Depressions

New York Public Library entrance

“I see from the medical assistant administered PHQ-2 that you have been feeling down lately. Tell me about that.”

“Uh, I am here for my knee. Why was she asking me about depression?”

“Well, we want to put a focus on mental health, you see…”

“What about my knee?”

“We’ll get to that at your next visit. Right now all we have time for is delving into this positive two question depression screen.”

“You guys never did this before.”

“I know. But here we are. Better late than never. So are you thinking about killing yourself?”

“NO!”

“Should we put you on medication?”

“I don’t like drugs.”

“Counseling then! Good choice. I’ve got a list of counselors in the area…”

“I am not paying for counseling and I haven’t got time for it in the first place. My knee is what is getting me down.”

“Yes, well. Come back in two week’s time and we can talk about the knee.”

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That wasn’t real. But it could be….

The healthcare organization I work for is now measuring my quality based on my medical assistant asking patients questions about depression once a year right before they check the blood pressure. 

I have yet to have a patient say this was a good addition to their rooming procedure but that is beside the point. Why are we focusing on this in the first place?

To save lives.

Personally, I hate questionnaires. They are an attempt to oversimplify a very complex problem. Can we really put depression into a box? Should we?

If the PHQ-2 is positive it should be expanded into the PHQ-9. The PHQ-9 should be used to monitor response to treatment. 

I much prefer a conversation with a patient to reviewing a questionare. I can tell, usually, when a patient is having a hard time but even if I can’t I still ask once a year at the physical as part of my review of systems. And if they say they are having problems I pry, by golly. Are we talking about a chemical imbalance or did their mom just die? Is it affecting their ability to hold a job? To take care of their family? My medical assistant shouldn’t be the one asking the questions. It should be ME. That is my job. Which then brings me to documentation. Make it easy for me. Don’t hide it on a different screen. My review of systems documentation should be sufficient shouldn’t it?

It frees the physicians up to do other more important things.

What is more important than mental health? But then, I wonder, are we perhaps overemphasizing it on some level, too?

When we made pain into the “fifth vital sign” we created a whole population who became focused on feeling no pain, a pharmaceutical industry happy to create addictive drugs that prevented anyone from feeling pain, and physicians caught in the middle. Ultimately, the prescription narcotic addiction crisis was the unintended consequence.

So I worry that we will over diagnose depression. I am not sure that assigning labels like that is all that helpful for most people. I worry that those who are truly ill, who need the most help, will be pushed out of an already failing system that becomes glutted with everyone else. I am already seeing this trend. Making my very ill patients wait three to six months for an appointment with a reputable psychiatrist is unacceptable but it is par for the course nowadays.

The mental health system in the US sucks and that’s the truth. It especially sucks around here. There is a dirth of good psychiatrists in my area. Same with counselors and psychologists. What are we supposed to do? Should we as primary care just push drugs on everyone? Drugs that have side effects and risks and which are not appropriate for all patients? Who then will manage those drugs? Me? With very minimal training? And if we push drugs but cannot effectively pair it with counseling support, what have we accomplished? We are supposed to help, to make people better aren’t we?

I’d really like to know YOUR thoughts…

A Down Sizing

Mission San Jose in San Antonio

I see and touch an awful lot of breasts. 

Just about every “uninhanced” woman on the face of this Earth has one breast that is slightly larger than the other. I certainly do. As I age it becomes more and more obvious… the left is fuller than the right. Every time I put on a bra or look in a mirror, I am acutely aware of it and I wonder if other women notice or care about their subtle discrepancies in size. Not that I would ever bring it up in the clinic, mind you. That would be akin to your beautician asking if you want her to wax your upper lip… creates a paranoia if there was not one there to start with. 

Thankfully, I have never had a man look at my chest and run away screaming.

