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I Need a Reminder. . .

. . .To Remember All These Reminders!

Walking around the hospital the other day, I came across a notice reminding physicians about documentation requirements. I had seen the note when it was first posted a few months earlier, but it had since faded into the background  wallpaper, and I don’t remember noticing it since. It made me wonder about all the notices that go un-noticed around the workplace. So I decided to start looking out for them, and was surprised to find just how many reminders there were. Here a but a few for your perusal.

Continue reading “I Need a Reminder. . .”

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The Squandering of Tobacco Settlement Billions

 

TO KEEP SMOKING!

Please enjoy this recycled oldie-but-goodie while I spend the next few weeks juggling a high case load with studying for the boards with taking care of two babies, etc. . .

Few things smell worse to me than the stank of a cigarette while trying to trying to load up on cholesterol via awesome blossom.  Perhaps one such thing is the beguiling tale of what perverse fate has befallen the gobs of cash money rewarded to state governments from Big Tobacco.  

This seemingly righteous pursuit was fought by brave attorneys general of 46 various states to regain money we dished out to pay the costs of Medicaid patients who, due to tobacco use, found themselves in various states of wheeziness and/or infarction.  So naturally you’re asking “why then did these same states more recently try to help Big T in getting a recent settlement against it reduced?”  Good question.  Read on. . .

Continue reading “The Squandering of Tobacco Settlement Billions”

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Restraint Is Hard

Being a Hindu, I have no idea how it feels to give up chocolate for Lent. Also, as I’m a crappy Hindu, I’m not sure how it feels to give up eating meat either. But I imagine it must feel something like this self-imposed writing embargo I’ve placed on myself until mid-November, while I get through a busy spot at work and prepare for board exams, among other things.

It’s been particularly difficult because in the past year so much has appeared to have transpired in the medical (and in particularly the pulmonary, critical care, sleep world) that has me itching to write. From the ethics of EMS services initiating therapeutic hypothermia to the use of CT screening for lung cancer, I have been finding it hard to resist the call of my keyboard. But alas, blogging doesn’t pay the bills (it actually makes ’em), so I’ll keep focusing on what does, and in the meantime, I’ll throw a few recycled oldies-but-goodies your way.

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Snow Birds and The Unfulfilled Promise of Electronic Health Records.

Please enjoy this recycled oldie-but-goodie while I spend the next 6 weeks juggling a high case load with studying for the boards with taking care of two babies, etc. . .

The migration has begun. All over Michigan, the annual migration of flocks moving south is in full swing. And behind those flocks, the other annual Michigan migration is starting too. Our office is starting to see our winter ‘checkout’ patients before they migrate south for the winter.

Over the next month, I’ll see a multitude of patients come in to get ‘checked out’ and get paper prescriptions to take with them to Florida in case they find themselves under threat of missing a golf outing due to varying states of cougheyness and/or wheeziness. Many of them have physicians in Florida that they sometimes see, and occasionally they get hospitalized while down there. They usually come back with an impeccable tan, an extra spring in their step, and a story of their various physician visits and /or hospitalizations with more holes in it than your average disability application.  They also explain that any tests that I’m about to order have probably already been done by their physicians in Florida, and they’d like me to take a look at those records before I order anything. We then start the dance of trying to get copies of their charts, which goes something like this:

Records Requested:                                 Records Received:
Request for chart.                                                     Nothing                  

Second request.                                                       Nurses notes 

Third request..                                   Copy of diet recommendations.

This whole dance has started to make me wonder about my ardent support for the electronification of medical records, which is supposed to do for medical care what the invention of sliced bread did for a fledgling sliced deli meat industry. By now we’re all aware that the Institute of Medicine (which by the way, to me sounds like a made up name) tells us that a gazillion patients are unnecessarily being decapitated every day because physicians’ illegible orders for ‘allow decaf for patient’ are being misinterpreted by hapless nurses as ‘and now decapitation’. Electronic medical records, says the Institute, would successfully ameliorate the silent killer that is physician penmanship.
But how does this impact the care of patients who had treatment from another physician or medical system, whether it was across the country or across the street? Nada. If I want to see those high tech electronic records, it still requires that I talk to a person, those records must then be printed, then faxed. Because of this, many of these tests end up being duplicated, and because of the awesomeness/stupidness of medicare, it has continued to pay for the duplication of these tests even if it has only been days since the original tests were done.

It seems to me then, that adding electronic medical records to the current system is kinda like adding a microchip to an abacus. . . in the end all you get might be nothing more than a fantastically expensive Goldberg machine. To me the only way that electronification of medical records will ever be the revolution that it’s backers claim it will be, is when there is a high degree of compatibility between systems. This would allow patients’ data to be shared among multiple different records systems. It would provide patients greater mobility between medical systems, rather than being tied to whatever system their PCP happens to be in. That greater mobility in turn might place greater pricing pressure on different medical systems as they are forced to compete to a greater degree. So how exactly do we implement this? I don’t know. But I promise I’ll start thinking about it once I’m done faxing all these diet recommendations to Florida.

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Money’s “Best Places to Live” is Not the List I Want to See

Money Magazine came out with yet another list of the best places to live. The article describes wondrous places full of affordable housing and low unemployment. What may not be readily apparent is that the cheap houses and easy jobs exist mostly because nobody wants to live in these  dark, snowy regions of our nations belly button, housed next to mostly people forced to relocate by various witness protection programs.
If  there’s a truth revealed by these lists and their popularity, it’s this; even in today’s hyper-connected society, we really have very little idea of how where we live stacks up with other parts of the country that are not California wine country, or hurricane ravaged areas of N.O. If I thought about relocating from my local municipality to another one in another part of the country, i really would have no clue  as to how they compare.  
Seeing lists like this is mostly pointless, for most of us anyway, as we relocate  based on where the jobs are, and not to end up in a city that ended up on  some magazine’s list. So ultimately what I want to know, what all of us really need to know, isn’t a list of places that we need to move to, it’s a list of places that are to be moved away from, to be shunned, avoided like Chernobyl.  Yes, what we really need is a list of “The Worst Places to Live”. Money Magazine, are you listening?

