Ask / Answer

Ask / Answer. Askanswer. Asskanser. Asscancer. Ass Cancer.

If you are a sex-machine-hot-as-shit-big-tittied-blonde-bombshell, what would your worst nightmare be? Probably something like this:

1. Die the same day some massively famous weirdo with a fake face croaks while spanking it to pictures in the local cub-scout handbook (speculation).

2. Look 40 years older than you are.

3. Die of Ass Cancer.

Yes, I had the poster and “used” it several times as a boy (and teen, and young adult, and old adult). Yes, I watched that lame girl detective show, and no, it was not for those brown haired hags. So it made me very sad when the first call I got after the news of this yellow haired vixen’s death from one of my sensitive colleagues went something like this: “So, you think she took it up the shooter?”

Human Papilloma Virus is a cause of cervical, and yes, ass cancer. So, Gisele, Kate, Brooklyn, remember, no glove, no butt love.

Insurance Anyone?

As most know, I recently broke my neck and was hospitalized for almost 2 continual months and had 3 subsequent stays for further care. Needless to say, the cost was more than any person could pay. How much you might well ask. I have NO FREAKIN' IDEA!!!

I'm reasonably well educated, despite having grown up reading by candlelight, but I can not make heads or tails of any insurance statements! And I'm a doctor?! +'s and -'s, benefits paid, deductible applied, insured's responsibility, etc All I can do is wait until the hospitals start complaining and then call and try to find out how much they expect from me. (Interestingly, hospitals are very easy to deal with and set up low monthly payments with no interest!)

Oh, and this is great, the insurance companies can actually take $$ back from hospitals that they have already paid if some pencil pushing "dr" beauro-cretin decides that a given treatment wasn't "medically necessary". One was to the tune of $52K!!!! I'm a doctor and I would have a treatment that wasn't "medically necessary"?!! PHUCK U!

And to top it all. This spring, on my insurance renewal date, the company was pleased to offer to continue my insurance for the mere sum of, get this, $2732 PER MONTH!!! I shit you not! I called to confirm and it WAS MONTHLY!!!

It's almost enuff to make me think a single payor system would be better. Maybe the savings in paper cost alone would help lower the national debt..

Propofol

Propofol, aka "milk of amnesia" (it actually looks like milk) is a wonderful drug to use in the ER. It rapidly produces a state of amnesia and analgesia and lasts a few minutes in the proper dosage. I use it to reduce dislocated shoulders, jaws, elbows, hips, and to maintain sedation while a patient is intubated and on the ventilator. If properly dosed it usually does not affect one's blood pressure very much and does not cut the respiratory drive and, after whatever painful procedure I need to do is done the patient slowly awakens over the next five minutes or so. They usually ask me when I'm going to fix their messed up whatever and I tell them it's done and they don't believe me. Awesome drug.

So I'm just kind of wondering what it was doing in a private residence of a certain celebrity who just died an untimely death? In fact, in a brief search of a reference I happen to have nearby the ONLY indications for it's use are for induction of anesthesia, maintenance of anesthesia, or procedural sedation (and some would argue the last indication). Also, it has a whole list of dangerous reactions when combined with opiates like methadone, dilaudid, demerol, morphine, fentanyl and the like. In fact, the combination can cause, well, death.

I wonder what the HELL it was doing there? I mean, was this particular celebrity dislocating his hip every day with all the moonwalking and thriller dancing? I am not even aware of it being a popular drug of abuse on the street though I may be wrong here. Turns out what it is good for is for putting people into an unconscious state for a few minutes while you do painful things to them and having the added benefit of them having no memory for the painful event. Just wondering, maybe you readers have some ideas?

Obama Declares Oxygen a "Right"

In a long overdue move the President of the United States of America, Barack Obama, has declared Oxygen for all a 'right' and has therefore pronounced it 'free'. The free oxygen will be funded by 'spreading money around' and taxing people who use too much of it. Credits will be given to citizens who trap their flatus in a jar or balloon and deliver it to the Central Oxygen Committee offices to produce clean burning fuel for hybrid human-flatus vehicles. Economists working with the administration say that the increased demand for oxygen will produce an increased supply much as playing powerball with your "special numbers" will win the jackpot.

