Can I Get Prior-Authorization To Kick Your Ass?

Whoever decided to put high-school dropouts in front of a computer with headsets on to speak with physicians or medical providers to discuss and approve or deny drugs or other therapies for patients was a real fucking genius.

Let me tell you how it usually goes when I try to get a wonderful, newer drug approved for my patients. I love Byetta and prescribe a ton of it. It is the only commonly-used drug for type 2 diabetes that lowers glucose AND helps patients lose weight. Unfortunately, since Byetta is newer and more expensive than your typical, cheaper generic diabetes drugs that cause FURTHER weight gain in these already-obese patients, it often required pre-approval from insurance carriers. We'll start with how the prior-authorization call usually goes (in reality), then we'll slide into the 'Twilight Zone' where both me and the insurance company customer service rep say what we actually WANT to say to one another.

Dr. Lofty: Hi, I was asked to call to get prior approval for Byetta for my patient.

CSR: Yes?

Dr. Lofty: Yes?

CSR: And your question is?

Dr. Lofty: My question is, what information do you need to get this drug that I believe my patient should be on approved?

CSR: Yes (pause, looking up algorithm for questions to ask caller under 'Byetta protocol'), so why does this patient need Byetta?

Dr. Lofty: Because they have gained 20 pounds over the past year on Actos and glyburide and in my experience I can get this patient's hemoglobin A1c down about 1% with about 20 pounds of weight loss using Byetta and getting them off of these other drugs.

CSR: I see. And what is the medical justification?

Dr. Lofty: I just told you the medical justification.

CSR: Yes, well, I'll need to fax over a two-page prior authorization form that will need to be filled out completely along with the last three chart notes documenting failure to achieve control with....

SLIDE INTO TWILIGHT ZONE...

Dr. Lofty: Hey fuckhead with your G.E.D. diploma hanging on your cubicle wall, I went to fucking medical school for four years, did three years of residency training plus a chief resident year, and have been practicing diabetes almost exclusively for ten years. My experience tells me this patient needs Byetta and I want him to have it NOW! Losing weight and shrinking the waist probably reduces cardiovascular risk in patients with type 2 diabetes.

CSR: Sir, we really don't give a flying fuck if your patient loses weight. We would prefer he or she remain on the cheaper, generic drugs that they are currently taking.

Dr. Lofty: Well, the patient sure would feel better in the long run losing twenty pounds and losing about 2 gallons of fluid from their legs.

CSR: Again, don't give a shit about this patient's quality of life. Too expensive to use this drug. This person won't be on our plan in two years, so we could give a rat's ass whether or not they lose weight or feel better. They'll be someone else's problem in two years.

Dr. Lofty: You're a dirty fuck stick...I hope you gain 200 pounds today and develop type 2 diabetes. You'd be begging me to put you on Byetta and I would give you shitty drugs like glyburide and Avandia to make your fat ass fatter!

CSR: Whatever. You doctors are so arrogant.

Dr. Lofty: Hey, Einstein. Can I talk to your supervisor? I want to get the ball rolling on a prior authorization to come down there and kick your sorry little ass!

Sue Me

Ethics be damned, I finally did it. I worked the overnight recently and one of our executive class frequent flier patients showed up in the waiting room at 2am. Dr. Deborah Peel (the patient) was, evidently, prepared for the fact that our ER cocktail lounge had been closed for a bit so she tanked up prior to arriving. Her chief complaint was that she was "really going to do it this time", as in, she was really, honest to goodness, no kidding and no reversies, going to off herself.

All she had done toward that end was polish off the better part of a fifth of Old Grandad with some valium as a chaser and yank out stitches one of my colleagues had placed in her wrist (very superficial wound) the week earlier. Apparently not happy with how quickly she had been brought back to a bed she 'fainted' out in triage and when I was called to see her in the room she had the "I've just seen a ghost" stare and was very good at it. Just as an aside I could well have said that it appeared that she had just had an encounter with the 'numinous', which is my favorite new word, but let me go ahead and tell the rest.

After I jammed a Q-tip most of the way past her turbinate (nasal passage) and she persisted with the stare I gave her narcan and she woke up a bit. Turns out narcan does occasionally have an effect on severe alcohol intoxication and this woman did not have opiates on board so that was interesting. It took about two minutes to figure out that she wasn't going to die within the next 5 hours so I felt a lot better. I ordered tests and meds and went to the next patient.

The next patient had his face mangled by a big dog. The patient and his girlfriend were extremely nice and I really enjoyed helping them out. The repair took me about 45 minutes and I had big flaps of facial skin to realign and the lip to put back together in two places.

As I was actually doing something worthwhile with the dog bite guy the aforementioned woman kept yelling that no one was doing anything for her pain. Debbie (as I call her now) denied being in pain when she 'woke up' so that, along with the fact that she was as drunk as Cooter Brown made it inadvisable to giver her pain meds. She would not leave her nurse alone though. Finally the nurse had to act so she came to me and I nodded conspiratorialy before she said anything.

ME (within earshot of drunk lady): "Wow, it sure sounds like she's hurting, better give her something strong... Why not try 650mg of paracetamol, but tell her not to take it unless she wants to sleep because it's so strong (wink, wink)".

NURSE: "Oh doctor! Are you sure???"

ME: "I think it will work and I think she needs it".

Paracetamol is tylenol (as the Brits call it). The patient asked what the pills were, she was told they were paracetamol and would make her sleepy etc... and like a good patient she swallowed the tylenol and promptly went to sleep.

Ethicists would probably say I abused my authority and engaged in deception. I don't agree as tylenol is a pain medicine and I would argue that I was setting the patient's mind up for successful treatment. In fact, I would argue that I was using CAM and that it worked like a charm.

The dog bite guy did well and he and his wife winked at me knowingly when the snores started from the adjoining room. CAM rocks!