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Does Oxygen Addiction Exist?

Ok, I know, the joke’s on me. We’re ALL addicted to oxygen, after all it’s in 21% of the air we breathe (if this is not the case, please check your location, you may be on the wrong planet). We all need oxygen physiologically, but I’m talking about psychologically. There are those patients that know, I mean absolutely know, that oxygen seems to make their dyspnea better, even though a check of their pulse oximetry shows an oxygen saturation of one-hundred percent even when exercising. So back to my question, does this mean that they are psychologically addicted to oxygen, or does the supplemental oxygen actually fulfill an as yet unknown physiologic purpose?

Ever since two studies in the early 80’s (one which showed an  overall increased survival with oxygen use, and another which showed a benefit with continuous oxygen over nocturnal use), supplemental use of oxygen for people with low oxygen levels has been considered standard of care. The current cutoff for an acceptable level of oxygen in a stable patient is, in general, eighty-nine percent (though there are always exceptions, let’s be clear, that I am talking about ambulatory oxygen in otherwise stable patients, and not about a hospitalized patient who is having a heart attack). For the most part, insurance companies will not pay for ambulatory oxygen therapy unless it is documented that their oxygen hits the magic number of 88, as we know that’s when the hemoglobin saturation curve starts to fall down a steep cliff. Or perhaps it’s because that’s when the Dr. Brown’s Delorean takes off. Either, one, I can’t quite remember.

Anyway, as I was saying, there is no known benefit to using oxygen when the measured levels are normal. And come to think of it, I don’t know of any data showing beneficial effects of its use in those with COPD whose oxygen saturation drops only with exertion (a common scenario where it is prescribed). Yet, many patient often insist on the continuation of oxygen even after it is explained that it is no longer medically necessary. To date I know of no study that shows beneficial effects of adding ambulatory oxygen to people with normal oxygen levels. One study compared forced air with oxygen in people with normal oxygen levels and found no reductions of subjective dysnea. Currently, the LOTT study is underway to see if ambulatory oxygen may be beneficial in patients with COPD and low-normal levels of oxygen. In addition, there are possible negative effects of oxygen, including the possibility of carbon dioxide retention, potential oxygen toxicity, and the hazards of transporting  and storing the stuff. Not to mention the dangers of  having inflammable substance being used by a smoker.

However, in my experience, patients who really feel that the oxygen is helping them with dyspnea do not care about these ideas, and are resentful about their physician talking about discontinuing it. Given that there is no data to continue the use of supplemental oxygen in those with normal oxygen levels, does their insistence in fact represent a form of addiction? I often see patients who refuse oxygen because of their misconception that their body will ‘get used to it’ and that they will not be able to get off of it. Thus far, I have brushed aside these concerns as there is no known physiologic basis for this. I wonder if perhaps I should consider the possiblity that their bodies might not get used to it, but their brains might.

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One Man’s Enterprising Solution to Beat High Drug Costs.

And that solution is. . . to become a drug rep. A fake drug rep. And get access to all the free free brand name (no generics here) medications your heart desires. The story at Pharmalot states that a well dressed man:

“walked into a physician’s office in East Northport, New York, which is on Long Island, and helped himself to about $300 worth of drugs from a shelf after claiming he was a pharma sales rep.”

The man was apparently later caught. Perhaps he was sent to jail. I say send him to D.C., this may be the kind of creative thinking we need to reduce our health care costs!

See the full story here. And the follow up here.

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Daily Docblock: International Espionage Edition

Around the world right now, there are evil nerds plotting attacks on our nation’s computer systems, while ours are plotting counter-attacks against theirs. But in my daily grind of looking at images sent from radiology centers, I have discovered something which could be wielded as a sort of super weapon in this war; the CT scan on C.D.  My plan is simple,  just send one  CT scan on C.D. to a high-placed member working on a sensitive computer network of one of our adversaries. It would labelled appropriately to entice the user to place it in the CD drive (“grandkid pictures”, “porn”, “Lady Gaga’s Latest Shoes”, etc. . .) Once the user places the CD in their computer, and clicks on any screen, then if these things work they same way they work on my computer, they are simply moments away from complete system shut down.

Their computers will freeze, becoming completely obstinate in their refusal to continue. If an attempt is made to close the program, or remove the disk, the program will ask for the disk to be placed back in the computer. If the disk is placed back in the computer, the program will state that the disk is not recognized. If an attempt is made to shut down the computer, the program will ask the user “are you sure?”. If the user clicks “no” the program will ask “why not?”. If the user clicks “yes” the program will reply with any number of vague responses such as “in progress…”, or “why?”.

 The process will be frustrating, maddening, even tech support gurus will be beffudled and have no choice but to  wonder about the wisdom of messing with a country that could produce something so diabolically powerful!  

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Daily Docblock: Denied Edition

 

It seems the doc-blockage never stops. A particular thorn in my side has been Care Core. They manage imaging services for an insurance that we accept and often deny coverage for CT scans. Once the requested test is denied, the physician may appeal by calling a 1-800 number, and much of the time, they end up approving the requested study. So my question is, why make the physician jump through hoops just to get the study done, when ultimately you are going to approve the test if a physician calls? Then again, maybe that’s the point, not every physician will have time in their day to call and appeal, and many of tests will not get done.