Douche of the Month: A Continuing Series from MDOD

If you are a physician, you have probably read or heard about Dr. Atul Gawande’s New Yorker article concerning the escalating costs in medicine. This man has Obama’s ear and was a senior health policy advisor to the Clintons when they did such a great job with health care, so pay attention - here is a quick summary for those who have not read it:

Dr. G. visited the Texas town of McAllen to find out why it has the highest expenditure per Medicare patient in the country. After his visit, he concludes that certain doctors in McAllen are overutilizing services because of a profit motive; he makes a convincing argument that more procedures are performed and more tests are done because certain doctors treat patients like profit centers. He compares this model to the Mayo Clinic, a low Medicare expenditure hospital, which he characterizes as ‘patient centered’ and an institution that utilizes a ‘collaborative’ approach to care. Finally, he generalizes these lessons to medicine as a whole: Entrepreneurial physicians are bad; collaboration and holding hands while singing about world peace is good.

Read the article. It takes about 15 minutes. He is a good writer and he makes a compelling case. All that said, I think he is a douchebag. Read on:

First: why are physicians talking about this article so intently? Well, my observation is that there is a large cohort of MDs who are real self-flagellators. For example, they actually are upset that a physician organization will look after the financial interests of doctors as a primary goal. Yes, there should be (and there are) doctor groups that have patient care, education, medical research etc. as primary focuses. But to actively oppose an organization that supports your financial interests points to an underlying psychopathology that was likely acquired at UC Berkeley and a guilt complex that would make the Catholic Church proud. Outright greed and patient ‘churning’ for cash is obviously bad; trying to build a financially successful medical business, to me, seems like a good thing. The Physician Guilt / Self-Hatred Complex compels these docs to confuse and equate these two very different things.

That brings me to Dr. Gawande - his CV reads like something any baby-boomer parent would jerk-off into a bowl of corn flakes over: Associate Professor of surgery at Harvard, a graduate of Oxford and Stanford with an M.D. from Harvard Medical School. Unfortunately, even the most impressive credentials do not stop one from being a douche-tard. How could this over-educated scientist make such a basic mistake: extrapolating a general conclusion via analysis of the outlier. That is, by focusing on the single most extreme example of Medicare overuse (McAllen, TX), where it is clear something rotten is going on, and then concluding that this somehow identifies the problem as a whole is just illogical idiocy. That brings me to my next point:

In life there are a few simple rules: 1. no ass-to-mouth; 2. you’ve got to fight for your right to party; and 3. when writing an article in a major print publication, do not use some lame personal anecdote related to your fucking kid falling down the stairs, going to the ER with a subdural hematoma, getting a CT scan, staying overnight, getting another CT in the morning, then concluding that this provides an excellent example of overutilization of CT scans because the kid lived. Tape these rules to your fridge so your children will read and live by them. Listen, dummy, if your experience had been that the second CT had provided evidence that the hemorrhage had progressed and your child’s life was saved because of “overutilization” would you draw the same conclusion? Uh, like, I don’t, like, think so, and, oh yeah, you can overutilize my teabag on your face, genius.

Lastly, like Jesus said “Those who live in glass houses should not throw stones at a prostitute, unless they have a lot of loaves and fishes”, or something like that. Gawande throws these stones from his glass temple at Harvard: for example, getting your gallbladder taken out at a Harvard hospital costs roughly DOUBLE what it costs in the community, with no differences in quality of outcomes. Yeah, that’s right: at Atul’s hospital, procedures are much more expensive, with no quality differences… why? You ask. Well, it’s because the Harvard hospitals (“non-profit” hospitals, by the way) act like a monopoly and force insurers to pay much more than they do elsewhere. So guess what, Atul the Fool: maybe you should point the finger at yourself and stop suckling at the teat of your predatory employer.

Hear my warning: this is the man who will make broad health policy decisions under this administration. I have said enough. I rock. Etothepi out.

Medical Economics

Ever wonder how doctors get paid? I know what you're thinking. We enter the room, spend 10 or 15 seconds mostly ignoring you, slap some ice-cold instruments onto your body just to watch you jump, then depending on when our next BMW payment is due, we make up a dollar amount that WE think is fair.

Doctors may have been able to charge what they thought was a "fair" price 40 years ago, but not any longer. Many docs don't even know what they charge (sounds amazing doesn't it).

As the largest single payer, the government sets fees and billing rules under Medicare that have been adopted in one form or another by the insurance carriers. So, it doesn't matter what the doc charges, the payers tell the doctor what they WILL pay. In most states, the doctor has to accept it and can not bill the patient for any more than their deductible or co-pay.

Recently, I attended a seminar on medical billing (not my idea by the way). I thought that an explanation of HOW the government determines physician reimbursement might be instructive to those who think it is random, and to those who still can't wrap their head around the concept that government involvement is a/the major problem in medicine already! As you read through the following (or at least skim it, because reading it might be hazardous to your health), please consider the vast bureaucracy of people necessary to determine, process, audit, and bill all of this stuff. Maybe you'll get an idea of why there are so many clipboard carrying useless flesh-bags in hospitals today (the ones Dr. Tim Johnson proposes that we retrain to provide your medical care).

