Audible Abdomen

Or: the Virus that Keeps on Giving

It’s a cross up as to whether being a parent or being a doctor makes you more likely to get the virus of the month.  I usually know what’s going around before just about anyone else does.  It was a bit worse when my children were little. 

Someone managed to bring home a stomach virus last week.  I had one child home Thursday and Friday.  He seemed to be better by Friday afternoon.  The other two got sick Friday night.  I managed to be sick along with all of them.  I got up early Saturday morning to cancel our haircuts because I didn’t want to pass this on. 

My abdomen is still a bit “touchy” this morning.  This is Day 5.  I’m getting tired of clear liquids, though I was able to eat some yesterday.  We have consumed more soda and popsicles at our house than we have in years.

The most annoying side effect for me is that I have very audible belly noises today.  I’m glad I don’t do pediatrics, because the munchkins would be having a field day.  It is going to be embarrassing enough to explain to the adults I see. 

It could be worse.  Yesterday I looked about 9 months pregnant and I could feel the gas moving around in there.  Just like feet when I was pregnant.  I got funny looks from all the males at my house when I said that. 

Maybe tomorrow all will be back to normal. 

I wish all my readers health.  Don’t forget to wash your hands, and stay away from sick people. 

Another Band Fundraiser

 This is year four of high school marching band.  I have written elsewhere about how much it costs to run the marching band.  And the kids have to raise money for any extra trips that they take.  They are going to Boston over spring break.

So – one more time – my boys (2) – and therefore their parents (2) are selling stuff to try and raise money for a band trip.

Anyone interested in candles or gourmet coffee?

We are even selling first aid kits.  Everyone needs one of those!

SIGH!!!

This is the LAST fundraiser for high school band. 

Can I paraphrase Martin Luther King, Jr.?  “Free at last.  Free at last.  Thank God Almighty, I’m Free at last!”

But I really do need to sell some of those candles and coffees. 

Too Busy OB/GYN, Where Are You

One of my favorite blogs is gone. 

Observations of a Too Busy OB/GYN disappeared from my blogosphere this evening. 

Where did you go????  Too many babies?  Or did you find a new home? 

I enjoyed this man’s stories and his humor.  I hope he lets me know where he’s gone.  I guess I need to start “belonging” to blogs I “follow”.  Can someone explain how to do that and why?

Thanks.  Laser.

Assignment Follow Up

I had some editorial changes to my article.

Did you know “Mom” and “Dad” are NOT proper nouns and should not be capitalized?  They are in my world, but I yield to my editors. 

I also had some issue with the indent dots when transferring from word.

I had to insert an image.

Here it is:

http://voices.yahoo.com/choosing-birth-location-hospital-vs-home-10874345.html?cat=5

Choosing a Birth Location – Hospital vs. Home

On Yahoo! Voices by Dr. Maryellen Smith

She’s Still Mean

A woman walked into my office a few minutes ago.  She said she needed to make an appointment.  She hadn’t been seen since before she had her child.  The daughter was 23 years old.  She couldn’t get in to see her regular gynecologist in the next town.  They are booked. 

Princess started making her an appointment.  She was getting the registration papers out of the drawer.  Ms Demanding helped herself to a lollipop while she was standing at the counter.  Ms D wanted to be seen within the week. 

Princess asked what kind of insurance Ms Demanding had.

Ms Demanding said she wasn’t working.  She had an insurance that we don’t participate with. 

Princess explained that we don’t participate with that type of insurance.  She told her the price for a new appointment.  It wasn’t our highest visit, but she thought it would be a long visit from the way this woman was acting.  We have patients pay for the visit.  We will submit the insurance, but the check goes to the patient.  [I can no longer wait 6 weeks to 6 months for payments from insurance companies.]

Ms Demanding went ballistic. She said, “Well, she’s still mean, then.”  She turned around, walked out and slammed the door.

That certainly didn’t make my day, or Princess’s either.

I hope she chokes on the lollipop. 

I was so annoyed, I had trouble finding an Amazon link for you guys.  Just go get yourself a gift card for someone you like.  I think Princess deserves one.  She had to put up with this.  I just listened from my office. 

Unusual Assignment

Before I started this blog, I was writing for a web site called Associated Content.  It got bought out by Yahoo, and is now called “Yahoo! Voices”.  Since I haven’t written for a while, I had to update my information and reapply for “Featured Contributor” status.  The major reason for doing this is that it pays more. 

When you do this, you have to write an assignment on a topic that the editors choose.  I think they were intentionally being mean.  They picked:

How to Choose Between Home or Hospital Birth

It took me all afternoon to find a way to write an article that didn’t start with things like:

·        How stupid do you have to be to want to deliver at home?

