Posts filed under ‘office workings’

Timing, like in life, it is also the only thing about blood tests and medication dosages


12/15/2014 at 10:31 PM Leave a comment

update on EMR

On the EMR (electronic medical records) front: things are not good. As anyone that has read my rants on this subject knows, I am not in any way encouraged to change my records from paper to digital bits and it is not a matter of being old and stuck in my ways. I like progress and have an iPhone, Facebook account, etc. I would even tweet if I had anything important to say in 144 characters. However the mass delusion perpetrated onto the primary care establishment that we should line up like lemmings to the cliff face and pay through the nose for the privilege of jumping off befuddles me. The link below is a third party report on the lack of success EMR systems have at the very thing they are supposed to provide.

Essentially, we are being recruited to be the ultimate Beta testers of a system that will not be ready for prime time for years. Without transparent standards allowing the easy transfer of multiple forms of data ( X-rays, reports, pictures) by all the different EMR systems, there is no point. What has become obvious is that the powers that be must know this but need to create the demand first. It should not surprise me that they are finding many willing (if not eager) takers. Providers are tripping over themselves to set a system up, costs be dammed.

At the risk of being the last man standing and being the last to purchase a fully functioning system at a fraction of the cost–so be it.

10/08/2014 at 6:21 AM Leave a comment

Health Insurance shout out

A short moment to give a shout out to all who made it possible to pass the new legislation.  Of course I do not know all that it will do (No one else does either) and all the unintended consequences, for good or ill, but the system is not only broken but decaying and no one else was even acknowledging there was a problem. I am sure that just like with Medicare the forces arraigned against it (GOP, AMA, others) will try to tell everyone they were for it.

How many times have we heard “We have the best health care system in the world.”? Except that we don’t, unless you are rich or lucky.

At any rate I am hopeful and happy, (of course the bill is more aimed at helping primary care than it is specialist care or hospital care or pharmacy care). Probably I am in a minority within my profession but that is not unusual for me.

On a related note I was talking to a patient about how difficult it is for us providers to know how much a medicine will cost. Each insurance is different in their copay amounts or deductibles, their formularies (which medicines they will cover) that the same medicine might cost a patient $10 up to the full price which could be over $120. Drives us crazy. We end up telling the patient that if it is too much to call us back and we will rethink it. Sometimes the medicine we write for is superior in some way but not so much that there is enough value to pay enormously for it.

For those of you out there on the receiving end if the medicine is much more than expected call back and question. Even after so many years I am sometimes shocked at how much a common medicine is.

03/25/2010 at 5:39 AM Leave a comment

special circumstances

To dovetail into my recent post about phone care is the special case of agoraphobia. The patient has an inability to leave the house or go far from the house. Sometimes they wont even answer the phone. This becomes a situation when there is an opening for treatment. A patient may get up their nerve, or they are desperate enough to call for help.

The standard reply is for her to make an appointment and come in. But that is the disorder right there, they cant do that. So what do you do? This is decidedly a tricky situation. I have gone both ways. In many cases I may  know they patient because they were not always this way, or I know the husband, etc. I have sometimes prescribed medicine over the phone to drop their anxiety enough to come into the office. Sometimes I have enlisted the help of the husband or parent to be in charge of the medicine. Someone in chronic fear cannot be faulted for taking too much of an anxiety reducer.

And in some occasions when I did not know the patient at all I have requested permision to contact their prior doctor to make sure I am not being played.

Some of you sharp people out there may have noticed that I used the female pronoun. It was not accidental. I dont know the general statistics but I have yet to meet a man who had agoraphobia.

PS—I just looked it up. four times as many women report agoraphobia as men. Dont you just love Google?

01/15/2010 at 5:13 AM 1 comment

A quick look is worth more than words can ever say.

Patients do not appreciate how I do my job. I routinely get questioned about a symptom. “My throat is sore.” they want a diagnosis. Clearly if it was that easy they would have replaced my with a computer, or these days, an APP.

The ‘presenting symptom’ or ‘chief complaint’ as we call it is only the very beguinning of the visit. It cuts the universe of potential problems significantly but half of infinity is still infinity. It is even worse on the phone. “I have had this rash for a week” does not help very much.

What I realized the other day is that the amount of useful, vital information that I can glean form a glance is enormous.