Every once in a while I come across a patient with a more dramatic mismatching, like the woman with one breast a cup size A and the other one a size DD. It created a serious self esteem issue. She had never had a relationship as she was terrified of anyone see her naked. She stuffed her bra with whatever she could find until someone sewed her a pillow to tuck in there instead.

Hey! Sugery can FIX that for you…

You would think this would be a no-brainer, but no…. Invariably the response from insurance companies on the request for augmentation or reduction is, “Not medically necessary.”

I always wonder who the people are making these decisions. Men? Women? If a man, would a woman make a different decision? Or vice versa?

I know the angst I have had over the years over my slightly different sizes. I cannot imagine the psychological burden carried by these women with their really noticeable differences. So what determines medical necessity? We allow breast reconstruction in breast cancer. Is is “medically” necessary? Maybe not. But it is psychologically necessary. 

So then, what determines something being psychologically necessary? What size disparity is traumatic enough to warrant coverage? One size? Two? Four? How do you measure something so subjective?

And then what else causing cosmetic angst should be covered? I had a mole removed from my face while I was still in med school. Right next to my left nostril. It wasn’t huge in real life but in my brain it covered half my face. Best thing I ever did for myself, getting that sucker whacked off. 

So, what are your thoughts? How is your breast size? What do you think about insurance covering breast augmentation or reduction? 

Showing Up

Empty barn at a livestock show

“Well, at least you will have some time off!”

I marvel at this well meaning sentiment because truthfully, jury duty does not feel like time off. It is more work than my real job.

First, I am spending hours on the computer trying to make sure patients’ results are communicated, orders and refills get sent, questions are answered.  I do this in the mornings before I go to court and at the lunch break if they give us enough time. I have a ton of anxiety… that someone is going to get hurt, that a patient is going to get upset, that a ball will get dropped. The office is terribly short staffed right now and I have to be out next week for my kids’ spring break. My jury summons could not have come at a worse time.

Second, while it is mind numbing, it is necessary to pay attention to everything that is presented so as not to miss the details. Someone’s future hangs in the balance here. It isn’t like I can sit in the jury box tapping away on my phone or reading a good book. I still have to focus on what is being said, boring or not. In the clinic I get to talk, interact with people, use my hands. Here? I am a fly on the wall, watching. Always watching. Never speaking.

My fingers and toes have frostbite. Why the heck do they have to keep the room so cold? So the one big man in robes doesn’t sweat while the rest of us freeze our asses off? A sweater is just not enough. I need a parka.

Here is something else: I don’t like any of my fellow jurors. They are annoying as all get out. What are the odds of selecting a room full of crazies? And what does that say about me, getting picked to sit here with them? Hmmm?

I hate that the judge and the attorneys have made a big deal over what I do for a living. “We have a doctor here, let’s pick on her.” I have to give my employment details on all of the forms. Why is it then necessary to announce to the entire court room who I am, what I do? They did not do that to anyone else. I hate the silly, ridiculous and even inflammatory medical statements people like the bailiff make around me as if they are wanting to goad me into weighing in, handing out free medical advice. It isn’t the free that I mind, it is the fact that I know nothing of their history and we do not have time to do a proper consult about their chronic cough right here, right now. 

This whole experience has been eye opening. 

Rant over. For now.

Hovering

Blimp in the sky
My childhood was tightly controlled. Every aspect of my life was minutely scrutinized and managed. 

I was not allowed to ever spend the night at a friend’s house. I went to a friend’s house once in grade school. Only once. My first sanctioned date was to a church to deliver fruit to shut-ins on Halloween night when I was almost 17. The guy who had asked me out was required to participate in a 30 minute interview process prior to being allowed to drive me less than five miles to the church. That interview ran the gamut from current grades, college plans, statement of faith, general health, etc. Physical contact with members of the opposite sex was strictly forbidden, going so far as not allowing me to give a male friend a platonic hug at his graduation. He hugged first. I guess I was supposed to run away screaming. My punishment for that hug back was to write 1,500 times, “I will obey my mother.” I was a junior in high school. My library books were prescreened before I could check them out until I was 18. I was not allowed to learn to drive until I graduated from high school. Dancing, ear piercing, and make-up were against the rules and the Smurfs were not allowed (Gargamel used magic doncha know). 