Follow the Money

America, here's what happens when you remove market forces from physician compensation. Seen above is a flier for a seminar where MDs can learn how to do botox injections and other cosmetic procedures for... drum roll please... money. Wonder where young Doc Jones went? He quit working under EMTALA and opened a botox clinic. I know the plastics guys hate this and I don't blame them... botox injections are expensive when done by an expert and Doc Jones might screw up a few faces before he gets the hang of it. Hope someone is there to replace him in the ER, and I hope that someone knows Vfib from normal sinus. Good luck patients!

At Amy's Request, 911doc's CAM Garb (and the POOPSTRONG vs CAM challenge)

I effectively use this "Complimentary and Alternative Medicine" costume to treat acute on chronic chronic fatigue syndrome, acute lancinating fibromyalgia, systemic candidiasis, universal allergic syndrome, non-specific overwhelmosis, and all Axis II disorders. It works just as well for these things as traditional "western" medicine.

One thing I have discovered with patients in sepsis who are hypotensive, is that if I jump in the room when they are not looking, that they become quite hypertensive quite quickly. Also, if I scream " OOOWA! OOWAH!" as I jump toward the patient the effect seems to be more pronounced. Unfortunately, in the case of these very sick patients, the immediate spike in thier systemic blood pressure is almost always followed by a massive intracranial bleed or a VFib arrest. The skull on a stick doesn't' work so well for that (unless I crack 'em on the chest with it and this HAS worked more than once to thump them out of VFib). Right now I am very pleased with my foray in to Complimentary and Alternative Medicine. It's awesome and fun.

aside: Manny Poopsalot, chariman and founder of our philanthropic sponsor listed in our sidebar, has called-out all practitioners of CAM and non-western medicine. A free POOPSTRONG FOR THE CHILDREN mug to anyone who can prove, using traditional western stuff like statistics and double-blind placebo controlled trials, that their methodology and interventions (in and of themselves) are any better at treating any ailment than the simple 100% organic latex wristbands that the POOPSTRONG folks sell (for the children). It's on CAM folks! You have been called out!

Shalom

Gonna be out of the country for a few weeks vacation in the promised land. No, not Hawaii, beautiful downtown Tel Aviv. I told my wife if she wanted to go to a hot city with a large jewish population Miami would be much more convenient, but shes the Boss. She might still be going solo depending on El-Al security. Hopefully they've forgotten about that little incident in Haifa in 1991. Its my own fault for talking up the place for the last 15 years, and since 9-11 its hard to make the case that its more dangerous there. Can't wait to catch baywatch in hebrew.

Only Democrats Can Get Away With This Shit (and HAPPY EARTH DAY!)

Okay, first of all, the names of the gay bars here are funny. I mean "Woody's"?? And "Bump" for a lesbian bar is just classic. How about "Stinky Dick's"? (I have copyrighted "Stinky Dick's" so don't steal it). How about "Lipstick Canyon"? But only a Democrat could get away with pinching Chelsea Clinton's ass. A republican, especially a white male, would now be wearing cement shoes and be resting on the bottom of the harbor. Fucking ridiculous double standard douchebags.

Also, since it would please me greatly to have a bunch of "Complimentary and Alternative Medicine" LIARS have to pay to advertise here I'm going to say "Complimentary and Alternative Medicine" or "C.A.M." for short, a few times here. The "healing touch" people are also similarly deluded and may not be as smart as the C.A.M. people in that the nurses I've met who actually practice "healing touch" do seem to sincerely believe in manipulating energy fields and such. Personally I find that a native headdress with do-do bird feathers in it, a rattle, a bone through my nose, and dramatic drums playing in the background sets the mood in which I get the best outcomes from treatment in the ER. Seems to scare the shit out of a bunch of patients though.

Next time someone tries to tell you about "C.A.M." or "healing touch" smile and nod and then say "prove it". They can't, all they can do is tell you why they can't, and the discussion then tends towards the 'bias' of the scientific method and white males etc... DELUDED LIARS AND CHARLATANS. A pox upon you all.

Revenge, a Dish Best Served Cold [(or how i learned to stop worrying and love dr. deborah peel (with propofol)]

A tri-malleolar ankle fracture is shown above. This is also a dislocation. The red dots are placed to show the track of the multiple fractures, the white arrow shows the tibia, the large, weight-bearing bone of the leg, translated forward on the talus bone of the foot. This is an orthopedic emergency as with a fracture-dislocation the vascular status of the foot can be compromised, so we have to put this back in place and this is done, usually, with a drug like propofol, and some cranking on the heel to pop it back in. Then it is splinted while traction is maintained, and then the patient gets an orthopedic procedure to fix it definitively. Recovery is usually quite complete in young healthy folks but you've got to get it back in place quickly.

Okay, kinda boring I guess. What is not boring about this particular patient is that he happened to be one of my medical school professors. He still teaches at my medical school and I recognized his name immediately. Turns out he has family in the town in which I currently practice. I saw his name on the board and went right in to see if it could possibly be the same person.

This patient, let's call him "Dr Peel", had insisted when the paramedics got to him, that he be flown immediately to his home institution. I told EMS on the radio 'absolutely not'. Besides the fact that we don't fly ankle fractures, we also can do them just as good as anyone else right here in Podunkville.

He was a little nicer when he realized that I was one of his graduates and I came back to the doctor's area and told everyone that I was living a wet-dream. I mean, here's a guy in great pain who is a PhD and made my life miserable for a year, with a bad injury, and completely at my mercy.