·        What have you been smoking?

·        Do you want your baby to die?

I mean, really!  I spent 4 years in medical school, 4 years in residency, and have been practicing OB/GYN for almost 30 years.  Sheesh! 

What I finally wrote was “Choosing a Birth Location – Hospital vs. Home”.

I basically explained about all the reasons why you needed to have trained physicians nearby if things go wrong.  Then I talked about some of the things that can go wrong and when they do. 

We’ll see if it gets published or rejected.

Around the Web – Making Your ER Visit Easier

Found another great article. 

This is written by an emergency room nurse.  Title is 4 ways to de-stress your ER visit.  I’ll list the short version, but strongly recommend you actually read the article.

1. Make a list of medications you take and bring it with you

2. Bring no more than two people with you.  Bring at least one in case you need a ride home.

3. Bring something to do.

4. When someone is talking to you, ignore the cell phone and pay attention.

Here’s a link:

http://www.emergiblog.com/2012/01/four-ways-to-de-stress-your-er-visit.html

For all those friends and relatives who wonder how I have time to do all that crocheting, I have the bag perpetually packed.  I just grab it when I go somewhere I think I’m going to wait.  From the local high school sports events to my kids’ medical appointments – it gives me something to do.  Of course, I got a kindle for Christmas, and it fits nicely in the bag.  So there may be less handcrafting.

Techno – Dinosaur – 8 – Hacked!

I started out today doing just fine.  I got the kids off to school, got to the office, cranked up the ol’ laptop, and went to do my morning stuff.  My e-mail inbox was EMPTY!!!!  I’m one of those folks that keeps a lot of stuff in there that I should run off or save to disk.  You all know who you are.

Actually, it wasn’t completely empty.  There was a failed notice to someone whose e-mail changed a while ago and I never deleted it.  There was also an e-mail from myself stating that I was stuck in London without money – you’ve heard it.  “…I’m freaking out…”

Now I am freaking out.  It got sent to my other e-mail account and evidently all my contacts.  If you get one, ignore it.  Just e-mail me back your correct e-mail. 

I reported to Yahoo.  I changed my password.  I Facebooked.  I Tweeted.  Computer Geek will be sooooo proud of me. 

There are all kinds of little red and green lines under stuff in the word processor as I type this.  I don’t care.  I’m blazing mad at the computer right now.  I’m also really glad that we don’t keep our patient information from electronic medical records “in the cloud”.  I knew there were reasons not to trust the internet. 

No Birth Control = Teen Mom

I have asked this question to teenagers in my office before: “What do you call a woman who doesn’t use birth control and is sexually active?” 

Their answers are interesting.  My favorite is “Stupid.” 

My answer is “Mommy.”

There seems to be a disconnect in teenager’s minds between sex and pregnancy.  A recent article from the Wall Street Journal by Katherine Hobson (http://blogs.wsj.com/health/2012/01/19/why-didnt-teen-moms-use-birth-control/?mod=WSJBlog)  lists some of the reasons that this age group continues to have unintended pregnancies.  The U.S. has one of the highest teen birth rates of developed countries. 

Half of teen moms with unintended pregnancies were using birth control.  That’s scary.  Birth control pills, IUD, injections, patches, rings (highly effective), condoms (moderately effective) and less effective methods.  Some of these require teaching and interaction with health care professionals.  In my experience, some teens have difficulties learning to use some of these methods.

Say what?

What concerns me more is that about half of these moms weren’t using any form of contraception at the time of conception.   Say what?  They had lots of interesting excuses. 

·        I didn’t think I could get pregnant at that time.

·        Partner didn’t want to use birth control

·        I didn’t intend to get pregnant, but didn’t mind

·        Had trouble getting contraception

·        Had side effects

·        Thought they or partner were sterile

What to do?

We argue about sex education in schools.  It certainly doesn’t sound like we are doing a very good job at home.  Abstinence education doesn’t seem to be working very well, either.  It’s a good idea to discuss women being in control of our own bodies and delaying sexual activity as long as possible.  A child is a life-long commitment. 

Women fought long and hard for the right for access to birth control information.  Now it’s time to let us use it, disperse it, pay for it out of insurance or public funding, and let young women have the right to determine when it’s time to bear children. 

Political opinion courtesy of this author, who grew up in them there radical 1960s, when “barefoot and pregnant” was a normal state for many women.

http://blogs.wsj.com/health/2012/01/19/why-didnt-teen-moms-use-birth-control/?mod=WSJBlog

Definition of “Old” or “Older”

It finally happened.  I am now officially “older”.

