Monday, December 21, 2009
Thursday, November 19, 2009
This lesson illustrates a conversation using two dialects of Doctish. The physician, Dr. Lucre uses the standard form, while his patient, Mr. Slippery speaks Evadian. (Translation is provided in italics)
Dr. Lucre: Good morning, how are you today? You're here?
Mr. Solvent: I'm fine I'm here
Dr. L: What can I do for you? Can I make this a 99214? I have a Porsche payment due
Mr. S: You told me to come in for a recheck. You have a Porsche payment due
Dr. L: How has your blood pressure been doing? I see your pressure is high today. It's always high
Mr. S: It's always high when I'm in your office. It's always high
Dr. L: Do you check it elsewhere, is it any different? You don't check it
Mr. S: Once in a while. No Here's my list of numbers. I made them up
Dr. L: We talked before about lifestyle modification. I see you've gained weight, have you been exercising? How about salt intake? You'll blow me off again and I don't get paid for talking
Mr. S: Your scales are off, at home I weigh less than last time. I try to watch the salt. I have this script memorized
Dr. L: Any side effects from your medicine? Can I get moderate risk?
Mr. S: Only the price. Didn't buy it
Dr. L: Any new symptoms in any way? Nope, not even limited risk. I need more HPI elements. Mx/Dx options?
Dr. L: Have you had any chest pain, trouble breathing, edema, etc... ROS x2, check
Mr. S: Nope Nope
Dr. L: Any Family Medical History of hypertension? need 1 pfsh, Check
Mr. S: Not yet. Check your notes, idiot! You ask every visit.
Dr. L: Let me check you over [does brief physical exam]. I need 12 bullets, Check
Mr. S: Why'd you hafta check my ears? He's padding the bill
Dr. L: It's a valuable thing to check. I'll get to charge more
Mr. S: Anything else Doc? Anything else?
Dr. L: I want to double your Hypotensin pill. Take your Hypotensin pill
Mr. S: OK, I'll need a new prescription. I tossed the old prescription
Dr. L: Ok, here you go. I want to recheck you in 3 months. Same same in 3 months.
Mr. S: Ok, 3 months. Same same in 3 months.
Tuesday, October 6, 2009
I recently saw an elderly gentleman whose wife thought he might be developing dementia.
To introduce the subject I stated "Your wife is concerned that you forget things. Do you have any trouble with your memory?"
"Not unless I want to."
Monday, October 5, 2009
DrRich (the must-read writer on medical rationing) has now published a must-read article on Emanuel here.
Saturday, September 26, 2009
Here is a portion of a simple flowchart which allows you to determine if you can keep your doctor if the Senate health plan becomes law. Click this link to see the whole chart. Alles klar?
Update: The chart doesn't seem to appear on the post at times. The original is here.
Monday, September 7, 2009
Thursday, August 13, 2009
Current public debate over the Obama/Congress health
care insurance reform bill(s) has been increasingly fixated on whether or not health care "rationing" would result.
What is medical/healthcare rationing?
"To ration healthcare is to withhold at least some useful medical services from at least some of the people who would benefit from them." (per DrRich at covertrationingblog.com)
Does the Obama administration's plan include rationing?
Actually, we already have rationing, but it's not usually recognized.
Medical rationing comes in two flavors, covert and open/explicit.
Covert rationing occurs every day, as doctors and hospitals jump through the hoops required by government and insurances to treat people. The various delays, frequent rule changes, preauthorizations, unexplained denials & etc. are rationing methods covertly practiced on thousands of patients every hour. These techniques are designed to manipulate doctors and patients to change diagnosis and treatment plans for the benefit of the insurance company or government budget. Much of the disgust with insurance companies derives from these practices.
Covert rationing is both ineffective and destructive of the relationship people have with doctors. The additional medicrats required eat up any savings. Doctors become seen as a hurdle between the patient and some desired end. I have had many patients leave my practice angry at me when I have been unable to convince a stonewalling insurance company to pay for something. HMOs are a special type of covert rationing where the doctor performs rationing on behalf of the insurer and for the benefit of him/herself.