First, you have your RVU's or Relative Value Units. Of course, there are 3 types of RVU's (the actual physician work, the practice expenses, and the liability insurance). The RVUtotal = RVUwork + RVUpractice expense + RVUliability.

Now you're probably thinking about the fact that in different areas of the country, these costs may vary and that is true, so there is the Geographic Practice Cost Index (GPCI). This ranges from a low of 1.0 to a high of 1.5 (Alaska).

Medicare uses a Conversion Factor or CF which varies from year to year in order to control payments. This factor was just lowered another 5.3% in 2009 to $36.0666666 per RVUtotal.

So, the formula is:

Medicare Payment = RVUtotal X GPCI X CF

So, all of this gets plugged in to determine a charge for each level of billing from 1 to 5 (where 1 is a patient with whom you have barely any contact, and 5 is complex) plus a critical care billing for the most life-threatening and time consuming cases.

So, we're done right? The doc just marks the appropriate billing level, right? Nope. Not in the ER anyway. For us, the billing fun is just beginning!

Remember your medical record? That thing that you THOUGHT was for keeping your medical information? Well that SHOULD be it's primary purpose, but it's not. It serves two other purposes that sadly have eclipsed it's importance as a source of information about you.

The first is obvious and that is as a source of medico-legal protection for the health care staff. Your record is replete with exactly what you said including specific symptoms you denied having, and specific warnings you were given, etc. Anything you refused or argued about will be in great detail. This isn't for your benefit. It's to protect us from the vultures. But I digress.......

The second alternate purpose of your record is that it has become your billing template! In order to bill you at any of the 6 billing levels, it must be documented that you were asked certain numbers of questions and examined in a specific number of areas.

Here's how this part works:

In taking the history of your presenting problem, there are 8 elements of your symptoms that I could ask (location, quality, timing, severity, etc); I can document your Past History, your Social History (job, smoking, drinking), and/or your Family History; then there is the Review of Systems (the litany of questions that don't seem to have anything to do with anything such as "do your gums bleed", or "do you have any rashes", or "any burning on urination"). There are 14 such body systems that can be touched upon in a system review.

Finally, there is the physical exam which can be broken into roughly 7 body areas or 12 organ systems.

Remember that no matter how good of a job that I do, only the stuff that gets written down will support a bill. If I spend an hour with you and document poorly, I can't legally charge for my time or effort....even though you will likely think I did an excellent job and appreciate my time and attention, it doesn't matter. Sadly for this very reason, your medical record is the more important patient to some providers. Especially with Medicare beginning to audit charts for billing compliance!

So, to justify billing any of the different levels, you actually have to document different permutations of: historical elements; past/family/social elements; certain number of system review questions; and certain numbers of physical exam areas documented. The higher the billing level, the more items from each list required to bill that level of service. (For example for level 4, you need 4 or more historical elements,; a family, social, or past history; up to 9 systems reviewed; & 5-7 body systems examined).

(In addition to all of this, your "medical decision making" is quantified based on whether the history came from the patient, a family member, the EMS, or others; documentation of Labs, Xrays, EKG's, reviewing old records and summarizing them, etc. Points are given for these activities that count toward more difficulty to "support" your billing level in case there is a question). Remember, all of this has to be documented for it to have officially happened!

Yes, in case you are wondering, legions of people known as "Medical Coders" actually sit down with each and every chart and count these items and bill the charts accordingly! All of these people make a good living, and their salaries are built into your medical care costs (and it's governmental rules and regulations that cause these people to exist).

So, now that you know how simple medical economics is, you know why it's so simple to reform the health care system! The government has simplified it so far, who would ever doubt that more government involvement couldn't possibly simplify it further therefore making it less expensive without cutting services!!!

So, the next time your doc has his/her face buried in a chart instead of making eye contact with you; or the next time the doc spends 5 minutes with you and excuses themselves to sit outside the room and spend 15 minutes with the chart, you'll know why.

-85

Solid Principles

A very nice gentleman from Australia contacted me recently asking me if I would submit to an interview regarding Obama's health care plan as handed down from on high at a Green Bay, Wisconsin event. I did the interview with him and he disguised my voice and put together a very interesting piece. I sound like Sandy Squirrel from Sponge Bob but that's fine. You can check out the interview at this link or you my download it from Itunes starting tomorrow. Interested in your take, but beware, I do go on a bit and the whole thing is about 35 minutes long. Thanks to Mr. Edwards for the opportunity and please check out his site (Solid Principles, linked above).

