Thursday, September 03, 2009

Weren't the Beatles from Liverpool?

For folks outside of medicine this may seem reasonable enough. For those of us who practice it we are scared shitless. The Brits, God bless 'em, have a name for this kind of practice and they call it 'tick box medicine'. We currently have the same thing, albeit not with ICU patients, in the form of "T-Sheets", which are directed, 'check box' patient charts in the ER. If the ER you go to doesn't have "T-Sheets" then they have something like it or an electronic equivalent.

T-Sheets were created by people with clipboards and bean-counters in the course of the billing and collection wars to make sure we get every red cent for a patient encounter (after all, we only collect 30 cents on the dollar in the ER). Personally, I like 'em, but that has a lot to do with a level of confidence (which may be misplaced) in my clinical abilities. Basically, T-Sheets are a 'don't ask, don't tell' chart, where doctors check forty or fifty boxes to bump the bill and a 'complete' neuro exam is done at the bedside in five seconds if the patient moves all extremities and doesn't think Nixon is president.

I would also put another name on this practice and I would call it "Crystal Ball Medicine". Is granny going to die? The magic eight ball says "YES"! And the magic eight ball does not lie. Score one for the bean counters (and satan). Now be a good chap and pop-off quietly for us... the bed is needed by someone who might not die until we put them on the protocol.


  1. Only thing with EMRs is with some of em' its hard to delete the stuff you didn't do...I was conscientious at first, but that 20 seconds/patient adds up over time...which is why I've been documenting cervical exams on 93 yr old men...

  2. I'm tired of the "complete exam" my patients "get" in the ED. This amounts to fraud when it is used to bump up the level of service.

  3. ndenunz,
    i agree completely... but be careful what you wish for as the bean counters have all physicians in their sites. you may find yourself, before too long, with the same lousy "t sheet" type system so that you can collect blood from the turnip. here's what i should have to write for a routine strep pharyngitis diagnosis...

    o/w healty 20yof with strep by exam and lab. rx with bicillin im and observed for 30 min. pt sent home after taking po's without difficulty.

    the end.

  4. Since everyone and his dog has an opinion on how doctors should conduct their business, I thought you guys would enjoy this physician's proposal.

  5. ndenunz, Was hoping you could explain what you mean for somebody not clinical.

  6. Read the proposed "Lawyers Reduction Act" in the WSJ just this morning. Brilliant!

    Thanks Peggy U for spreading the good cheer.

    It's about time lawyers got their due, and let the doctors be doctors.

  7. 911,
    Appreciate your honesty.
    Personally, still use paper charting and I code the level of service myself. Also, my office manager is a certified coder so I should survive an audit if it comes to that.

    Anthony, I am I primary care doc and read the reports that get generated when my patients go to the ED. Sometimes the level of care seems (How do I say this diplomatically?) inflated.

  8. ndenunz,

    but see where we are? your practice is being dictated by people who do not practice medicine. how did we get here? the minute we quit expecting patients to pay for their own care or buy their own insurance. we could do wonders in the ER or in the office for folks who would simply make an effort. i'd take $20 as my fee for the strep case and charge them that plus the medicine and be done. instead, we have to send this through forty different middlemen, all who suck off the top, all of whom work 8-4, and none of whom can be sued for their homes. the end result is that strep case in the ER gets billed out at some ridiculous amount and no one knows what anything really costs.

  9. i'd take $20 as my fee for the strep case and charge them that plus the medicine and be done.

    And there are so many of us customers who would rather do it that way too!!! You guys should create a referral service to connect patients with doctors who will take fee for service at a reduced cost. Like eHarmony, sort of. Compatible attitudes and all that, to make for a good business relationship.

  10. Peggy, Peggy, Peggy,
    $20??? you'd be lucky to get 20 CENTS out of most of these entitled deadbeats... Saw a guy last week, simple knee sprain, dude wanted a fentanyl patch, Stat MRI, and sameday appointment with "Whoever dat dude was that did Tigers ACL"
    Told the guy he could take some OTC advil and walk it off, boy was he pissed, good thing he had to go back to the State Prison...
    Hmm how long is that sentence for Aggravated Buggery???


  11. Frank - I was just attempting to take 911DOC up on the offer :) I'd happily pay cash up front for the routine stuff, if it meant less expense and hassle for everyone involved.

  12. Off topic, but if any of you need a lift to Seattle on Tuesday, there's a vanpool heading that way. I'm sure you could energize the conversation on the way. :)

  13. 911,

    Point(s) taken. Good discussion.
    Just for kicks you ought to try volunteering at a free clinic. Not as much BS to wade through.

  14. i do volunteer in a free clinic... it's called the ER and people come to me 'because it's free'. not an ounce of shame about it either. they call the ambulance 'because it's free'. but i take your point.