Case number one: I am interrupted because there is a patient in triage that is Severely SOB (Short of Breath, he may also be an S– o- B—) but that is generaly not relevant. I go up front and look at the patient, perhaps even talk to them. Within a second or two I can evaluate how bad the SOB is and whether we need to do something that second or whether we can continue with the vital signs, paperwork and I will see him after I finish with the current patient.

I can get respiratory rate, and effort, color of lips and finger tips, fatigue, pursing of the lips, amount of distress in the patient.  I have seen patients at all stages of respiratory distress from trivial to mild, to serious (wether they are hidding it or maximizing it) to severe, to desperate , to needing intubation to terminal. It would be hard to describe where on that spectrum the patient is  with mere words.

Case number 2: in Pediatrics in the winter we get lots of kids with asthma attacks. Kids are amazing and they can be at the edge of respiratory failure and still be trying to act normally. Te time between the kid not acting normally and the danger zone is much narrower. But after seeing thousands of kids, it is easy to see someone as they come in and not only evaluate them but get them started on treatment. It helps that for the most part they dont come in with the problems older adults come in with.

Case number 3: Chest pain in a young person. It only takes a minute to decide that a young (20’s) person is not having an acute heart attack. It is very rare anyway, but within a minute I can decide how to sort it out and get the appropriate test started while I finish with my current patient.

That quick glance is vital to us. Some of that could be obtained in the so called virtual visit, other parts of it not so much. More on this in future posts.

01/10/2010 at 5:50 AM Leave a comment

Trip to the candy store-Not!

Interesting lessons I have learned about people. It is important to have skin in the game for them to value anything. Free generally comes to mean worthless.

I am the only spanish speaking primary care in  the area and I attract quite a following. These people do have some money but clearly dont have insurance. They are generaly desperate for someone to talk to them about a variety of usually minor ailments. When I started I only had a few a week and I would charge them as the mood struck me. Usually quite low. It was a disaster.

Instead of my getting people that needed help, I started to get people that had nothing better to do. Although we still discount significantly, now the fee is standard for everyone but is not insignificant ($49) and I am back to taking care of the sick.

This same point is specially true for patients with medical assistance. They have no out of pocket expense and there is no problem to small that they will not come to the office for. Or make many appointments and not show up. There is no consequence.  Sometimes they just need to get out of the house, sometimes the parent doesnt want to go to work (she gets a note she was at the doctors office). If you compared the number of visits by a kid on MA versus one that has a copay vs. one that has no coverage the contrast is amazing.

I hope that as the powers that be work on health insurance, that they include skin in the game for everyone. I mean everyone. It does not have to be alot. But I have yet to meet the patient so poor that they could not afford a pack of cigarettes. A $5 copay would not be a barrier for anybody.

05/17/2009 at 5:18 AM Leave a comment

Poor historian alert

I had a call from a patient. He had been in just 6 days ago for a skin infection and we were getting a mid course evaluation. Typically if we pick the right antibiotic in a non immune suppressed patient the results are quite dramatic, if we dont it gets worse. So usually we just need a call in a few days to sort it out, worse or better how hard can that be?

Apparently very hard. This patient was notable for not being able to give us any consistent reliable history about hsi own rash. Hence the term poor historian. For someone like me who has always focused on patterns, distictions and similarities, it is hard to comprehend. 

But he is not trying to be difficult, he just cant (or wont) tell us when he first noticed the rash, wether it hurts or not, how fast it is spreading. You literally cannot get much info. So when he tells us on the phone that there is no change. but the symptoms are better, except the rash that is worse, my student is confused as to what to do next. do we see him immediately?, change the antibiotic or leave well enough alone?

It got me to thinking that since in medicine we rely on History so very much, those who cannot provide it well do end up paying a price. The price of more visits ( as in this case to see the rash), slower path to diagnosis, and confused physicians.

I have tried to understand the mindset of a poor historian, but no amount of careful questioning reveals anything useful. They just seem ‘not to know’ the answers to questions only they should know. I have had occasion where the patient will look at his wife for the answer to ‘how bad is the headache now?”

It is like practicing Pediatrics on an adult but generally without the parent available for questioning.

04/20/2009 at 5:31 AM Leave a comment

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