I gave him great treatment and got his ankle fixed up but I couldn't resist the following. This guy had taught anatomy and physiology, a first year medical school course, and knew it cold (as one would expect). This course is one of the many 'hoops' courses in med school. It's not that it will be important for us to know it in such detail, and for some of us it's not important at all, but you've got to jump through the "hoop" or you won't finish medical school. It's hard, it's incredibly detailed, and we had to know it all. So, when I gave Dr. Peel the propofol, instead of having him count backwards from 100 to get an idea of when sedation was adequate for me to pull on the ankle, I asked him to define the branches of the brachial plexus. At this point in my career all I can tell you about the brachial plexus is that it exists, and it's a bunch of nerves that extend from the lower C-spine out to the shoulder.

Dammit if Dr. Peel didn't get it all exactly right, even with high doses of propofol and a sloppy tongue. 100% correct. Damn. I got a nice note from him a few weeks later, he did well. Damned eggheads.

Also, as an interesting aside, google ads continues to plop a whole bunch of JCAHO ads on my site. Probably because it's bot sees the word "JCAHO" a lot here. Also, "CMS". I hate to have these businesses advertise on my site simply because we write "JCAHO" and "CMS" a lot. Of course, if all of you were to click on these ads these companies, parasites on parasites, would have to PAY ME BITCH! So, I do recommend clicking these ads often and seeing what wonderful services these douchebags offer. JCAHO. CMS. Click click. JCAHO, CMS, JCAHO, CMS.

Corrollary to post below..

Short version..
Had a pt present today with a rash. Which, BTW, was 12 hours ago that was now GONE!!!!
Left PO'd as in "shut this place down" because I couldn't tell them what caused the rash that was GONE TWELVE HOURS AGO!!
At same time I was taking care of a family who's wife/mom had just died tragically in a MVA..That's what we put up with on a daily basis people...
That's how we, in this specialty, HTFU, on a daily basis...

Fuckin POS pt, I wish you would, well, you guys fill in the blank for me...

For "Dedicated Dad"

I've been doing this a long time. And I humbly say if any ED doc or neurologist gave me or any of my family or friends thrombolytics for a stroke like symptoms, I WOULD SUE THEM!
Does that make it easier for you?
There is NO predictive test or scale that says when it is appropriate to do so! Fuckin period over and out!
My past institution was involved in the initial research for this treatment and after 3 of the first eight died and 4 of the others converted to hemorrhagic stroke and worse outcome, we respectfully withdrew from the study and never gave the drugs again. And this is a group practice/training institution/medical school institution that is in the top 10 largest in the nation.
There is NO convincing evidence that this therapy helps and in many, if not most, cases makes it worse, given the fact that we have NO WAY of predicting how a "stroke presentation" will turn out. They are just as likely to walk out of the hospital as go to a nursing home with the same initial presentation.
I have personally cared for many patients who presented with a complete hemiparesis, who recovered COMPLETELY with nothing but OBSERVATIION..
God, I want to say more to/at you but will refrain given the stated fact your loved one had a less than 100% recovery, and I am sorry for that, but it had NOTHING to do with the individual treatment or percieved lack there of..
I'm too old for you people to get me this stirred up!!!

Why Do I Bother??

I recently had a patient with chest pain. His story sounded very GI, probably reflux. But, the guy was 65, smoked, was overweight, and had elevated cholesterol. The clincher was that he had a positive stress test a week before.

I talked to the patient and numerous extended family members about the diagnosis and plan. I explained that it was likely that he had acid reflux. His EKG was normal, and despite a history of 12 hours of constant pain during the night before his cardiac enzymes were negative.

However, since he had numerous risk factors and a positive stress test, I was admitting him for a cardiac catheterization. Everyone thanked me for my time and explanations.

Two days later, one of the crazy daughters came down to the ER and wanted to know how to report me to the medical board. Turns out the guy had triple vessel disease and was going to bypass the next am.

What a waste of my time to even have talked to these people. I did the right thing (they're very welcome by the way) despite the fact that I thought his symptoms were non-cardiac. Hell, maybe he had both coronary disease AND reflux!

Of all of the complaints that I have racked up over the past 18 years, the vast majority are from crazy family members.

love those lawyers

Just read about a Massivepooshits court reinstating a case where a man had an accident (automobile) allegedly due to a side effect of medications prescribed months before, and that the prescriber could be held liable. Now doctors will not be able to prescribe anything without looking over their shoulder. I for one have decided to follow each and every patient 24 hours a day that I have ever seen and make sure they take their medications as prescribed, and that they don't drive while taking any soporific medication (read:no more narcotics, whether you are in pain or not). Hooray for tort reform. That state, once the bastion of clear thinking people (granted, that was over 200 years ago) has slid off into the abyss of social/cultural relativistic marxist-based socialism. They can't fund their glorious 100% coverage health care, and they dug a gigantic 14 billion dollar hole where the roof leaks and the ceiling falls in. But they do have Teddy (give me the keys) Kennedy and that other "war hero".

Oh, and I can marry a dude there.

Drackman Teil Zwei

(Due to numerous requests I present part 2 of the Drackman saga. Names have been changed to protect the stupid, any resemblence to persons living or dead is coincidental)

"Welcome to Alabama, George Wallace, Governor" read the sign, and with the 97% humidity it certainly wasn't Kansas anymore. Pedlars stood along the road selling watermelon and boiled peanuts. Occasionally in the median strip you'd see a real life chain gang tending to the weeds. More churches in one small town than all of Orange county. Despite being named after a dead Confederate general, the highschool wasn't so bad. Surprisingly, chicks dug the surfer hair and fake surfer slang. My Anaheim "C" was A material in Alabamy. I did have a little trouble with the language. "WATS RAWNG WIT YEW? CAINT YEW HEER GOOD" replied one educator when I asked him what the fuck he had just said.