911doc

Moral Compass Broken

Wow it's getting bad out there. Witness this, which I can only describe as geniosity or summin' like that. Relativism and the politically correct movement has brought us to this point. The point where we can't say that having sex before marriage or even outside a monogamous relationship is WRONG... we have to couch it in terms of public health concerns, concerns for the group, and we have to pay kids a dollar not to do something they shouldn't be doing anyway.

For those of you who will answer, "Who the hell are you to judge?" I have a few answers. One, by simply saying "Who the hell are you to judge," you yourself are forming a moral judgement about me so your argument is self-refuting and illogical. But more than that I am a father and a physician and a human with a universal moral code built right in, just like you.

If this program succeeds however I want to be paid $100 a day not to steal, or administer the wrong medicines to patients. I know I can do this if I can only get that $100. I am also happy to be paid not to grow corn, make methamphetamine, grow pot, poison city water systems, and make fun of the idiots in Washington. Sign me up for the free money.

Trich, no treat

Trichimonas vaginitis is a stinky frothy sometimes brown discharge from a bo-gina, that usually smells like day old cod. It is one of many infections, most sexually transmitted that make a bo-gina leak and stink, and usually bring a 19 year old to the ED at 3 in the morning eating Cheetos with a stomach ache. Speaking of smelly vagina holes, did you hear about Barbara Boxer talking to a Brigadier General of the Army Corp of Engineers, asking him to call her Senator instead of Ma'am, a term of respect all military men use, and having the balls to say that she earned her title? What a POS waste of flesh this woman is. He should have answered her questions with the back of his hand.



(To the editor-I had to find some way to sneak this in without it being completely political, but she truly is a stinky vagina).



S. Cat

*editor's note: concur

Oldfart's Birthday

He's 98 and still kicking ass. Well, he looks 98. Love 'ya bro. (Hey Oldfart don't look at this link... don't want you to bust your mellon running in the dark to the gun cabinet, besides, remember you have three in the nightstand... remember?).

The MDOD Vocabulary Contest

BEHOLD THE CHILD, OBAMOPRAH! ALL PRAISE HER, UHH, WORTHINESS-NESS.











I'm searching for a word, but exactly the right word. "Pitiful" is close but far too commonly used. "Delusional" is close but may not be right. I think the best word may have to come from profanity. Here's the story.

There's a dude we see here every week or two, always by ambulance, and he's here again today. He drinks enough to sink a ship but he is still afloat. He is very hard to understand and to the extent I could understand him today I understand that he is short of breath. That's it. I thought. Until I went in a second time and he added "sore chest" but that's really not important even though you will be paying for his admission. He's also got Rhinophyma, which is merely an interesting aside and you may look it up if you like.

Here's the problem. This guy has no home to speak of... maybe a shack, he has no money, but he does manage to go to the local 'health food store' where he stocks up on relatively expensive herbal medicine. He's got about twenty bottles of the stuff. On the top someone has labelled their uses... one says, "for heartburn" and it contains some root of some sort in some concentration. Another says, for "locked bowels" and has some other herb in it in some other concentration. So this guy is a health-conscious guy, dutifully paying probably half his SSI check a month to the natural health food store for 'food supplements' with, charitably, barely greater than placebo effect. But then he cops the ambulance ride when he gets sick. I mean, why not go to the health food store? So, what is the name for this (and I will not accept 'ironic', dontcha think)? I mean, the natural cures are not working dude, especially not with the lice... especially not with them.

Oh, and a big MDOD congratulations to Iranian president-elect (and kookoo-bird from the pits of hell) achmidinijad (phonetic, sorry) on winning a huge victory in a free and fair election which is a bit of a surprise since Obama was putting his full weight behind the other guy.... shocker. Israel into the sea! 'Bout time, running all the world banks and Hollywood and the trilateralist commision and killing Jesus and baking rolls with children's blood and all. 'Bout time. I do like Jerry Seinfeld though.

FOR THOSE OF YOU NEW TO MDOD THIS LAST PARAGRAPH IS BEST CLASSIFIED AS DARK HUMOR, SATIRE, A JOKE, WHATEVER. IF WE DON'T STOP IRAN'S NUKE PROGRAM THOUGH THE ABOVE MAY HAPPEN AND THE GREAT DUO OF OBAMA AND OPRAH WILL NOT BE ABLE TO SAVE US EVEN IF THEY WERE TO MATE AND PRODUCE OBAMOPRAH. SERIOUSLY, NOT EVEN THEN.