Cash Flow

Fountain at the Alamo in San Antonio

“You tell that doctor to write me a prescription for something affordable!”

*Click*

My medical assistant glanced up at me with a shocked look on her face. There was no need to repeat the conversation. I had heard every word.

“That does not make any kind of sense. It is a generic medication. It should only cost $40. Max. Call his pharmacy and find out what that med is going to cost him there.”

Later in the day I read the computer message that said it was going to cost $340 for a one month supply. Hell. I wouldn’t even pay that. 

I typed out a quick message and routed it back, asking why it was going to cost that much.

It is the brand name. If you want them to fill the generic you have to write for the generic. 

Except that I HAD written for the generic. I always write for generic. 

I sent back a stongly worded message pointing this out and telling them to fill the frickin’ generic. 

This was followed by a string of other patients with similar complaints all from the same pharmacy chain. Insurance companies refusing to cover prescriptions that patients had been getting without issue because the pharmacy chain was filling brand name instead of the generic option. It makes them more money. I would have never known this was occurring if the insurance companies had not denied coverage. 

From a drug coverage standpoint we love to hate on insurance companies but pharmaceutical company and pharmacy shenanigans are one of the reasons healthcare costs in the US are skyrocketing out of control. 

So I tell patients to be aware of what they and their insurance companies are paying for. If there are significant changes, please ask questions. Shop around to other pharmacies. The variability of cost from one pharmacy chain to the other is astonishing. AND, talk to your doctor. The only way I find out about these kinds of things is from patient complaints.

Just maybe don’t yell at my staff… 

Elongated Shadows

Carved wood totem

Suddenly, the exam room was plunged into darkness.

Thinking that the energy saving motion sensor had somehow felt the room was empty, I was placing the sutures with my back to the door and the patient was lying very still since I was stitching up his face, I raised my hand and waved.

Nothing.

“Well, that’s a first…”

The patient made a nervous laugh. 

I stood and using the glow of the light visible from the battery powered laptop that was perched on the countertop, I made my way to the door. Sticking my head out, it was clear the entire clinic was without power. Other patients and staff stood in the hallway, waiting expectantly. 

But the power never came back on.

For the next hour we saw the remaining patients by the light of our cell phones, doing the best we could. I was not able to look inside ears or do EKGs. I could not order any tests or X-rays. Our clinic phones did not work. We had to *gasp* handwrite our prescriptions. The centrifuge could not spin our blood vials before transport to the lab.

In fact, almost the entire city was without power thanks to an accidental severed line somewhere… according to reports from the power company.

Tens of thousands of dollars worth of vaccines in our fridge/freezer could potentially go bad as the ETA on the power coming back on was maybe 12 hours away. Some of the staff graciously packed up the vials boxes and drove them to another clinic with power for safe keeping.

The movie theater cleared out next door. None of the traffic lights worked and the backed up intersections were utter mayhem. My kids’ school was pitch black and they had runners bringing to the front kids for pick up since the intercom system did not work.

You know what, though? It was fun! A dry run for the zombie apocalypse… We’ve got this! 

It was a glorious feeling.

And then? 

I spent the entire evening when I got home trying to catch up on the charting and patient calls that I could not get to from the office. Why is it that ONE hour without power turns into THREE frickin’ hours of work? How is that even possible?

Grrrrrrrr…..

Veracity


He chuckled to himself. Potassium level?

Let’s make this one 6.5….

He hit enter then scanned down the list. 

Ahhh… a 90 year old woman. Perfect!

This time he picked the sodium level. 

126

In thirty minutes he had changed the results on over three dozen patients. Just one or two per provider, not enough to cause much of a stir…. Since none of the docs at the various system clinics spoke to each other.

*******************************

Potassium level 6.5? No eveidence of hemolysis noted. Damn.

She sighed and dialed the patient’s number, hoping he would pick up.

“Hello?” a male voice said

“Mr. James?”

“That’s me…”

“This is Dr. Stephens. I was calling to discuss your lab results. Do you have a second?”

“Sure, Doc!”

“Your potassium is showing as rather elevated. Most of the time this ends up being an error but at this level, if it is true, it can kill you. We need to get it rechecked. The best place to do that is the ER. They will recheck the levels and do an EKG and if it is really elevated they can bring it down.”

“Are you sure?”

“Yes, sir. I know going to the ER is not a cheap proposition but I don’t feel like at this level we have much of a choice.”

He sighed audibly. “Ok, Doc. If you say so. Should I go right now?”

“Yes. I’ll call ahead and let them know you are coming and why.”

She had alerted the lab to these abnormal results several times. Each and every time it seemed they were proven false. It had been occurring since the mandate that all providers had to use the system laboratory instead of sending their samples to an outside place. Invariably she was told it must be a problem with the way staff was drawing the blood. 

Only it wasn’t… She knew that was not possible.