Open rationing occurs when an explicit decision is made to not cover a useful medical service ( e.g. no dialysis past age X) and is considered by many Americans to be distasteful, even evil. I practice in a state whose Medicaid system developed a controversial explicit rationing system in order save enough money to cover tens of thousands more people. It worked fairly well until the Federal medicrats put the screws to it. Open rationing is a common bogeyman in American politics.
The Congressional plans have no explicit language establishing open rationing. That means that covert rationing will be the main method of attempting to control costs in the system initially, and it will continue to be both ineffective and destructive. As long as people can make someone else pay for their medical care, no one will be able to quench the unceasing appetite of Americans for all possible care, all the time, immediately, for every ailment and symptom (The Happy Hospitalist often states: FREE= MORE MORE=BANKRUPT).
That is a huge flaw in the Obama plan. It can not control the costs because it cannot control the volume (this is a major problem with Medicare/Medicaid). The volume of services can only be controlled by external controls (rationing) and patient choice ( make 'em pay). Controlling waste and fraud are illusory solutions.
Initial attempts to control costs in a national system will follow the line of least political resistance using feeble and infuriating covert rationing, but in the long run will require explicit rationing as other nations have done. Yes, ObamaCare will have rationing, of the irrational kind.
An excellent source for discussions of these issues is DrRich at covertrationingblog.com, everyone interested in these issues needs to read his explanations and analysis.
Sunday, June 28, 2009
She would rig a bomb and wrap it as a gift to herself. If she ever developed dementia, she'd forget what was in the box and open it.
A nurse told me her advance directive includes a provision that if she cannot remember to ask for her medicines, she's not to receive them.
I'd add the exception that the care provider should give me morphine, antiemetics, haloperidol and lorazepam as needed.
Any other ideas?
Tuesday, June 23, 2009
Waiting times for certain tests and surgery are thrown about and highlighted or trashed, but rarely is any data offered. Here is the 2008 Fraser Institute report "Waiting Your Turn", which provides a comprehensive look at the numbers. Take a look at it, some of the best graphs of the overall effects are on pages 57 and 58.
Highlights of the report include an average 8.5 week wait from referral to seeing a specialist, and another 8.7 weeks to receive the treatment recommended by that consultant. One of the shortest waits was medical oncology (think chemotherapy) which was 4.6 weeks from referral to treatment. Overall the wait times nearly doubled compared to 1993 (referral to treatment went from 9.3 weeks to 17.2 weeks in 2008).
One can well argue whether these waiting times are medically significant or not, whether this person or that person might have "had an untoward outcome" as a result.
My point instead is that Canada's medical system is not the health care nirvana that some claim. Canada has rationing by an ever lengthening queue.
No national health care system can afford to pay for everything, for everyone, always. All the handwaving about 'efficiencies' and EMRs will not conjure enough cash to prevent rationing, whether open or covert.
Tuesday, June 16, 2009
An example of this approach is to reward (or not penalize) primary care doctors(PCP) for blood sugar and A1c "targets" achieved by their diabetic patients, typically A1c <7 and fasting CBGs <120. The PCP is rewarded or not based on the group performance of patients with the condition as though he/she is the only variable in the equation.
I have a middle-aged patient who elected to seek and receive surgical treatment for obesity in part because he had inadequate control of his diabetes (A1c 7.5-8) despite multiple medications, etc. He had no A1c (7.9) and CBG (~140 fasting) improvement after surgery, so the surgeon obtained a medicine/endocrine consultation(I was not involved). My patient is motivated and compliant with both medications and lifestyle choices.
The consultant recommended that my patient discontinue his diabetic medication as long as his fasting CBG stays below 180!
Now, if my patient chooses to follow the consultant's wisdom instead of my recommendation leading to worsened A1c and CBG numbers, should I be held financially responsible, as the PCP, for my patient's failure to meet the goal? Should my name go on the bad doctor list? Should I fire the patient?
Friday, June 12, 2009
The loss of the conscience clause is simply one more nail in the coffin, but a crucial one. It marks the transfer of decision making from the doctor and patient to 'someone'.
The someone will be a government medicrat.