So when my kids started playing with the neighbor kids, I found myself hovering. It was suddenly necessary to inspect the yard for mushrooms. Rake leaves. Hunt for pecans. Maybe I’ll just wander around looking disinterested while spying on their conversations. 

What am I afraid of?

I’m afraid that my kids will do something offensive, something that will get them labeled as weird or bullied or worse. I am afraid that someone will hurt them, physically or emotionally or sexually.

But I am also afraid that my kids will be judged unfairly because they are *my* kids. That they will be used as pawns in an attempt to get to me. The whole doctor thing. I have been burned before.

Because of the control I experienced as a kid, it is exceedingly difficult to let go of control of my own kids. It is all I know. BUT as I commented to someone yesterday, I am not raising pets. I am trying to grow a couple of independent human beings. 

My kids make jokes about butts and farts and you find that offensive? Maybe it’s your fault for letting your kids play with mine. Your kids are going to pick on my kiddos? My son and daughter are very, very good at karate. You want our kids to make friends so you can say you hang with the doctor? Well fine. I cannot assume everyone has ulterior motives, can I? I will cut you off if necessary. 

So this weekend when they all started playing together again I forced myself to let it go. I went inside and busied myself making homemade marshmallows. I even closed the back door. 

And you know what? They did just fine without me. 

Outcomes

eileandoonancastle3cropped

His voice shook.

“She’s in ICU. I thought you should know.”

I felt my body grow cold. She and her family had been patients of mine for almost ten years. She was so young. Younger than me, in fact….

“They aren’t sure if she is going to make it.”

“What happened?” It was supposed to be a simple cyst removal.

“Her small intestine was perforated. They have her belly open, said they couldn’t close it yet.”

I had used a new surgeon, someone I had never used before, because the mass was blocking the tube from her kidney to her bladder, causing quite a bit of pain and endangering the kidney itself. She needed surgery quickly and no one that I typically used was available to work her in. 

“That’s just awful. Keep me posted on how she’s doing. I’ll be saying a prayer for her and for you.”

“Thanks, Doc.”

As I hung up, the guilt welled up. I felt personally responsible for the bad outcome, even though my hands weren’t the ones actually in her belly. MY hands had hit the referral button, signed the order. 

She trusted me. 

She ended up making it, but it took a huge toll on her both physically and emotionally and financially. It affected her relationship with her husband. It affected her kids. They had almost lost their mother and it left them all shaken and ungrounded for almost a year. Things are only now starting to look up.

I feel guilty when patients don’t like someone I refer them to. I feel that I have let them down. I feel guilty when I find a cancer, as if somehow it was my fault. I should have prevented it. Maybe I could have found it sooner somehow? And, yes, I feel responsible for surgical errors and outcomes.

So when I tell patients they need to see a different specialist than the one they picked out, I worry how far to push it when they aren’t agreeable. When I know a back surgeon is bad, how much do I tell a patient who is not listening to my gentle suggestions to seek a second opinion elsewhere? Where is the line professionally and legally? 

These are my thoughts on this Monday morning….. 

The Troll Under My Bridge

Bridge partially obscured by rays of sunlight

“Hey, Doc?”

“Ummmhmmm?” I was trying to figure out what button to push to get his tetanus booster to propagate into the right field of his health maintenance screen. I had a cuss word on the tip of my tongue that really wanted to get said…

“Are you happy?”

That made me stop what I was doing and look up at him. 

People don’t often ask me that question. Most people just assume that I am super happy. I mean, I do have that nice looking fake wedding ring, right? Plus, there is the fact that I work hard to project joy and happiness for my patients. They don’t need me dragging all of my baggage into their office visit. 