I went to a new dentist yesterday because my dentist of over twenty years has retired.  That’s probably my first clue.  I saw the younger partner.   She’s the daughter of the older partner.  After my cleaning, she was telling me that my problem was like that of many of her “older patients”. 

I know she does most of the children in the practice.  I switched because she has been so patient with Mr. Impatient (my autistic son).  We switched him to this practice after he got scared about something at our established practice and refused to go back.  He originally saw “Papa” dentist, but has bonded with “Daughter” dentist.  We even went through her last pregnancy with her.  Mr. Impatient got concerned when we had to reschedule because she was off on maternity leave. 

Anyway….I have had this discussion with patients and other physicians in the past.  I also have had it with insurance companies when talking about hormone replacement therapy.  How old is “old”?  How old is “older”?

My personal opinion is that “older” is at least ten years older than you are.  Probably more like twenty.  I think “old” is ten to twenty years older than your parents. 

Since I am of “daughter dentist’s” father’s generation, I’ll take older.  It’s OK even if my kids are only a few years older than hers.  I started late. 

Example of “Just a Medicine Refill”:

     1.     Pharmacy faxes refill or patient calls the office

2.     Princess takes a message if pt calls office – patient’s problem, where she can be reached, what medicine, what pharmacy

3.     Princess pulls chart

4.     Princess attaches refill request or note to front of chart and lays it in doctor’s inbox

5.     Dr. Lasermed checks

          A. when patient was last seen (no refills if more than one year for some meds, 6 months for others … by law)

          B. when patient last received the medicine

          C. is it legal to refill over the phone / fax

          D. is there any reason why this patient should not have the medicine now?  Is she overdue for a visit or test?  Should she still have some medicine?

IF the medication is approved,

6. either the fax is filled out, or the pharmacy is called. 

7. There are two separate places in the chart where this needs to be noted – on the progress notes and on our “medication sheet”.  This is a separate part of our chart that has every medication prescribed since the mid 1990s. 

8. The chart is returned to Princess, who checks to make sure all of this was done.

9. A bill is generated if necessary – ya think?

10. The chart is filed.

IF the medication is not approved, the patient and pharmacy are called and an appointment is scheduled. 

This is a SIMPLE medication refill.

Wanna hear about a prior authorization?  I thought not. 

Giving doctors your credit card before an appointment

Giving doctors your credit card before an appointment

Many physicians’ offices have started a new practice – asking for a credit card deposit before scheduling an appointment.  This is much more common for new appointments, but you may also see this with repeat appointments.  Some just ask for the number, some actually charge a deposit.  Why? 

There are several reasons.  This is an incentive for patients to actually keep their visits.  We have a remarkable number of “no shows”.  In some offices, for new patients, this can be as much as 75%.  This time is reserved for the particular patient, and we can’t fill it with someone else.  We still have to pay our staff and overhead.  So we lose money if you don’t show up.

It’s interesting that we don’t even blink when we are asked to give that same credit card for a car reservation, a hotel room, or even a table at a restaurant.  But putting a deposit down at a doctor’s office?  It’s like we actually have to pay for health care!

That’s the issue.  We have become so disconnected from paying for our medical care.  “Bill my insurance” is commonly heard in every front office.  Patients have no idea about deductibles and co-pays.  They also have no idea what it costs to wait for their insurance to pay and bill for the difference whenever we finally hear from the insurance.  Often patients don’t pay at that point. 

New fees

It’s a good idea to ask about cancellation policies when making your appointment.   Insurance companies don’t pay those fees.  Every office has different policies.  Some practices waive a fee if illness keeps you from turning up.  Some offices will give you written policies.

Some medical practices have introduced other fees in the past few years for things that were previously free or for which a patient might not expect to pay.  A physician’s office in New Mexico charges a $10 fee to rewrite prescriptions for controlled substances, which expire seven days after first issued.  A family practice physician charges his patients a per-visit malpractice insurance surcharge.  Other surcharges reported among family physicians include a charge for referring patients to specialists and for a prescription or refill not attached to an office visit.  You will also start to see fees for paperwork like FMLA, physical forms, pre-authorizations, insurance issues, etc. 

You may try reading your doctor’s Web site carefully to see if things that were once free now come with a price.  You can also ask when you schedule your appointment or when you come in for your visit.  Doctors are charging for more of these types of things because they are becoming much more time consuming without payment.  Insurance companies and patients are also paying less and less for each visit.  We have to spend our time or our staff’s time (or both) doing so many of these things. 