*********************************

The board gave a standing ovation. Revenue for the system had reached an all time high. It had been a banner quarter. Things had been looking grim for so long….

A nondescript figure in a dark suit with a light blue silk tie sat silently in the corner, arms crossed, smiling to himself. 

The Cost of Protection

Carved flowers on a Victorian tombstone.
There have been several times over my career that I have had to step in to protect a patient from their family. Each and every time it gets nasty. It takes a certain kind of person to abuse their child or to molest a mentally challenged adult or neglect an elderly person to the point they have maggots in their wounds. Those kinds of people fight and they fight dirty.

I marvel at how some attorneys can look at the facts of a situation and defend it by attacking and terrorizing the physician who had to make the call. It is exhausting and terrifying and can leave you questioning yourself and your judgement throughout the process:

Surprise subpoenas summoning you to appear in court in 60 minutes, requiring you to cancel all of your afternoon clinic appointments at the last minute.

Threats of lawsuits.

Antagonist depositions. 

Lies and accusations made publically.  

Nothing in medical school prepares you for this sort of thing. Physicians have malpractice insurance but this is not malpractice. There is no one to walk you through it unless you hire your own expensive attorney.

Eventually you are vindicated but not before your life is made a holy living hell. It takes a toll on your family and friends as well, as you cannot discuss it with anyone else. The process can drag on for months or even years.

You are isolated and alone.

Fortunately, all of my experiences have been before social media. I have seen, of late, some unbelievably ugly online attacks made on physicians who are only doing their duty and trying to protect the vulnerable. It appalls me how quick the rest of the world is to jump onto the hate the doctor bandwagon when they do not know the whole story. Physicians are not allowed to defend themselves due to privacy laws. The rest of the world will never know the whole story.

What some people seem to forget is that our role as physicians is to assess the situation and make a recommendation. We are required by law to report suspected abuse. We are not omniscient super humans and maybe we don’t always get it right. All we can do is our best. In the end is up to the courts to decide guilt or innocence. 

The price we pay to do so is often very, very high….

Menorrhagia

Light in Boston art museum

She was new to me.

She was mentally challenged although I will admit that I don’t even know what the right PC word is anymore. Clinically I have tons of appropriate labels but speaking to all of you, I don’t know what term to use that will guarantee that I do not offend someone. 

On top of that, she had developed dementia. 

Her sister spent her entire life as her personal caretaker… never married, never had children. Out of her several siblings, she was the one who stepped up to the plate. She genuinely cared. She had watched countless times as the medical community wrote off her sister. She had watched the untold emotional and physical suffering and she felt the unfairness acutely. 

One of the toughest things to deal with in this population is menstrual problems. Periods by themselves are bad enough when you understand them. Imagine trying to deal with your period when #1 you don’t know why you are bleeding from between your legs and #2 that bleeding is irregular and excessive. 

As a physician, working up menstrual problems is especially hard when you have a grown person who is willing to slug you, who screams and cries and is so terribly, awfully afraid of what you are going to do to her. I don’t believe tying someone down, forcing myself upon them, should be necessary. That sort of thing only exacerbates and perpetuates fear but it took us 45 minutes just to draw her blood. I held her hand. Her sister held her other hand. Two other staff members worked together to do the draw. No one got hurt, most especially the patient, but it took us 45 minutes to get her calm enough to endure four sticks to find a good vein.

In fact, it had been years since anyone had even tried to draw her blood because of how much of a challenge it was. Still, it had to be done. And we did it. But for the rest of the day I was running 45 minutes late. I could not catch up to save my life. 

I cannot go in to each patient afterwards and explain what happened. Patient privacy. Takes too long. Etc. etc. etc. But to all of those patients who graciously accepted my ambiguous apology, thank you. Thank you for not slamming me on patient satisfaction scores. Thank you for giving me the freedom to take care of this one person who really needed me.

You made a difference. 

You helped save a life. 

You are all my heroes and I am lucky to have you as patients.

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….. 

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I always block my ID when calling patients. If I don’t, I start getting direct calls from patients. Those kinds of patient calls are the minority, to be sure, but they are exhausting and disruptive and are sure to occur when I am on the toilet having a rather tough poo (lots of noisy grunting) or whilst in the midst of mind blowing sex (also lots of noisy grunting) or something else equally awkward like changing a high lightbulb while precariously balanced on a ladder (probably also involving lots of noisy grunting).

One consequence of this is that patients don’t answer my calls. I have to leave a message and wait for them to call me back, sometimes an hour later. It happens almost 50% of the time when patients call the answering service, even though they are expecting me to return their call. It occurs 90% of the time when I have to call unsolicited, like when the lab alerts me that a patient’s potassium is 2.3 or their platelet count is 10 or maybe the hemoglobin level is 4.5 (these are very bad things by the way) and I need for them to go to the emergency room.

