Based on One Test

Denial of services because the child is “no longer retarded enough”

I am acquainted with a family who is currently fighting a denial of further services for their autistic child.  This child has been getting social services for many years.  He is a pleasant child.  The family works hard with the child.  He has made amazing progress over the years. 

He did not speak when he started school.  He now does speak, but is not always understandable.  He has many typical autistic behaviors.  He has been working with a social service agency, social workers, special education teachers in school, speech therapists, and hard working parents.  He continues to make progress.

The psychologist changed tests at his last evaluation.  His IQ went up twenty points!  Some of his other “daily life activities” scores went up.  The parents tell me that the booklet they filled out about activities of daily life is being ignored because the psychologist won’t sign it.  He says it is because he wasn’t there when it was filled out.

Two people from the agency (which is located 500 miles away) who have never met the child have determined that he is no longer eligible for services.  This is based on numbers that have made a jump in the last year.  They are based on one test and are not consistent with testing done over the last decade or more.

The psychologist and physician both specifically state that he needs to continue services or go to a group home.  The social workers agree.  The parents want to keep him at home, but admit that they need help. 

There is an appeals process, but the parents are not hopeful that anything will be changed. 

What’s up with this?  One test? 

Pain Scale – Who made it up?

Ten is supposed to be the worst pain ever!

Sometime in the last few years, there appeared a new “vital sign”.  It’s called the pain scale.  We can’t measure this one with a thermometer or a sphygmomanometer.  This one is much more subjective.  In other words, we ask you to grade it yourself.  You will get asked “on a scale of 1 to 10, with 1 being no pain and 10 being the worst pain you can imagine, how much pain are you having now?”  At least that’s the plan.

I love to have people sitting quietly across my desk saying “8” or “9”.  Remember “10” is supposed to be the worst pain ever.  Like if you just got run over a truck, or stabbed 50 times, or….  You get the idea.  My doctor friends who have had kidney stones give them an “8”.

If you are fully conscious and well aware of your environment, it’s not a ten.  If you’re not crying or screaming, it’s not a nine.  If you can still breathe calmly, answer questions and remember your birthday and social security number, it’s not even an 8. 

Remember that the top number is 10.  Anyone that has a number greater than ten has obviously not listened to the question.  We hear “11” or “12” fairly frequently.  We also hear “20” and “30”, and occasionally “100”.  You don’t get any more credit for numbers over ten.  Really.  Except that the medical people taking care of you think you are stupid. 

You won’t get seen faster in the emergency room or the doctor’s office.  You won’t get any more pain medication.  In fact, you will probably get less pain medication, or none at all.  Those of us that do this for a living think that you are looking for pain medication, not really in pain if you say your pain is a “15”, but you can’t stop texting or talking on your phone.  Really.

“I Need to Speak to the Doctor”

If you PROVOKE PRINCESS – Here’s Your Potential Penalty 6

Princess loves to answer the phone and hear:

“I need to speak to the doctor.”

Usually the caller doesn’t even identify himself or herself.  They don’t say where they are calling from.  They don’t want to tell Princess what they are calling about. 

This is not a new problem.  It has been happening since I first started practice.  Remember that I am a gynecologist.  It is funny that not all the callers that do this are female.  It is never a family member.  It is never another doctor or doctor’s office.  They always identify themselves and tell Princess what they want.

Examples of who it might be include (but are not limited to)

·        A patient wanting an appointment

·        A sales person

·        A family member of a patient wanting information.  We cannot, by law or ethically, give this out.

·        An “anonymous friend” wanting to tell us something about a patient.  I really hate these people.  If you can’t leave your name and phone number, why should I believe anything you say about someone?

I absolutely don’t understand it.

I can also tell you right now that, if you aren’t willing to tell Princess who you are, where you are calling from and what you want, the call stops right here. 

Triplet Stuff 2 - Same Classroom or Not?

This is a dilemma that is faced by every parent who has multiple children entering the same grade.  Do you put your children in the same classroom or not?

I think the answer varies from family to family and from child to child.  It also varied for us from year to year and from child to child.  So, for me, the answer is a big maybe.  Here are some of the reasons why.