I carefully chose my college by curricula, majors, and placing in Penthouse's rankings of party schools. Having finally realized I wouldn't be a major league shortstop, I turned to my backup plan, F-15 Pilot. Curiously, the ROTC didn't seem too interested, but it didn't matter, as I didn't have the 20/20 vision then required for flight training. Then depression set in. As he signed my physical papers, the doctor mumbled something about "Flight Surgeons" and that maybe I should try that route.

After a few weeks of drowning my sorrows with authentic Alabama Moonshine, the doctors mumblings stuck in my memory. Returning to the Air Force recruiting office I was greeted by a locked door and a sign saying they had left early for the weekend. As luck would have it, the Navy recruiter was still there. "Sure, Navy Doctors get to fly, and we'll pay for medical school to" said the 280 pound Chief Petty Officer. "Come back when you've been accepted to Medical School".

The Professor in charge of the Pre-med program was helpful. "Get all A's, do well on the MCAT, do some token volunteer hospital service, and tell them you want to practice in a small Alabama town delivering babies and reducing dislocated shoulders at friday night football games." After some 20 years my life finally had a purpose. Whenever physics or botany got boring, I'd imagine all the hot chicks I'd be making it with in a few years, as I roared up to the factory they worked at on my Triumph Bonneville, just like Richard Gere in "An Officer and a Gentleman".

One cold January day the mailman handed me another envelope from a school I had applied to. Preparing to add it to my enemies list, I noticed it was heavier than the usual rejection letter. Sure enough, I was in... SUCKERS!!! Scrambling for the $50 deposit to hold my place in the incoming class, I began my journey into medicine and more importantly, a Navy jet.

Get Your Bumper Stickers Here At M.D.O.D.

Please help support M.D.O.D. - each bumper sticker is only $100 and goes directly to us doctors. You know, we don't make what your daddy made in the 'good ole days'.

I have to 'Laff'

The New York Times is a generally well-written newspaper. They have a (self-admitted) liberal bias, but if you read the reporting with this in mind, it is an excellent and readable news source. Unfortunately, the quality plummets when you turn to the editorial pages (the health reporting is also horrific, but that is a subject for another day).

Paul Krugman is a regular editorial columnist: a Princeton professor of economics with a Yale undergraduate degree and a PhD from M.I.T. He often comments on health care issues, so I read his column. Then I take the paper and wipe my ass with it.

I certainly don’t make any claims to have an answer to grand health care policy problems, but I did take one course in economics in college and got a B-, so I figure Prof. Krugman should be able to teach me something. Wrong again.

Here is a gem from a recent article of his called “Voodoo Health Economics” (if you don’t get the political reference, watch “Ferris Bueller’s Day Off” again):

“It’s about time someone … made the case that Mr. McCain’s approach to health care is based on voodoo economics — not the supply-side voodoo that claims that cutting taxes increases revenues (though Mr. McCain says that, too), but the equally foolish claim, refuted by all available evidence, that the magic of the marketplace can produce cheap health care for everyone.”

Um … OK genius. I think it was page 54 of my “Macro-economics for Dummies” text that introduced the Laffer Curve. For you econo-morons, look at the above picture: now think … hmmm, if I tax everyone at 100%, my tax revenues will be … ZERO! Yeah, because no one will work for free, idiot! Not only that, but statisticians have shown definitively that higher taxes DO NOT increase tax revenues (see http://politicalcalculations.blogspot.com/).

One idiotic statement I can take, but when he scornfully dismisses the “magic of the marketplace”, I start pulling out my hair. Adam Smith is going to haunt your tweed- wearing, arrogant, bearded, ivory-tower, smug, pseudo-intellectual ass after he reads your retarded article. (begin sarcasm) I can’t imagine how a capitalist model could produce an efficient economic system! The US has flailed in ignorance for these past two hundred and thirty two years! Thank you for your insight Professor! (end sarcasm)

I’m glad I went to East Tumecula Community College and not Princeton so I didn’t have to listen to this type of bozo for 6 years. Prof. Krugman should stop patting himself on the back for being so fucking clever and go re-take Econ 101. Maybe the “Bloom Picayune” would hire him.

Go Read This

Awesome post over at MonkeyGirl's place. Hope we can send some $$ to the cause.

Tax Day

Speaking of stools, just mailed off my taxes. The accountant says the IRS doesn't scrutinize Felons returns as closely so I got that goin for me. Thats my fave ex-Prez Ronaldus Maximus introducing his economic plan back in 81, you'd never suspect he took a slug in the chest not long before. Anyway, had a great Sunday outing with some buds from the synogogue, blasted targets of Osama and Sadom, while chuggin Iron City, and cursing affirmative action. I'm not bitter though.

Dannon Activia Yogurt and Bifidus Regularis

With Dannon's Activia yogurt doing so well because of their addition of a 'probiotic' bacteria called Bifidus Regularis, I have decided to pitch the meth lab equipment I had stored in the garage. I am setting up my own 'probiotic' lab in the garage to see if I can find an even better bacteria to help keep those bowel movements regular. I am pretty sure I could sell it for millions, maybe billions of dollars.

Here are some names I have been throwing around in my head for my new, improved, scientifically-engineered, probiotic bacteria. Let me know what you think. Feel free to add your own suggestions.

Shittus Frequencis
Poopus Perpetuous
Crapus Awesomis

Excrementus Incredibalis

Stoolus Colossalus

Dungus Titanicus

Meadow Muffin Astronomicus

Cow Pieus Habitualis

Isn't it Ironic... Don't-cha Think?

I hate that song.

So I'm cruising down the main page of the blog when I discovered this Google Ad. WTF google?

Now I have no personal beef with Doctor Dr. Robert M. Tobin... for all I know he may be a prince of a guy (he sure looks like one), but really, when companies can spring up and thrive merely to help physicians, nurses, and hospitals keep up with ever-changing mandates from JCAHO and federal agencies like CMS then... well, what happens next is something like you see in the video below.