If the medicrat has the power to determine what services the doctor must provide, he/she has the power to determine what the doctor cannot provide.
If the doctor is forbidden to provide a service, the patient cannot receive it.
Where does this already happen? Look to Canada, where all medical care comes through the government system, and physicians are prohibited from operating outside the rules. Most Americans know that Canadians can wait months for many tests and surgeries because Canadian doctors have been prohibited from providing care except by the medicrat rules (although a recent court decision has led to cracks in the concrete). If someone wants the hip surgery sooner, they must leave the country rather than wait.
Currently in the USA, a government program or insurance company can decide to "not cover", that is, not pay for a service. The doctor may recommend, and the patient may decide to have a service and pay for it out of pocket. Although this can be inconvenient and expensive, the final decision is made by the patient. The patient preserves his/her autonomy, as does the doctor.
No national health plan can pay for everything, all the time, for everyone, although the politicians will pretend for a time. As expenses run away, the pressure to lower costs will lead to intensified hidden rules and restrictions (covert rationing) and eventually to explicit rationing. The current "not covered" will increasingly morph into "not medically necessary". Will it become forbidden?
Insist that any plan protect this freedom: that when your surgery/test/procedure/consultation is denied or delayed, you have the liberty to pay out of pocket without leaving the country.
Otherwise, expect your bladder difficulties to be treated by Vogon poetry.
Monday, June 8, 2009
Friday, May 8, 2009
What if my patient requests a procedure which I believe is wrong to perform? Which is against my conscience?
The Obama Administration has recently proposed removing the new Bush-era regulations concerning the "Conscience Clause" protections for health-care personnel and abortion. Many electrons have been rearranged in internet debates in discussions (usually) narrowly focusing on whether doctors may refuse to provide or refer for abortions.
Limiting debate to abortion allows the many venting spleens to miss the critical point: there is no conflict in reality, rather a division of responsibility.
My position is straightforward. The patient has autonomy and the responsibility to decide what legal medical services to seek. The physician has autonomy and the responsibility to practice in the manner s/he chooses. As a physician, I choose whether to provide or refer for any legal procedure or service for my own reasons. If I decline to refer for a procedure, the patient is free to seek care elsewhere in this very commercial society. If it's abortion, must I walk her fingers through the Yellow Pages?
"But doctor, don't you have a duty to provide what the patient wants"?
No. I have a duty to provide medically necessary care to my patients within my scope of practice under the conditions I determine within the law. If a patient, an insurance company or the government requests my services otherwise, I have the right and, at times, the duty to refuse.
My conditions include obvious items such as my training, skills, location, payment and time of day (I have voluntarily limited myself in some contracts and agreements), but also include my belief systems and ethics.
My responsibility is to answer these questions in each individual case:
What can be done?
What needs to be done?
What should be done?
These answers cannot be separated from either my clinical judgement or my ethics. Many similar situations have critical ethical differences we hide in other language. For instance, how many pronouncements against the "octomom" fertility doctor were couched in medical language such as "it was not indicated" when meaning "it was wrong and should not be done"?
Is it wrong to refuse "octomom" multiple embryos on moral grounds?
Is it wrong to refuse clitorectomies?
To assist suicides?
To refer for abortions?
The patient is free to seek these services. I am free to decline.
As I would not be a slave, so I would not be a master. This expresses my idea of democracy.
Friday, April 24, 2009
A doctor has autonomy to decide the mode and scope of his/her practice of medicine. Mode, in this context, refers to employment, location, associations, etc. Scope of practice is simply what services the doctor provides. Some conditions of practice are prescibed or regulated by national or local law (such as non-discrimination statutes), and some conditions and practices are prohibited, otherwise current U.S. law allows freedom for doctors to decide these things.
Employee or self-employed? If employed, by whom and under what conditions? Where?
Solo or group practice? Locum tenens? Staff model HMO? Government?
Doing which procedures? Under what conditions? For whom?
(Scope of practice enters into the mode of course, as a doctor needs to perform within the requirements of employment).
When I chose solo, rural, self-employed practice I accepted certain conditions which came with that decision and are different from other modes of practice. For instance, I have more independence and flexibility to follow my own values, but more responsibility for the business side of practice with less security.