1.     One of my sons is autistic.   When he was small, most of his learning was in a special education environment.  He needed to be separated from his brothers so they did not feel the need to “care” for him. 

2.     When my boys were very small (preschool), they seemed to need to be near each other.  Besides:

3.     There was only one preschool classroom for the 3 year olds, 4 year olds, etc.  By necessity, they had to be in the same class.  When the kids entered regular school, there were multiple classrooms of the same age children. We could then decide.

4.     Some schools have a policy about twins and more.  Ours did not.  I would use that as a guideline.  If you feel that you need to do something different for your children, push to do what’s best.  I have always done this for my kids.  I call it “being a Mom”.

5.     When my boys were in kindergarten, one of them was much more advanced at reading.  The other was much more advanced in math.  Evidently they made a pact between the two of them that one of them would do the reading and the other would do the math.  This is when we decided that perhaps it would be a good idea to separate them for a while.  They weren’t too happy.  I think they had become too dependent on each other. 

6.     Another issue can be jealousy or competition.  Some children do not do well if one of the others is better at something.  While they do need to learn to deal with this, it can be better to have them in separate classrooms for a while for parent sanity.  The only insane part of this was having the same spelling list three weeks in a row.  Of course, running through the same spelling list with three children the same week wasn’t much better!

7.     Remember that the school counselors, teachers and administration have probably “been there” before.  Most of the time they are willing to help you work it out if you go in with a positive attitude that we are all there to help the children.

8.     As the children advance in school, there will be classes that are only offered once a day.  For example, there is only one section of marching band. (Go, Eagles!) Two of them are in the band.   Since they have opted to play different instruments, they don’t sit next to each other.  The other one and I are the cheering section.  Mr. Lasermed is president of Band Boosters this year.  I think he lives in the concession stand.

The moral of this whole story is that it is important to be flexible and to do what feels right for your children.  What worked for my kids might not work for yours.  It’s also helpful to take advice from other moms and from educators.  Listen to your kids, too.  The whole goal is to get them the best education that we can with the least amount of stress for everyone. 

The Pneumonia Shot

*Free Medical Care –Stuff Doctors Offices Do For Free That Takes Time

This morning a woman called my office asking about a pneumonia shot for a family member.  Mr. Phone Caller (Mr. PC) is a patient at the local Veteran’s Administration Clinic.  He is in his 80s.  Evidently there is no problem getting flu shots, which he has done.  Their policy is that you have to see your “provider” (I hate that word) to get your pneumonia shot. 

Mr. Phone Caller last had a pneumonia shot in 2006.  He can’t get an appointment with his new “provider” until February.  Mrs. Phone Caller is very worried.  She sounded older, and seemed to be quite concerned that he might die without the shot immediately. 

We don’t have pneumonia shots this year.  We didn’t do many two years ago, so we stopped carrying them.  When we did, we gave them to anyone who needed one.  I think that’s why Mrs. PC called.  

Princess talked with her first.  She suggested that Mrs. PC call the local Health Department.  She did and got “the run around”.  She called us back.  I spoke with her and promised we would call around and see what we could do. 

Princess called one medical practice and I called another.  The practice I called wasn’t really interested in giving a vaccine to someone who wasn’t an established patient.  The practice Princess called said they would see the gentleman.  Mrs. PC will have Mr. PC there sometime within the hour.

All of this took about 15 minutes of non-continuous discussion and phone calls.  Mrs. PC is not a patient of ours.  Mr. PC is not either.  They have no charts.   No paperwork was done.  We generated no charges.  Mr. PC will get his pneumonia shot.  Mrs. PC will feel better because he is protected.  The only thing we get out of this is a little bit of knowledge and a couple of warm fuzzies. 

*Free Medical Care may become a series.  These are things that are done in a medical office that are not paid for.  This is mostly for your information, but sometimes I just need to vent. 

Phone Etiquette – 2 Answering Unknown Numbers on your Phone

My cell phone rang one day with a number I did not recognize.  Since I leave the number for patients to call, I answer unknown numbers.

“Who’s this?” the person on the other end of the line started the conversation.  The tone of voice was really rude.

“You called me.  Why don’t you tell me why you called this number?”  I wasn’t going to identify myself to this rude stranger.