But now that the question had been asked I took a momentary inventory of my happiness quotient. Am I stressed? Sure am.

But, am I happy?

Then it hit me. Yes, yes I am happy. Very happy. You know how I know? Generally, I dislike the holidays but this year I find myself looking forward to them. The sound of Jingle Bells does not make me want to strangle some innocent, unwitting fluffy creature. 

I do my best writing from dark places but right now, I don’t want to go there.

So I say all of that to say that while you may read dark things, like yesterday’s mediocre medical poetry, I am not writing them because I am some shell of a person paralyzed by grief who spends the day curled up in a corner thumbing through a lifetime of regrets. Hardly. I have better things to do. And when I do go to dark places it is not because they are my places. Often I borrow them. And I don’t live there. Not for long, at least! Not anymore.

Today, I am happy. 

Today I am thankful. 

Too Hot

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“Hey, Doc! You’ve lost weight. And you look glow-y…”

All day long yesterday, I heard this from patients. Over and over again. It felt weird because I’ve not really lost weight.

Much weight…

“What’s your secret?” one patient asked, then leaned in and whispered conspiratorially, “Are you in love?”

“Um, yes. Yes, I am in love.”

This is what love does to you.

That, or the stress from an EHR (electronic health record) change over looming ahead combined with hot flashes….

Take your pick.

Doubling Over

IMG_5232

“Good news! We got the results of your coding audit and you missed only three things. Please add a 99214 with a modifier to these three office visits so we can post the charges.” The email went on to list the names and dates of service that I was to address.

I go through this every audit. They always find something to nitpick about every year. One year they tell me to do X. I start doing X. Then the next year they tell me I should never do X, I should be only doing Y. Y was what I had been doing before X. And so on….

I don’t like being wrong. I don’t like making mistakes. I don’t like being told what to do, especially if it is something they are going to change on me next year.

Feeling defensive, I looked back at the visits in question this time.

Seriously?

“No way in hell am I going to add those charges. If coding wants to talk to me about it, I am happy to have a discussion with them but I will not be making these changes to the superbill.”

The office visits in question were yearly physicals. Yearly physicals are considered preventive care by insurance companies and as such, the office visit and routine screening labs are covered at 100% by the insurance company. It is not applied to a deductible. There is no copay, no out of pocket expense. 

A “free” visit.

What the coding people wanted me to do was tack on a routine office visit charge in addition to the physical exam visit charge because I addressed something new, like back pain, or made changes to meds for one of their chronic medical problems, like increasing their blood pressure medication.

The problem with this is that particular charge is not a preventive service. It will go to the patient’s deductible. They will get a bill for another $120-140 (or whatever the contracted rate is for their plan) and for most insurances, that means the patient will be paying that entirely themselves out of pocket until their deductible is met. Meanwhile, I get paid for two office visits in the time slotted for the one.

I have been practicing medicine for over ten years. I have known for a long time that it was within my rights to do this but I rarely chose to except for a handful of times in the most extenuating of circumstances.

Just because we can do something does not mean we should do it.

When I have patients skipping specialist referrals and imaging and labs and meds that they really need because of the increasing costs, it bothers me. I need to make money. I do. I have to be able to purchase supplies, pay my staff, and pay the office rent. I need transportation. My kids need clothes, food, and a roof over their heads. The kids will need to go to college and I will need to retire eventually. I make more than enough for this right now, though. I don’t have to double dip. 

The thing that puzzles me at this point is why is coding making it an issue now, this year? It isn’t anything new. There is a lot of paranoia in the medical world about what the future holds for physicians financially, especially with all of the crappy changes to Medicare reimbursement, and that may be part of the reason corporate is starting to pressure us further to maximize our bottom line. I do have to make money for them to make money, after all.

And then I start to wonder. Is there something they know that I don’t?

Should I be grabbing everything I can now and retire early… get out of this business entirely before it collapses so I can go do volunteer work somewhere I am really needed?