robert Centor has an important post about hubris. It’s not a long post, if you want to click through and quickly read it. It’s about the danger of overweening pride and overconfidence that can come from blindly believing the praise that is often heaped upon us by those in our care. Essentially Dr. Bob is saying that we must avoid believing all the wonderful things our patients say to us.

One the one hand, I agree completely. Pride indeed goeth before a fall, and in our line of work, the pain of our falls is literally felt by others. The line between the confidence we need in order to do what we have to do, and over-confidence that leads to potentially fatal errors of judgment is painfully narrow. All too easy to slip over without even realizing; the only safeguard is constant vigilance.

There’s a phenomenon known as the Imposter Syndrome that affects basically everyone early in medical training (and many other endeavors as well.) It occurs when someone tells you how smart you are, or what a good doctor you are, and you think, “Geez, I really have them fooled. They have no idea that I haven’t a clue about what I’m doing.” Although this feeling gradually (oh so gradually) abates over years (and decades) in practice, I’ve always felt that hanging onto at least a shred of it functions as a bit of a “hubris safety net.” Being able to honestly say to oneself, “It’s nice to hear that, but I’m really not as great as they think,” is, I think, a good thing.

On the other hand…Yes, there is another hand here:

I’ve been in solo practice for a long time now. Days can go by without talking to another physician; weeks without seeing one. No residency director is evaluating me every six months, yet I’m pretty sure I’m doing a good job. Once every few months or so, I get the equivalent of positive feedback from a colleague. Usually a patient returns after seeing Dr. X telling me how Dr X regaled her about how great I am. Sometimes another doctor will also say it to my face, though frankly I still wonder a little that they’re just buttering up their referral sources.

So how do I keep up my morale, my self-confidence, my emotional well-being? Dr. Bob and others in teaching situations have the immediate and ongoing positive responses from their learners. In the inpatient setting there are always plenty of other physicians as well. Hubris can indeed be seductive with so much positive feedback around, but how can one maintain one’s emotional well-being from patients alone, without succumbing to the dreaded scourge of hubris?

I believe I have the answer.

I got the following letter earlier this month, reprinted here in its entirety with permission from the author:

When I was pregnant with [my son] you asked me if you would gt to care for him as a patient. I was slightly offended. The doctor that kept me calm through an ovarian mass in my 20s, a depressed suicidal husband in my 30s, always answered the office phone with a same day appointment, always answered my frantic phone calls or responded to my messages asking for help, saw my daughter through every illness and age related medical milestone, wrote me a note to stay home from work when I was too mentally stressed to work the day after our beloved dog was put to sleep, a doctor that I trust my own life and the rest of my family’s life with, asked if she would be graced with my baby as a patient. Well I certainly didn’t want him in a giant practice with a million doctors that have no clue about our family history and that wouldn’t recognize him at the grocery store. [We often run into this family while food shopping.]

You are brilliant, funny, and obviously the best doctor ever! Thank you for being awesome and for choosing your calling of medicine. We appreciate it! May the universe bless you with abundance, always. Love…

Obviously reading this feels wonderful, and it’s not hard to understand slipping into hubris while doing so.

The key is to appreciate and accept the expressed emotions of gratitude and affection instead of taking it as an objective assessment of my superior knowledge or abilities. It gives me warm fuzzies whenever I think about it, and that’s good enough.

Posted by: notdeaddinosaur | December 22, 2015

They’re Onto Us

Some folks have been talking about replacing doctors with machines of various kinds. Note that no one who actually has anything to do with taking care of real life patients is talking about this. It’s mainly venture capitalists and other people who think they can make lots of money selling machines to replace doctors who are talking about machines taking the place of doctors.

However, I’ve just discovered that the developers of Watson, the Jeopardy championship computer, have nailed it (via xkcd):

Watson Medical Algorithm

Posted by: notdeaddinosaur | December 13, 2015

Eighth Night of Hanukkah

Eighth night

Ivory elephants. I love elephants, so Menorasaurus Rex will just have to wait another year.

That’s it for this year. A very happy Hanukkah, and a peaceful and loving Holiday Season to all.

Posted by: notdeaddinosaur | December 12, 2015

Seventh Night of Hanukkah

Seventh night

The second gift from my contractor friend. Made of brass, clearly handmade, though no idea when or by whom. Here’s the story:

This guy is an inveterate yard sale denizen. He’s found all kinds of amazing things that he’s picked up for a song (all the brass hardware from a defunct bar for $100, which is why the bar in our new basement is so magnificent.)

He was browsing one day and saw this atop a box of detritus, and, thanks to his Jewish education from me, he recognized what it was. He was also pretty sure that the garage sale guy who was selling it did not. So he asked.

“Do you know what that is?”

“Not a clue.”

“What do you want for it?”

“Three bucks?”

“Sold.”

 

Posted by: notdeaddinosaur | December 11, 2015

Sixth Night of Hanukkah

Sixth night

An adorable ceramic shtetl village menorah.

Posted by: notdeaddinosaur | December 10, 2015

Fifth Night of Hanukkah

Fifth night

This was a gift from the wonderful contractor who worked on both my houses and my office. He’s a curious guy (not Jewish) and he made me tell him all about the Hanukkah and menorahs. He got this one for me one year at Bed, Bath & Beyond. But the following year, he brought me another, with a really cool story behind it. You’ll just have to wait two more nights to see (and hear) it.

 

Posted by: notdeaddinosaur | December 9, 2015

Fourth Night of Hanukkah

Fourth night

I can’t even remember where or when I got this one. But it’s very nice, isn’t it.

Posted by: notdeaddinosaur | December 8, 2015

Third Night of Hanukkah

Third night 2015

I actually picked up this beauty at Bed, Bath & Beyond last year. It’s the word “Hanukkah” in Hebrew with holes on top for the candles. The shamash (the one lit first, which is then used to light the others) is all the way to the left, atop the final hey, which as you can see rises up a bit.

Posted by: notdeaddinosaur | December 7, 2015

Second Night of Hanukkah

Second night

The baby brother of 2012’s Eight Night magnificence, another Rosenthal woven brass piece of art.

Posted by: notdeaddinosaur | December 6, 2015

First Night of Hanukkah

I bought myself two new menorahs this year, and here is one of them:

First night

The candle cups are mounted on a chain, which means that even though it’s stretched out in this picture to look fairly classic, it can be bent and bunched up into all kinds of cool configurations.

Posted by: notdeaddinosaur | December 6, 2015

Hanukkah 2015

If you will forgive a little post-dated blogging, it’s time once again to return to an old Dino-staple this time of year. Not every year, actually. In fact, I’ve only done it three times before in nine years of blogging. That’s right: it’s Hanukkah, which means I get to post more of my menorah collection, including not just one, but two new ones I got this year.

Starting later today and then daily for the next week, I’ll be posting a picture from my collection.

Here’s a recap from previous years:

2007:

  1. First night
  2. Second night
  3. Third night
  4. Fourth night
  5. Fifth night
  6. Sixth night
  7. Seventh night
  8. Eighth night

2011:

  1. First night
  2. Second night
  3. Third night
  4. Fourth night
  5. Fifth night
  6. Sixth night
  7. Seventh night
  8. Eighth night

2012:

  1. First night
  2. Second night
  3. Third night
  4. Fourth night
  5. Fifth night
  6. Sixth night
  7. Seventh night
  8. Eighth night
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, 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

Birthdays

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.”

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