“This number was on my phone and I wanted to know why you called me!”

I explained that I had been doing a band fundraiser earlier in the day at the local Wal-Mart.  A fellow came up and asked to borrow my phone.  His ride wasn’t there.  He made a couple of phone calls from my phone until he could locate his friend and get a ride home.

“Oh, OK.” Click.

Well, Excuuuuuuuuse me!

Soap Opera - Doctoring in a Small Town

This week we have been dealing with another patient / family “issue”.  Princess got a phone call yesterday from a fellow who demanded to speak to me.  It always amazes the both of us how many people think you can call a doctor’s office and get put through directly to the doctor.  But that’s another post.  Anyway, the caller (TC) wanted to report that the grandson of one of our patient’s (OP) saw her trying to sell her prescription medications.  He stated he was the boy’s father.

Our protocol when we get a report like this is to call the patient.  We have them come to the office with all their pills within 24 hours.  If the count is correct, we don’t get terribly concerned, though we do monitor them more closely.  When Princess finally got through to OP’s mother (PM), PM said that she had been expecting our call. 

The family was “in court for nine hours” yesterday.  The boy in question lives with his grandmother (OP).  His deadbeat mother (DB) has been getting his assistance check and keeping it for herself.  DB does not support the child. She does not work.  DB evidently has multiple schemes to obtain controlled substances, money that she does not have to work for, etc.  DB has an apartment with her boyfriend and her sister.  TC was her boyfriend, not the boy’s father.

This same group (DB, TC and the sister) had created problems for another patient (P2) we have because she refused to sell them her medication.  P2 had to move and has quit two jobs so far to get away from their harassment.  She has a protective order keeping the whole group away from her.  It doesn’t work very well.  P2 says she feels like she needs to go into the witness protection program. 

I don’t write soap operas, but I feel like I could feed ideas to a few of them.  Both these patients travel over 30 miles to come here because the “group” has caused problems with so many doctors in the town they live in that no doctor there will see them.  I wish I had known that before they came here. 

I’m not sure how big a town you have to be in to not have to deal with this kind of stuff. 

I am your Doctor, not your Mother

The Directions are on the Bottle

I had a patient in the office that I see frequently for chronic pain.  One of her prescriptions has to be written every month.  There are many medications like this.  It is a controlled substance.  It is dangerous to take too much of this medicine.  

You get 30 days of pills and it needs to last 30 days.   This patient had filled her prescription 20 days ago and had ½ pill left.   Here we go again.  I sighed. 

“Have you been taking more of the medication than what you were supposed to?” I guessed (hoping that she had not been selling her pills).

“I’m having pain in the middle of the night, so I get up and take more of the stronger pills.”   She has a prescription for other medication for pain, but is almost out of that, also.   She didn’t call the office to report problems. 

This patient and I had this problem before.  Her insurance will not pay for more pills.  She cannot afford the ten days of medication.  It costs as much as a house payment. 

I felt like I was reprimanding a three year old child.  “This is the last time we can have this conversation.  If you can’t follow the rules, you’ll have to find another doctor.”

Basically, I can’t be your Mommy.  You need to grow up and follow the directions.  Can you spell W-I-T-H-D-R-A-W-L?

Phone Etiquette – 1 “Blocked Number”

I think I understand the idea of blocked phone numbers.  People don’t want the person on the other end of the phone to be able to call them back.  Maybe they are calling from the back line of a doctor’s office.  Maybe it’s a personal cell phone.  I’m really not sure who they are. 

If you call my personal cell phone from a blocked number, be prepared to be ignored.  If your phone does not at least have a number I can identify, I surely am not going to pick up the call or call you back.  I may be an old fart, but I want to be able to identify the person I am talking to.  I don’t think this is covered in the etiquette books, but it probably should be.

Autism, the I-Pad and Speech

Personal Reflections

I just watched a story on 60 Minutes about how some schools are using the I-Pad to help autistic children communicate and learn.  It doesn’t work for all of them, but it does work for some.  Most of these children were small.  They looked to be between 4 and 7.