OR, the patients have the feature activated on their phone that will not allow unidentified callers through. That requires that I call the answering service back, then they have to call the patient and walk them through how to deactivate the phone feature, then call me to let me know I can try the call again. Sometimes that still does not work because they are unable to deactivate the feature and I have to call the answering service to call the patient back for an alternate number. 

What I really, really want is a way to ID myself when calling without showing my phone number. “Dr. Victo, phone number unavailable.” Or some such thing. 

Maybe that already exists and I am just a dork when it comes to telecommunications… 

My First

Buckingham Fountain in Chicago

I don’t remember my first patient. Not from medical school or residency or even private practice. It struck me when Linda Bethea of Nutsrok asked the question, that I have no idea who those people were at those milestones in my life.

What do I remember, then?

I remember being terrified. 

Was I going to make a fool out of myself? Would I misdiagnose something? What if they didn’t like me? 

There are many patients that I do remember over the years. They all taught me something. Even if I made a mistake. Even if they didn’t like me. Even if I didn’t like them. Even if I don’t remember their names or their faces now. Who I am today, as a physician and a person, is largely due to an accumulation of experience from all of them. 

So maybe I don’t remember my first. Or even my second. But maybe that doesn’t matter so much. 

I bet I WILL remember my last…

(Go check out Linda’s new book!)

Reaching Out

On my request for questions last week, Dearlilyjune asked:

Studies show that transgendered patients often avoid going to the doctor when they should. Is there a way you would reach out to/encourage that demographic?

Here is the thing, and I am going to be very open here, I would not know the first thing about specifically reaching transgender patients and recruiting them into my practice. I wish I could write some erudite treatise or share some story of compassion that would wow everyone of you but I cannot. 

I don’t try to recruit any particular types of patients, however I will treat anyone and everyone, regardless of sexual orientation, gender, religion, race, or lifestyle.

The first time I encountered a transgender patient was in residency and truthfully, I sucked at it. No training, no experience. I had grown up sheltered from anything and everything. And to be honest, I thought that I would never meet anyone who was transgender. What are the odds, you know? What so many forget, and what I did not realize at the time as I was just starting out, is that the world is full of “alternative” lifestyles. Just because you don’t see it does not mean it isn’t happening. I am privileged to know a lot of secrets and I can assure you that the world is not full of just plain vanilla. Oh, no. Very little vanilla, in fact….

What I have figured out over the years is this (and these rules apply across the board for all patients): Be respectful. Make clear you are not judging. Ensure your staff keeps their professionalism. 

Too often transgender men and women are treated as circus freaks. I have witnessed it. That would certainly keep me from seeking help as a patient and it is not the type of medical practice I want to be a part of.

The bottom line is that all people deserve respectful, compassionate medical care. 

Period.

No matter what.

Down The Pipes

ventilation shaft on a boat

He had just been here last week. Why was he back so soon? 

The tag line on his visit said, “NOT BETTER.”

What do you mean you’re not better?!!?!!?

Somehow, I always feel a bit defensive when patients don’t get better, it is as if the illness has exposed my weaknesses. I have come up short. I know it isn’t logical, but this is the way I feel.

Do they think I did something wrong?

Sometimes they do.

I took a deep breath, burying that defensiveness so it would not show on my face, then knocked on the door and entered. 

“Hey, Doc.” He looked at me apologetically. “They told me I couldn’t work and would have to get paperwork from you.” 

He passed me a thick stack of FMLA forms.

“You couldn’t work? You had said your cough wasn’t that bad. Did it get worse?” 

“The cough got better. Everything was better but I lost my voice. I went to work every day and each day they sent me home. Other people, they just take them off the phones and put them somewhere else. I don’t know why they wouldn’t let me do the same.” He looked ashamed. “I really needed the money. I got a family to take care of.”

For five days his employer told him he couldn’t work because his voice was raspy. Each day he was sent home. Now I had to complete pages of paperwork for FMLA* stating he had a serious medical condition that prevented him from working. 

A hoarse voice does not constitute a serious medical condition. 

And yet, if I did not complete his paperwork, he would lose his job…

I am constantly backed into the corner by employers in various ways. If you want to get rid of your employee, tell them. Do it for legit reasons. Don’t make me the bad guy. Really. But it is so much easier to pass the buck, to let someone else take the fall, to make them do your dirty work for you. 

Look, we like you, but you missed too many unauthorized days. Too bad your DOCTOR wouldn’t fill out your paperwork…

“Please, Doc?” His eyes pleaded with me. 

I completed his paperwork. 

“Hey, maybe you need to start looking for a new job. Just in case, you know?” 

He nodded. He understood.

At least he was being honest. I checked. 

There are plenty of patients abusing the system, too…

*FMLA (Family Medical Leave Act) allows certain employees to take up to 12 weeks off in a calendar year for a serious medical condition or to care for someone else with a serious medical condition. It is unpaid leave but it does make sure you have a job to come back to. For a physician it is about five pages of stupid questions to complete.