See future post: Example of “Just a Medication Refill”

My Gout is Getting Better – and Steroids are Interesting

I wrote a post the other day about diseases that present in strange ways.  It basically was about the pain in my toe from my gout. (http://dr-lasermed.blogspot.com/2012/01/stereotypes-and-diseases-only.html)

Hopefully you all will be happy to know that I’m finally getting better.  It has been an interesting journey.  I did all the usual stuff, even taking a medication that I hadn’t taken in 6 years (since the last really bad attack).  No luck.  Finally, I broke down and called my doctor. 

Gasps from my audience!  The doctor got a consult! 

Thank goodness my internist gave me his cell phone number, because something is going on at his office right now (details, folks when I get them) and I can’t get through to talk to or see him.

He told me that we might have to try steroids, since nothing else was working.  Steroids and I don’t get along very well.  I get lots of fun side effects.  Here’s a partial list of common side effects that I have run through in the last couple of days:

·         headache

·         vertigo

·         insomnia

·         nervousness

·         mood swings

·         edema

·         elevated BP

·         glucose intolerance

·         facial erythema

·         acne, dry skin, thinning skin, bruising or discoloration

·         dizziness, spinning sensation

·         nausea, stomach pain, bloating

I have gone from hardly being able to walk to feeling much better.  My toe is still purple, but it is almost normal size.  It only hurts a little bit.  Now if I could only sleep. 

But I am getting lots of work done. 

Great Blogs / Books I

One of the blogs I read regularly is going to do cartoons all week next week.  Dr. Fizzy is a funny woman doc from somewhere in the Midwest who draws great cartoons.  She promised me a mention if I mentioned the book she published on Amazon.  Here goes:

Here’s her web site.  Of course, you can also find it in the column to the right under “A Cartoon Guide to Becoming a Doctor”.   http://doccartoon.blogspot.com/

Here’s a link to her book: 

http://www.amazon.com/Cartoon-Guide-Becoming-Doctor/dp/1105091023/ref=sr_1_1?ie=UTF8&qid=1323646385&sr=8-1

From time to time I may mention other books that other doctors have written.  I figure that any physician who has also taken the time to write a book while practicing medicine full time deserves a hoo-rah!

I Couldn’t Say it Better: Medicare vs. Doctors

Http://Insureblog.Blogspot.Com/2012/01/Medicare-Vs-Doctors.Html    

Tuesday, January 17, 2012

Medicare vs. Doctors

Suppose you were self employed and the government decided not only which services they would pay you for, but how much you could accept and not a penny more as full payment for services rendered. How would you like that?

Believe it or not, that is exactly how Medicare treats doctors.

They provide them with a list of roughly 7500 different services that are reimbursable and then hand them a price list as well.

The doctor does not get to decide which services are best for the patient, nor are they allowed to set a price for their time. If a doctor CHOOSES to provide additional services not on the list because it would be of benefit to the patient they do so at their own expense.

Is there any chance that Medicare can get all those prices right? Not likely.

What happens when Medicare gets them wrong? One result: doctors will face perverse incentives to provide care that is costlier and less appropriate than the care they should be providing. Another result: the skill set of our nation’s doctors will become misallocated, as medical students and practicing doctors respond to the fact that Medicare is overpaying for some skills and underpaying for others.

The problem in medicine is not merely that all the prices are wrong. A lot of very important things doctors can do for patients are not even on the list of tasks that Medicare pays for. Some readers will remember our Health Alert on Dr. Jeffrey Brennan in Camden, New Jersey. He is saving millions of dollars for Medicare and Medicaid by essentially performing social work services to reduce spending on the most costly patients. Because “social work” is not on Medicare’s list of 7,500 tasks, Brennan gets nothing in return for all the money he is saving the taxpayers.

We have also seen that there are other omissions — including telephone and e-mail consultations and teaching patients how to manage their own care.

Welcome to Medicare. We trust you will enjoy the ride.

In addition, Medicare has strict rules about how tasks can be combined. For example, “special needs” patients typically have five or more comorbidities — a fancy way of saying that a lot of things are going wrong at once. These patients are costing Medicare about $60,000 a year and they consume a large share of Medicare’s entire budget. Ideally, when one of these patients sees a doctor, the doctor will deal with all five problems sequentially. That would economize on the patient’s time and ensure that the treatment regime for each malady is integrated and consistent with all the others.

Under Medicare’s payment system, however, a specialist can only bill Medicare the full fee for treating one of the five conditions during a single visit. If she treats the other four, she can only bill half price for those services. It’s even worse for primary care physicians. They cannot bill anything for treating the additional four conditions.

Who comes up with these rules?

Oh yeah, the government. That explains it.