I remember the frustration of trying to unlock communication.  My autistic son didn’t start speaking until he was around six years old.  We tried all kinds of different things.  American Sign Language (ASL) was helpful.  I think something like the I-Pad would have been wonderful if it had been available at that time.  Mr. Impatient is a whiz at computers. 

There were several mothers who talked about how difficult it is to not be able to understand what is inside those little guys.  I could see the tears welling as they talked about their precious children.  Any small progress is like moving mountains.  In fact, I started tearing up as I watched this program.

I still remember the very first time my son said “I love you, Mommy.”  It was one of the sweetest moments.  I waited a long time to hear it.

Compliance with Medications

Taking Medicines as Directed

I find that one of the most difficult problems in medicine is getting patients to follow the directions for their treatments and medications.  Over the years, I have developed a few tricks for this.  Some are those I do when I get health care for myself or my family, and some are those I work out with my patients.

I always ask several things about the medication. 

·        Is there a time of day I should take it? 

·        How many times a day do I take it?

·        Are there any major side effects I should know about?

·        Should I avoid driving or any other activities?

I know that I can remember to take medications no more often than twice a day.  So, when my oral surgeon tried to give me an antibiotic that is 4 times a day, I told him that was “a set up for failure”.  We negotiated a different medication.  When I got put on a twice a day heart pill, I found that the second one got forgotten more often than not.  So we found a long acting pill.

I have patients that can’t remember if they have taken their medications.  I tell them about pill counters.  I have showed patients pill splitters.  I have switched to generics if possible.   I even have the lists of different store discount medications – you know – the $4 and $5 lists – right on the corner of my desk to help with medication costs.

The moral of this story is that you should talk to your doctor before the end of your visit about your medications so you can do the best job of taking your meds.  Hopefully this will help you get well.

Dr. Lasermed’s Flu Vaccine Fun Facts

Don’t forget to wash your hands and cover when you cough.

Influenza is a viral illness that is more common in the winter months.  It is an infection in your respiratory area causing fever, cough, sore throat, runny nose, muscle and body aches, headaches and / or fatigue.  Not everyone with flu will have all these symptoms, and having these symptoms does not necessarily mean you have the flu.  Most cases are self limited and you will get better in less than two weeks.  It’s worse than a cold.  There IS a test for it.  One you don’t want to pass (or is that fail?)

Some people get worse, progressing to pneumonia and other illnesses.  In an average flu season 36,000 people in the United States die of diseases related to the flu.  A whole bunch more are stuck in those crummy old hospitals or visit my friends in the emergency rooms.

If you have that stomach virus, it’s not “influenza”.  It’s “gastroenteritis”.   That’s a small comfort when you are cramping and feel like dying.  The only good part is you get to stay home and watch TV. 

Those who are at higher risk are:

·        People over 65 (I will NOT use the word elderly)

·        Pregnant women

·        Young children

·        People with medical conditions (diabetes, heart disease, cancer, asthma)

·        Health Care Professionals

The only way to prevent getting the flu is to be immunized.  You can have the shot, the nasal spray (if you are in the appropriate age group) or the super strong shot (new last year).  The CDC recommends everyone over 6 months old gets a flu shot.  If you are reading this, you qualify.

Flu shots do NOT cause the flu.  You may feel sore or have some aches for a couple of days.  Some years I get a sore arm.  Some years I don’t.  The year I didn’t get a flu shot (because of the shortage), I was sick all winter.  I qualify for the high risk groups because I’m a “health care professional”.  People keep bringing germs into my office!

 One other reason we should all get flu shots is to keep the virus from spreading.  There are some people who can’t get shots, but are at risk.  One example is those babies under 6 months old.  So, if the rest of us have immunity, they are safer.  It’s actually called herd immunity.  Mooooo!  And it works.  That’s why we immunize kids for all the stuff we immunize them for.  The more kids that have the vaccine, the less likely we are to have outbreaks of bad diseases.   

One of my kids has asthma.  So I take home shots for everyone every year.  I chase my kids around the house.  I have had to get them down from the bunk beds.  I finally made an agreement one year with Three Speed that he would take a shot if he could give me mine.  He was nine.  He has gotten quite good at it over the years.  Does scouting have a brave Mom badge?