For hastening the apocalypse and making me live "1984" you guys (and girls) at JCAHO (and all it's clones and minions) deserve to work for yourselves for eternity.

"Study" results

I just read a headline that said "Inhaled insulin linked to lung cancer". Ladies and gentlemen, the trial lawyers have reached the starting gate, post time in 1 minute.

But let's look a little closer at this "headline". To some Enquirer reading troglodyte who can't or wouldn't read the fine print, the exclamation "Oh my God, how could they have approved that medicine. I know someone who knows a friend whose cousin might have taken that!".

Just because you have A and B and C, it doesn't mean that A caused C or even that A plus B caused C. You see, causation is a difficult thing to prove, especially in a drug trial like this. What the "headline" didn't tell you is that ALL of the patients in the study that developed lung cancer were current or former smokers. So let's see, 6 out of 4,700, or 0.12% (an extremely low number to begin with) in the drug arm developed lung cancer, and 1 out of 4,200, or 0.023% (also an extremely low number) in the control group developed lung cancer. I wonder if the smoking had any thing to do with it? Hmmm. Could it be that they were just unfortunate enough to put 5 extra patients with tiny undetected neoplasms due to smoking in the drug arm? No, it couldn't be the smoking that caused the cancer, could it? Oh, to be John Edwards, with tongue hanging out and drool from the mouth, knowing how easy it is to dupe 12 barely literate folks into giving him millions, all the while handing out coupons for $10 to the thousands of suckers in the class action suit.

On a lighter note, I am in the long process getting out of ED. 911, I hope to beat you to the punch, but it will probably take a year or so. I'll keep you posted.

Dr. Calvin

I've had patient encounters like this. The cartoonist left out the part where Suzie demands oxycontin and threatens to sue. I hate feet. It'd be different if it was a Heidi Klum asking for a massage but its always Roseanne Barr with an attitude. After the one anatomy lecture, feet are sort of ignored, everyone knows how they work and theres a whole profession dedicated to them if something goes wrong. For my money nobody beats Navy Corpsmen in taking care of nasty tootsies. I did my first digital block/toenailectomy under the tutelage of a 20 year old corpsman. Of course, putting in the block probably hurts more than just ripping the nail off, but its fun to do.

Let The Stanley Cup Playoffs Begin!

If I was coaching the Detroit Red Wings, here is what I would tell my team before the game tonight. I hope they would get it...

"OK. Tonight I want to talk about giving 110%. Giving 100% means giving everything you've got. Giving 110% means giving 10% more than is humanly possible. If we are going to win the Cup, we need 100% of you guys giving 110% 100% of the time. If only 50% of you guys give 110% and 50% of you guys give 100%, I guarantee you 100% that we would only win 50% of our games. Suppose 75% of 110% gave only 50%, and 50% of 100% gave 25%, and 75% of 100% were not feeling 100%, then we'd be in a heap of trouble. That's why we need 100% of you guys giving 110% 100% of the time.

OK. LET'S GO OUT AND PLAY SOME HOCKEY!!!!!"

We Don't Want You to Get Hurt

JCAHO and Press-Gainey and 'core measures', I submit, are the health care industry's version of protection rackets. I stand to be corrected so all you fans of JCAHO and Press-Gainey please do comment here and tell me why I'm all wrong, but here's the essence of my case.

A 'protection racket' is an age old scheme whereby individuals are strong-armed into paying money to crime syndicates or gangs to, ostensibly, avoid harm at the hands of "real criminals". Of course, the deal is that if you don't pay the protection money to the gang or syndicate then you are targetted and then, if you live, you have a real reason to pay the money, namely your broken arm or busted nose and the desire to, well, live.

Even though the kind of 'protection' we pay for with JCAHO and Press-Gainey has nothing to do with physical harm, doctors and hospitals have become dependent on getting good scores so they can advertise their "five star rating" or whatever, and individual ER groups often base bonus pay on a physician's Press-Gainey scores. These scores and the methods used to obtain them are NOT TRANSPARENT, and have the science of statistics behind them to be sure, but really, how much sense does it make to ask patients whether they received good care? First off, if you are answering the survey, you lived! Awesome. Secondly, it is an unfortunate axiom of the ER that if you are not really sick you are probably going to wait a long time and why the hell would you then want to fill out a survey telling someone how great your experience was?

How reliable is the data that is put into their equations to generate 'patient satisfaction scores'? Do they control for education level? Cultural bias? Whether the patient got free care or had to pay? And most importantly, do they actually ask if the patient, whatever the perception of their care, was treated appropriately from a medical perspective? No, they don't. Again, correct me if I'm wrong, and then explain to me and our readers, in terms we can understand, why Press-Gainey scores should be obtained to begin with. Why pay for information we can get anyway? For their 'lack of bias'? Well, PG is biased to keep their jobs so WTF?

It is not as if we are selling cars here. You may know jack shit about cars but you damn well pay for them when you buy one. In this context I understand, really, why being all about customer service will increase your business' success as you definitely want repeat customers. Also, while someone may lie to a car salesman about their income in order to get a better price, they have no other reasons to fabricate stuff outside the financial because the car salesman can not prescribe narcotics.

Next, and to tie the two together, I am unaware of any double blind placebo-controlled trial that shows that getting good JCAHO scores OR good Press-Gainey scores correlates with good patient outcomes and hence excellent medical care. Again, I may be wrong and stand to be corrected so please do tell me.

Etotheipi has already started in on these guys so please check out his previous post with the neat sharp sign.

Here's what happens in real hospitals with JCAHO and Press-Gainey. When JCAHO comes to town everyone goes into a tizzy. The most important things in the ER are, evidently, that we keep coffee and soda out of the nurses and doctor's areas. Coffee, soda, and food are still allowed in the patient's rooms though. Also, all the nurses and doctor's get handed little cards that we can read from in case the JCAHO flunky asks about what we would do with a blood spill on the floor. I want you all to walk in a straight line all the way to the lunchroom and everyone be quiet!