Hospital Payment for Ratings

One of the latest gobment schemes to “improve” medical care is to start paying hospitals based on patient ratings.  You know those rating surveys you get after you have been in the hospital, the emergency room or had outpatient services?  Someone actually tallies those up and scores each hospital based on “patient satisfaction”. 

This has absolutely nothing to do with how good your medical care is when you are seen.  It has to do with how you think your care was. You get to rate the food, the attitude of your providers, the cleanliness of the facility, etc. 

If you don’t like the things you were told, you can give the hospital a low rating.  Unfortunately, many of those things are things you need to be told.  Things like:

1.     You don’t need to go to the emergency room for a problem you have had for months and months.

2.     A cold will get better on its own.  Antibiotics do not help.  Really.  They just increase your risk of other problems.  Like bacteria that are resistant to antibiotics or diarrhea from the medications.

3.     The pain scale only goes to ten out of ten.  You can’t have a pain of twenty or thirty out of ten.  If your pain is ten, you shouldn’t be able to sit quietly and text on your cell phone.  Tears and difficulty breathing should be involved. 

4.     Coming to the emergency room for the same problem over and over for the same problem is a waste of money and time.  That’s what doctor’s offices are for.  Unless they tell you to come back, follow up with YOUR doctor.

5.     Coming by ambulance does not get you seen sooner.  It also costs a lot of money.  If you need emergency services, call them.  If not, don’t.

6.     Yelling, screaming or being abusive to the staff doesn’t get you anywhere.  In fact, they think of ways to make you miserable.   They may not do any of them, but they think …

7.     Not all female personnel are nurses.  Not all male personnel are doctors.  This is a pet peeve of mine.  I am a female who got my M.D. in 1980.  Yup, over 30 years ago.  I still get mistaken for a nurse.  It doesn’t make me happy. 

8.     Waiting is part of the system.  Plan on it.  It doesn’t matter what you are there for.  Emergencies happen.  The person with the heart attack or gunshot is going to be seen before a fever or rash.  It’s called triage.  BRING SOMETHING TO DO.  I always have a book and my crochet bag.  I have made many scarves and worked on blankets at doctor’s and dentist’s offices, while waiting for procedures to be done, etc. 

We need to get over our “drive through”, instant gratification mentality.  Medicine doesn’t work that way.  Most times it’s a process.  There are a lot of people involved.  The doctors and nurses have to wait for your lab work, your x-rays, your records etc.  Sometimes they are waiting to see how a particular treatment worked.  Your consultant doctor may be in surgery or in a delivery or busy with someone who is “bleeding out”. 

So long as you get the best care you can when it is your turn, anticipate the wait.  Use the time wisely.   Don’t get upset.  Meditate.  Read a book or write one.  Your attitude makes a difference about the whole experience.  Then you can give them a better grade, too.

Hot Flashes – A Personal Journey

The only good thing about having hot flashes in January is, well, it’s January.  It’s easy to go outside, open a window, take off my sweater or turn the heat down.  I haven’t worn long sleeve shirts since about 2000.  By now, you would think I would have this hot flash thingy down.  I have been having hot flashes off and on since the late 1990s.  Fortunately, I went on treatment.  Unfortunately, a medication I started yesterday restarted the hot flashes.  At least my cheeks are nice and rosy.

Hot flashes are much more common in women than men, and usually related to our “change of life” or menopause.  They can be caused by medications or other problems.  As a gynecologist, this is a common complaint in my office.  Some women tolerate them well.  Others become irritable because of sleep disturbances.  Usually there are other symptoms of low estrogen.  If a woman has not had a hysterectomy, menses will often be irregular or stop completely. 

Many women do not want to try hormones.  There are non-hormonal “over the counter” treatments.  Soy products sometimes help because they work like estrogen.    We also sometimes use some blood pressure medications or other prescription drugs.  But, in my opinion, and in my experience, the best medication is good old estrogen - with progesterone if needed.  Of course, you should consult your very own physician.  And there are reasons some women cannot take hormones.  You should at least discuss it. 

Here’s a great article from USA today about why most other treatments don’t work for hot flashes.  I hate to say it (not really), but “I told you so!”

http://yourlife.usatoday.com/health/medical/womenshealth/story/2012-01-16/Hot-flash-remedies-Estrogen-may-be-the-best-answer/52604096/1

“It could be for one of several non-hormonal drugs, including some antidepressants, which modestly reduce hot flashes. But the first choice — except for women with a history of breast cancer or other health conflicts — is still hormone therapy (estrogen, often combined with progestin).

It reduces hot flashes by about 90% and "it's actually very safe, but that's not getting across to the public," Warren says.”