My scope is based on my training, experience, preferences and belief system. It has changed with time, mostly I have reduced the procedures I perform after my skills atrophied since training (e.g. most joint injections). I no longer do obstetrics for financial reasons. I received no training in procedures I intended to not perform for whatever reason.
My next post will address one threat to this liberty.
Monday, April 20, 2009
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Monday, April 13, 2009
Doctish is a dialect of Medicalese in wide use, however misunderstandings commonly occur with its use. Despite CMS mandates, there remains insufficient availability of translators due to scarcity and expense. Many phrases seem to have the same meaning in English but mean something else entirely. In addition, a superficially similar but unrelated language with many dialects (Alternivarian) causes confusion through similar terms with bogus meanings [ed. note. Although Alternivarian often has Medical or Medicalese appended to its name, it is an Alien toungue from another universe with scant connection with physical reality].
This guide will be published in installments so as to maximize your learning experience and our revenue.
Lesson 1 Common expressions
Doctish phrase / Plain English translation
Hello, I'm Dr. ______. / Let's get on with it. I only have 7 minutes
Who referred you? / Who is to blame?
How can I help you? / What can I do to you?
How did it happen? / You did what?
Which toe is it? / I'm blind.
Where do you hurt? / Where will you hurt even more in a minute?
Lemee feel it. / Minute's up.
Does that hurt? / Stop screaming!
We need to run some tests. / I'm hear lawyers' hoofbeats.
We need to do a diagnostic procedure. / I have a Porche payment due.
This won't hurt a bit. / This will hurt.
You will experience some discomfort. / This will hurt a lot.
I'll give a few pain pills for home. / This will hurt more than you can imagine.
The results are back. / Oh, oh.
I'm not certain, but... / I'm certain.
Do you have an advance directive? / You're toast.
Is there anyone else I should talk to? / You're toast and I need to butter up the next of kin.
I'll send a report to your regular doctor. / I've run out of procedures to do on you.
You can follow-up with your PCP. / Not my problem!
Friday, April 10, 2009
One Monopoly Parkway
Stoner Brook, IL 67067
April 1, 2009
Dear Hospital Administrator,
Today a new standard for obstetric services was released by The Health Commission®.
The THC® has led American hospitals to adopt Beyond Perfect Care™ as the standard the last several years. Now we have moved on to the next step, the Medical Village concept. Today’s new rules continue that triumph requiring a multi-disciplinary team approach to human reproduction to increase quality offspring and decrease costs.
Team members will include one of each of these specialties:
Specialty Responsibility to the team and expectant mother/donor
Sociologist compatibility for coupling
Psychologist mental health/readiness
Geneticist check for defective genes
Coitupractor prevent defective technique
Fertility specialist successful implantation
Medicaider arrange medical card
Tutor help with school
Gestationist monitor antepartum course
Cert Micturation Asst collect urine samples
Phlebotomist collect blood samples
Malpractitioner collect legal fees
Ultrasonographer assess fetus/determine sex
Nomenclaturist advise on names
Fashionista advise on clothes
Induciologist induce labor
Anesthetist stop labor
Partitionist restart labor & assist
Caesaropath deliver baby
Med Student feel useless
Videographer take the movies
Neonatologist assess newborn
Postpartitionist monitor postpartum course
Social Worker sign up for stimulus money
Grandma take care of infant
All charting will be done using Electronic Maternal Records. Scoring of each birth will be done using the 10 point judging system of the American Gynastics Federation following the guidelines of our Beyond Perfect Care™ rules.
For more information go to our website www.chickencheck.org
Kim McRobert, MD
Multidisiplinary Requirement Team
The Health Commission®
Parasitizing American Hospitals for over 30 Years
Thursday, April 9, 2009
A person called our office requesting to become a new patient. He wants be referred for hyperbaric oxygen therapy (HBOT) for an old stroke. He also stated that he is happy to stay with his regular doctor for everything else, but wanted to see me since he had heard I use alternative medicine. [note: I have that reputation as I do not argue with my patients over such "woo" unless I believe it to be harmful]
I declined the invitation.