"Core measures" are an attempt to graph the ungraphable, and an attempt to put numbers on "quality care". They are also worthless. For instance, even after we knew that drawing routine blood cultures on patients with community acquired pneumonia DID NOT improve outcomes or change care in all but the sickest of the sick, JCAHO implemented this core measure and added $500 or so to all patient's bills by mandating this lab test. Art of medicine? Dear readers, ever hear of the New England Journal of Medicine? The Journal of Trauma? See, we already do this with rigor and thoroughness and JCAHO is, well, it's fucking JCAHO.

Press-Gainey gets us all worried fielding complaints from patients. The ER is "too noisy" or we "ignored them" and "spoke harshly" to them while they were here. This translates, often, into loss of income for us or even loss of our jobs. Only 1/3 of our "customers" pay for our services. Since most people who answer the surveys are already pissed off about their six hour wait guess what comes in on the survey? A lot of pissed-off patient complaints. Also, and again correct me if I'm wrong, admitted patient's are not surveyed so there is a preselection bias towards ER abusers.

To continue the analogy, while not knowing jack-shit about cars might make you prone to buying a bad car, outside of medicine no one knows an iota of jack-shit about why we do what we do and why we order the tests and studies we do in the ER. Getting that JCAHO star therefore means lots of money to our bosses. Protection racket.

News flash! Even though you are a nice person and are sure you are not having a heart attack I have to look. You came to me with chest pain, I've never seen you before, I have no records on you, and I can not, without committing malpractice, just write you a work note and tell with my hugely developed clinical acumen and Xray vision that your "indigestion" is "nothing serious" and "not your heart".

But here's a kicker, guess what we do after a bad patient outcome or with problems in how we deliver excellent care in the ER? We ask each other and do research and go to conferences and see what the pointy-headed academics are doing. We never say, "Hmm, why not ask JCAHO or Press-Gainey about this?"

JCAHO and Press-Gainey are parasites. They are solutions in search of a problem. With rare exception none of the JCAHO or Press-Gainey folks are practicing physicians. These companies have grown eighteen heads and can not be killed. They are feasting off the detritus of the piles of money that get shuffled around in the medicine game. Unfortunately, hospital CEOs and ER group directors have signed on because, I guess, having some information (however shitty it might be), or some way to put intangibles on a graph (and to show the upward trend), is worth something to someone.

Finally, it's nice to have a bullet in your gun when coming to the table to negotiate a contract with your ER group or when you want to ride herd on your nurses. Press-Gainey and JCAHO provide the bullets. Then, when they are fired, just like the Chinese, those who are executed have to pay for the bullet.

Dr. Q and the Missing Vasi

Dr. Q was one of those guys who wanted to be a doctor since he was 6. And not just ANY old doctor, but the Double-Dog-Dare of docs, a heart surgeon. The Navy had thrown a little rusty hemostat into his plans as Dr. Q would have to spend a few years diagnosing pilot's runny noses until leaving for Surgery residency and hopefully, cardiothoracic fellowship. He could tell you all about the different types of pacemakers and valves and coronary anatomical variants. Dr.Q just had one little problem (besides the fact he was 5'2" and had a voice like Sara Jessica Parker, but thats another story). He was CLUMSY!! Not just occasional "Oops"clumsy, but Homer Simpson melting down the Reactor clumsy. We did vasectomies at our clinic, primarily so we didn't have to see as many malingerers/patients at sickcall. One afternoon I recieved a stat overhead page to the procedure room, something that never happened, figuring it was a joke, I slipped on my Goucho Marx glasses and went to see what prank awaited me. Entering the room I was greeted by Dr. Q wearing his Lupes. Retreating to the corner, he whispered "I can't find the Vas!!"(The Vas is the little tube that carries you-know-what that you have to snip ) going into Marcus Welby mode, I reassuringly said "no big deal, the vas can be tricky to find sometimes..) "NO" he said, "I can't find the specimens" Dr. Q had indeed expertly clipped both sides and removed a segment to insure no ambitious sperm would ever make it out, however the vital tubes were nowhere to be found. Sort of important, as they had to be sent to the pathologist to prove we had removed the right thing. The patient never even looked up from his Maxim while this Tom Foolery went on, just satisfied he was getting his military free medical procedure. After a few minutes, we found one vas stuck up under the mayo stand, the other hiding under a sponge. Not being sure which was the left and which was the right, we guessed, and added (Mayo Stand) and (Sheet) to the specimen description space on the pathology form. Dr. Q is now a respected heart surgeon misplacing more important parts.

How to be Annoying and Useless: an Introduction to JCAHO and Press-Ganey.

Apropos of prior posts, I feel the NEED to highlight for the readers what, in my mind, is the doucheiest of doucheitude in medicine: JCAHO and Press-Ganey.

We've talked about these gorillas (see cartoon) in the past, but for you new readers, let me briefly introduce you:

JCAHO, (which, for some reason, is pronounced "Jay-Co", not "Ja-Ca-Ho"), also alternatively called, unironically, by the self-designated Orwellian moniker, "The Joint Commission", is a clusterfuck group that "accredits" hospitals by coming in for about one day a year and making sure a bunch of forms have been properly filled out. They have introduced to the medical lexicon gems such as "sentinel events", "core measures" and, the "do not use" list of abbreviations. I went to their web site to see if I could dig up some bullshit and it took me, oh, seconds to navigate all the way to the home page to find the first of many sucktasticisms: They are announcing the Speak Up! program to help patients understand docs better. Each letter in "speak up", of course, stands for something (these turd farmers love the acronyms). And we get to the "U":

"Speak Up™ urges patients to:
Use a hospital, clinic, surgery center, or other type of health care organization that has undergone a rigorous on-site evaluation against established state-of-the-art quality and safety standards, such as that provided by The Joint Commission."