A really good source of information is:

http://www.cdc.gov/flu/

Health Insurance 101-4

Deductible and Co-Payment

This is something that many people do not understand.  It should be relatively simple.  For the millionth time (big sigh here):

Deductible:

This is the amount that you have to pay “out of pocket” (they mean your money) before the insurance company is going to pay anything. 

Remember your previous lessons:

The Insurance Company has already determined what is Usual and Customary (101-1).  This may not be what the doctor charges.  Your doctor may not be a “participating provider” (101-2).  In this case he or she can charge more than what the insurance company “allows”.  And if the doctor does not participate with the insurance company, they will reimburse you (101-3).

Are you keeping up and studying? 

OK, who is responsible for paying the deductible? 

If you said the insurance holder (i.e. you) you passed the pop quiz and may progress to the next part of the course.  

You are also responsible for knowing how much it is, and how much of it you have paid.  Otherwise the office will collect either what your card says is the deductible, or the entire bill and then refund whatever they get from the insurance company.   

Co-Pay:

This is how much you have to pay every time you have an “encounter”.  It may be:

·        A percentage of the charge

·        A percentage of the usual and customary

·        A fixed amount

·        The difference between the percentage of usual and customary that your insurance company is going to pay and the total charge (if the doctor does not participate)

You must pay your deductible first.

The Band 2011

The Band 2011

This is a test.  Tall guy is in here.  I don't see Three Speed. 

Go Eagles!   Now I need more Photos from Yearbook Gal.

If you PROVOKE PRINCESS 5

If you PROVOKE PRINCESS

Here’s your POTENTIAL PENALTY *

What we want to charge patients for:

Princess gets quite upset when you leave a phone number and it is either:

     *not in service

     *mailbox full

     *no answer the multiple times she tries to call you about something

     *the person that answers has no idea who you are, says they have had that number for years, then hangs up on her.

Personally, I want to charge you for Princess’ blood pressure medication.  I’m probably gonna have to give her some paid time off to get that blood pressure down – then you’re going to pay. 

*This is a recurring feature. Princess and I get certain patterns of phone calls that we find annoying. We would like to present them to you, with what we would like to charge for them. Unfortunately, we can’t. Charge that is. The phone calls will remain annoying. Princess says she could get rich if she could charge for all this stuff.

She Wants What?

Princess reported the following phone conversation:

Mrs. Wantsitall:  I need to cancel the appointment for my daughter this afternoon.

(This is less than 24 hours notice – we charge for this)

Princess:  Why would that be?

Mrs. Wantsitall:  The kids were approved for insurance you don’t take last week, so she is going someplace else.

Princess:  OK.  Are you keeping your appointment?

Mrs. Wantsitall:  Yes, but I don’t want my Pap smear today because I’m feeling sort of crampy.

Mrs. Wantsitall:  By the way, can the doctor write a letter for Teenage Wantsitall for school to break the rules because she wants to, and have it done by 1:00 PM today when I come in for my appointment?

Princess said she would check. 

Note that she has been getting samples of her birth control pills from us when she doesn’t have the insurance we don’t take because we understand about Mom’s financial issues. 

This is what we as doctors have to deal with on a daily basis.  :-(

Identical vs Fraternal Twins (or Triplets)

The definitive article (because I wrote it!!!!!).  It was published on Shine. 

http://shine.yahoo.com/event/yahoocontributornetwork/making-sense-of-multiple-birth-babies-identical-or-fraternal-2584864

Enjoy!

Alzheimer’s from several points of view

I really do read all those blogs on my blog list.  Today I read this on the pharmacychic’s blog:

http://pharmacychick.blogpharm.com/2011/10/15/the-story-of-life-at-the-end-of-a-needle/

It reminded me of a story about my Dad.  The last few years of his life he had Alzheimer’s.  It was hard to watch him decline.  But he could remember things from long time ago without much problem.

Tall Guy and Three Speed are Boy Scouts.  They needed to do a project about someone who used to be a Boy Scout.  So we took a trip to visit “Pa” (and “Mema”).  It was a lovely afternoon.  My Dad (“Pa”) told wonderful stories about his days in scouting.  I had no idea.  He was at scout camp when Pearl Harbor was bombed.  He was the first Eagle Scout in his troop.  There were some issues with this because he was Lutheran and they met at a Methodist church.  He laughed over this!