The person later that day showed up at the Office front window and argued for 10 minutes with my receptionist about my decision. He only needed a referral to a nearby HBOT center and promised he would take little of my time. Oh, he also wanted to discuss other alternative therapies with me.
He had found a HBOT place in California, but didn't want to pay for the trip, motel, etc. Could he make an appointment so that I could convince the nearby HBOT center (2 hours away, only treating chronic wounds) to treat him for the stroke? "What kind of wound do I need?"
I continued to decline, and he left unsatisfied.
An individual has the right and responsibility for their own health. If unsatisfied with one doctor or practitioner or course of treatment, s/he is at liberty to find others to provide the health care sought (providing it is legal).
This man exercised his freedom finding a place for his desired legal treatment from the internet, but wanted a cheaper, more convenient outlet. I exercised my freedom by declining to be involved. He felt I was wrong to do so, that it is my job to help him obtain the health care which he has decided he wants, in the manner desired.
The patient has autonomy (self-rule) to make their own health care choices (within the law).
The doctor has autonomy to make his/her own practice choices (within the law). This includes the mode of practice and under the circumstances s/he decides.
The self-rule of the patient does not give the right to rule over the doctor.
Monday, April 6, 2009
Who is in charge?
Who is in charge of a person's health?
Is it the patient?
Is it the Doctor?
Is it the Medicrat?
Do you remember the old rhetorical question, "Whose body is it, anyway"?
When I was in training, I was subject to a great deal of instruction to not be "paternalistic" toward patients and to respectfully obey their autonomy. I could advise, warn, and teach, I could give them options and try to help, but ultimately the patient made the decision for him/herself.
Today, however, we are seeing the erosion of patient autonomy and a forced resurgence of paternalism as doctors are blamed when someone makes 'bad choices'. Pay-for-performance (P4P) schemes where the Medicrat decrees the Doctor is responsible for the patient's smoking, weight, exercise, etc. What happened to the patient's autonomy?
It is not the Doctor's prerogative to steal the patient's freedom.
It is not the Medicrat's right to overrule the patient's liberty.
It is a person's right and responsibility to exercise autonomy; self-rule. And to live (or not) with the consequences, whether good or bad.
“Liberty means responsibility. That is why most men dread it.”
George Bernard Shaw
Saturday, April 4, 2009
The Guardian drops print edition to publish via Twitter
Econoland-a new theme park
A new breed of tartan sheep
Mountain Cleaners in Switzerland
Flying Penguins was from 2008
A round-up of recent years is at the Guardian and at April Fools Day on the Web.
Here is the video of perhaps the most famous April Fool gag of all--the 1957 Spaghetti Harvest from BBC
Wednesday, April 1, 2009
The medical crisis results from excess investment in sub-prime specialties during the 70's and early 80's. The bubble became unsustainable during the late 1990's when primary care prices dropped and doctors found themselves in specialties they couldn’t afford. Despite working longer hours and seeing more patients, they fell farther into insolvency. Many abandoned general medicine altogether, leaving behind blighted patients and devastated communities. Some fled into hospital medicine or to refinance careers in a new specialty .
The current proposal would establish a new regulatory body with broad powers, a moratorium on second residencies, and would subsidize each sub-prime specialist with almost $37.26 per year for two years in an attempt to keep doctors in practice.
Many analysts blame the residencies for the fiasco. “Teaching institutions encouraged sleep-deprived medical students to accept residency contract terms little less than indentured servitude. These predators knew they could market the derivative doctors to other institutions and practices before the bubble burst.” asserts one observer.
Other experts disagree. “As students they knew what they signed up for. They were well aware of the low pay and long hours. We need the Government to be firm and refuse to subsidize such risky behavior.” stated Dr. C. P. Tea of the American College of Remunerology .
However A. Fool, MD says she was enticed by the U.S. Government itself. “Federal policies were a giant bait-and-switch. We students were encouraged to enter general internal medicine and family practice and residencies were paid many Federal dollars to expand training slots. Once we completed training and entered practice, the rules and payment system were changed. We’ve been RUCed.”
The proposal will soon be submitted to Congress.
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