Hmmmm. Self-serving? Annoying? Chock-full-o-'business-speak'? Oh yeah. If they were just merely useless that would be OK, but these fucksticks have literally changed the practice of medicine by putting up continuous blockades to the delivery of care: fill out yet another form; 'accredit' yourself to wipe shit on a card and see if it changes color; answer to clipboard carrying nurses if you don't fulfil your core measures; and on and on...

Now, Press-Ganey. This is a survey company that asks patients to respond to questions about the quality of care they received. Really it is the PERCEIVED quality of care measured, often from non-paying "customers", who demand perfection and know very little about medicine (a hospital, by the way, is not a hotel. Sorry.) A 'mean nurse' can fuck your Press-Ganey scores relative to other hospitals. A doc who will say "no, I know better" to the annoying patient will drop you to the bottom of the list.

I learned about these a-holes when a rep from the company came to present their survey findings to the hospital. First, he introduced his company by mentioning that it was founded by "Doctors Press and Ganey". I looked up "doctors" Press and Ganey and they, in fact,are not real doctors but PhDs in statistics and cultural anthropology. Nice to be lied to right out of the box. Anyway, I shit you not when I say I was in awe of the audacity of the rep, standing in front of a group of doctors and making the following statement (one of many winners): "Patient privacy is important. On your survey patients said the privacy in the ER was lacking. Let me tell you how you can fix this for NOTHING! When you pull the curtain to separate the beds, say 'I'm doing this for your privacy', and your scores will, I guarantee, improve!" In other words: privacy is a problem; instead of ACTUALLY making the ER more private, PRETEND that it is more private and the PERCEPTION will improve. Fix perception, not the actual problem. Great recommendation, Jackoff. This is the essence of Press-Ganey.

This is but a brief introduction to the people who now dictate how medicine is practiced. Control has been handed to the paper pushers and taken away from the doers. I weep for our profession.

A Special Gift

A great little gift appeared in my inbox recently. Check it out above. In relation to the JCAHO monster I am glad we appear to someone as a 'tank'... I think we are more like a mosquito, but nonetheless, check out the artist's homepage here, and to my friend who sent this, many thanks.

My favorite procedure.

This ain't no Disco, aint no country club either. I've always been a procedure guy. I&Ds, Chest Tubes, PA catheters, vasectomies, if it involves cutting or sticking something count me in. But to me nothing beats excising a thrombosed external hemorrhoid. Sure your ruptured triple A's get all the glory, but fix someones ass and you've made a friend for life. Its one of those things I learned by myself, like sex. In 1980's Alabama no self respecting medical student asked a resident for help with a butt procedure. My first time was with an inmate from the county jail, his name was probably Billy or Mac or Buddy, and he presented wearing an authentic Alabama ball and chain. "I gotta Pone doc" was his Chief Complaint that I dutifully documented on both the jail and ER records(even in 1985 there was red tape). I had never heard of a "Pone" before, and had to ask a nurse, who informed me it was a peri-rectal abscess. With knife in hand I began the search for the pone. Funny, there appeared to be no infectious process awaiting the touch of cold steel, merely a purplish swelling near the butthole. With no internet, I excused myself and actually bothered one of the residents who called me a dumbass but did tell me what to do. Hands shaking, I skillfully extracted the clot that had made Buddy's life so miserable. I've run into many Buddys since that night, and even the occasional Lois, but it never gets old.

"Triumph" on Star Wars (guest appearance and gratuituous 'bird' from Mr. Spock)

If you have not seen this, get a beer, sit down, and turn it up.

Queen Amidal All Grown Up

Looks like Hilary is going after the Star Wars vote. I don't know why but this pic makes me feel all warm and fuzzy.

Believing patients...

This actually links up with the prior post. I just don't want it to get buried and not read.

This for the "Anon" everyone is bashing...

I'm going to assume that you are a good person and what you have experienced is fact. In light of that, read on...

The last time I "believed" what a patient told me (and that is probably not the right way to put it, but it works perfectly for your post) was a year or so ago. Please read on.

One of my OWN ED NURSES, late 30's, came in with RLQ abdominal pain. Insisted it was a kidney stone (she had had one before) and only wanted Toradol for pain. She told me there was "no way" she could be pregnant (as in abstinence). So I believed her. Surely I could believe one of my own nurses. So I did NOT order a pregnancy test. I did the renal stone CT, which was negative, and treated her as a recently passed kidney stone( some blood in her urine). I only told her to take Ibuprofen for pain which was just fine with her, as in not SEEKING drugs.

Two weeks later she came back for continued pain, worsened. And guess what?! She was pregnant and had a fucking ruptured ECTOPIC pregnancy with a hemoglobin of 8! Thank God she #1)loves me #2) remembers she told me there was NO WAY she could be pregnant, so I won't be sued... (Oh yeah, also in last year had a 54 yr old woman who had had a tubal ligation come in with belly pain and have a POSITIVE pregnancy test!).

So take your fucking size 2 ass somewhere else with with your complaints about how we should believe you or anybody else about ANYTHING they say in the ED, got it? It's up to us to decided whether you have a serious illness that might kill you, NOT YOU!!

Now stay off our blog unless you want to learn something!

My Exit

For regular followers of our blog, first, thanks. We all love the fact that some of you appear to like what we write here and it is a fantastic outlet to express frustrations we can't express at work.