After we left, Dad asked Mom which one of my boys was which.  He couldn’t remember their names.

So sad what the disease does. 

A Rewarding Day at the Office

It’s Not What She Thought It Was

I saw a very nice woman today as a new patient.  She scheduled an appointment for “endometriosis problems”.  Since this can be tricky, I scheduled a long visit.  Good thing.

In my experience, patients with chronic pain tend to get frustrated.  They want to get their “side” of the story out before they think the doctor is going to stop listening.  This is because a lot of doctors DO stop listening and because CHRONIC problems tend to be very frustrating.  They go on and on….

I had to keep going back to her story.  It didn’t add up to endometriosis.  I reached into my magic left hand drawer (where I keep all the neat information sheets, forms, etc) and pulled out a questionnaire for a problem called “interstitial cystitis”.  This is a very painful condition of the bladder – which sits right in front of the uterus.  (The plot thickens, my friends)  Most people score under 10 on this “test”.  My lovely patient got a 27!

Her examination (yes, Virginia, I did one of those, too) showed that her bladder was tender – the cystitis thing – but her pelvic organs were totally not tender.  It’s hard to have endometriosis when none of the organs that usually have it are tender, and the time patterns just don’t fit.

I may not be the brightest bulb on the tree, but I was taught to take time and figure out what’s wrong with my patients.  There is a medicine that is specific for this condition.  It does not require surgery.  It should not require narcotics and muscle relaxers.  She was also on the wrong hormone treatment if she did have endometriosis. 

Could I do all this in 15 minutes?  No.  Do I want to practice 10-15 minute medicine?  No.  Was my day rewarding?  Absolutely!

Parenting Triplet Babies – 2

Feeding Time

I had a pediatrician who made the comment about one of my children: “If he doesn’t want to eat, don’t feed him.”  I believe the doc was implying that my child was overweight.

My babies started out a bit on the scrawny side, at about 4 ½ pounds each, and 18 ½ inches long.  They were 6 weeks early, but did well.  Once they figured out how to eat (a common problem with preemies), they haven’t stopped.

I NEVER played those “airplane” games, or any other games with my kids once they had learned to eat.  I took home one of my exam stools from my office.  I lined the boys up in their high chairs.  I had one bowl and one spoon. 

Whoever was on the left got the first spoonful.  I moved down the line.  By the time I got to the end, the first guy was ready again.  When the mouth didn’t open, I figured the little “monkey” – er – “angel” was finished eating, and skipped him.  When no more mouths opened, we were done.  Mouths and fingers got washed, they got down and we went on to the next thing.

I guess you can imagine the look on my face when the pediatrician said what he said.  Force feed a child?  Who on earth had time for that????????  What was he thinking?  I believe my jaw hit the floor!  It still makes my brain hurt.

I was never so happy as when they figured out how to hold a spoon or hit their mouths with those Cheerios!

Comments Are Fixed!

Comments appear to be fixed – and I didn’t need my high school friend.  Try it!  You might like it.  I would. 

Thanks in advance.  Dr. Lasermed

If not - e mail at lasermed@gmail.com Thanks.

Medical Office Quandaries - 4

Missed Appointments

I’m sitting here staring at the walls at the moment because a patient didn’t bother to show up for her visit that was booked for an hour.  Ms Noshow also didn’t bother to cancel.  Princess called her twice yesterday and again this morning to remind her that she had an appointment.  The current phone number went to voice mail. 

She has been a patient for a little over a year.  I have at least 5 different phone numbers in her chart.  There are multiple notes in this patient’s chart about leaving messages, phone not being turned on, and her phone not being in service.  It helps to write this down, so Ms Noshow can’t say we didn’t try.

PEOPLE!  What happened to common courtesy?  It doesn’t matter whether it’s a 5 minute visit or a 2 hour visit – that time was reserved for you.  If you’re not coming, you should call.  It has gotten to be so common for people to forget that most offices call one or two days in advance to remind people. 

Several years ago, I finally instituted a charge for this.  Princess and I agree that wasting our time needs to be paid for.  Some people don’t pay the charge.  We don’t see them ever again.  Sigh.