Some months ago I posted that I was leaving ER medicine for a job with more regular hours and more sensible patients (and probably less pay). Unfortunately this has temporarily been put on hold, guess why... because of paperwork. Evidently the kind of paperwork that I need to get processed to start my new job will take, at a minimum, six months. This supports the old adage "poor planning on your part does not create an emergency for me" (unless, of course, the poor planning is on the patient's part and I am on the receiving end in the ER). It sucks to be the exception to the rule but it is what I signed-up for (parenthetical to prevent ending sentence with preposition and nod to Winston Churchill for this rule "up with which he could not put").

OK. Time for plan B or C or D. For the moment, and much to the disgust of Dr. Deborah Peel and various anonymi I will continue to be a full time ER doc and will continue to post about the circus that I witness every day.

Cheers

Spock busts a move

Not sure what Spocks doing with a reflex hammer, McCoy must be tied up taking care of

some malingerer, I mean patient, with what ever the 23rd century version of fibromyalgia is.

It's Emergency April Fool's Day

In the spirit of April Fool's Day we are, just for today, going to do the following in our ER...



1. We will see all comers regardless of their ability to pay, and regardless of whether they are drunk, high, lying, in the country illegally, have just murdered someone, or are coughing up blood after having smoked four packs a day for 50 years and have never seen a doctor before.

2. We will pull out all stops for all patients and do the absolute best medicine anywhere in the world for all patients mentioned in #1 and collect what we can from people with nothing to do with any of the patients in #1.

3. We will smile and respond 'yes ma'am' and 'yes sir' to patients and their families when they call us "asshole" or similar epithets and hit us, spit on us, and threaten our lives.

4. We will comply with all regulations and laws promulgated by the federal government to do all of the above without any funding to back up said rules, and with full exposure to liability for medical negligence for any of the patients mentioned in #1.

5. We will strive to comply with all JCHAO regulations, my favorite of which forbids us to eat at our work space (ostensibly to protect the health of the patient), but allows patients to eat in their rooms in the ER and upstairs.

6. We will surrender our power, gained by detailed expert knowledge and training, to people with clipboards who work 9 to 5 and haven't seen a patient in their lives, or, if they have, are no longer involved in patient care.

7. We will approach the art of medicine by applying a strict business model, striving for customer satisfaction with our patients, and look quizzically at each other since we have no idea how much particular tests or procedures cost, and have no expectation of being paid by any particular patient.

8. We will 'go paperless' and put dotting the "i"s and crossing the "t"s on the computer ahead of getting stuff done in a timely fashion for our patients.

9. We will dump more and more work on fewer and fewer providers (nurses, doctors, techs, and paramedics), and buff out that bottom line for our masters with clipboards and 9 to 5 jobs and zero clinical experience etc...

10. We will look the other way as our EMS system is abused by people calling 911 who "can't get a ride" to the ER or have that pesky 4am insomnia which is very uncomfortable for them.

11. We will happily put our helicopter crews at risk by flying at night and around dangerous obstructions to rescue the folks who plow their cars, drunk, into other cars, into crowds of people, or into bridge abutments, and cry a little each time a crew is lost.

12. We will see the same patient for the same complaint for the thirtieth time this year and spend thousands of dollars of other people's money looking for an imaginary diagnosis because the patient simply wants narcotics.

13. We will groan as clipboard people create new forms to supplement old forms and new requirements to supplement old requirements.

14. We will meekly comply as clipboard people and entitled patients demand quicker throughput in the ER while doing all of the above.

15. We will listen sympathetically to patients who are doctor shopping and tell us, "no one has ever done anything for me" while trying to make sense of their 500 page charts.

16. We will attend required meetings at 7am after working all night where freshly showered and manicured clipboard people in suits tell us that we need to work harder, faster, and better for less money.

17. We will look at the salaries of hospital administrators, often equal to or greater than ours, and put a grim smile on our faces while swallowing very hard.

18. We will wonder how an undergraduate degree cum laude from a top university, a doctor of medicine degree from a top-ten medical school, and a top-ten residency in our specialty of choice is worth less than an undergraduate degree in business from the State College of Northern Bumfoodle (with distinction).

19. We will attempt to resuscitate 96 year-old, severely demented nursing home patients because their family, not having seen them in 8 years, rushed to the hospital when they heard that 'dad was sick', and are demanding that we do 'everything'. We will crack the old man's ribs doing CPR, and wince with every 'snap', suck vomitus out of his oropharynx while we intubate him under chemical paralysis, and push tons of drugs into his veins in hopes that we get him back to his normal state of nothingness (with the family staring daggers at us).

20. We will walk into patient's rooms and smile at them while we wait for them to finish their cell phone conversation and order their super-expensive pregnancy test (that costs $5 at the drug store). We will then send their bill to the taxpayer.

21. We will break the spirit of brilliant and motivated medical students and residents as they shoulder the burden of 100 hour work weeks, an almost universal sense of patient entitlement, and we will pay the residents less than minimum wage.

22. We will give depositions to attorney's representing patients whom we may have harmed in some way and fret about our licenses and family and sleep and whether we really hurt or killed someone.

23. We will work shifting schedules that are akin to flying to Europe to work a few days and flying back here to work for a few days. Then we will take a few days "off", then repeat.

24. We will wonder why we chose to do this.

25. We will tell our kids not to go into medicine.

26. We will search for an exit and despair at our silver-plated handcuffs.

27. We will pay down our medical school debt way into our forties and then think about getting a nice house or car.

28. We will watch "House, MD" and laugh hysterically at that farce while knowing that people think that's what we do.

29. We will work a ten hour shift and realize, right at the end, that we are really hungry and need to pee really badly.

30. We will smile and feel good when that one patient in ten, thanks us for helping them.

31. We will consider going back to school to get a more valuable but much easier "advanced degree" so that we can get out of medicine and maybe retire at sixty.

32. We will pronounce a baby dead after trying everything we know and cry with the parents and cry later too. Sometimes the parents will be drunk..

33. Come to think of it, we'll just do this every day... I was mistaken, it's Groundhog Day.