.comment-link {margin-left:.6em;}

So many lawyers, so little time...

"The prospect of hanging focuses the mind wonderfully"--Samuel Johnson

My Photo
Location: Louisville, KY, United States

Gastroenterologist, cyclist, cellist, Christian, husband, father, grandfather.

Sunday, August 21, 2005

It just happens

I'm in my office on a scorching Sunday afternoon, catching up on roughly three, OK, four weeks of administrative stuff and listening to Leo Kottke on Napster. I'm not complaining; if I weren't here I'd be at home paying bills. It's pretty much a wash.

At the end of the week I was about as blue as a Kentucky Wildcat sweatshirt, pondering the meaningless of it all, etc. etc., when I had the most delightful office-full of elderly patients on Friday. If you don't get a chuckle out of an 88 year old lady telling you that: "just because I'm old doesn't mean I'm dead. If Mr. X ain't interested in the (92 year old lady he was hitting up on in my office), you send him my way," then, well, you will chuckle. It can't be helped.

Old folks are supposed to be the bane of a highly-efficient medical practice: they are slow, have a million problems of which usually none can be resolved, and the Medicare payments they generate barely cover office overhead. However, I do not have a highly efficient practice, and Friday is always a "slo-mo" day for me. It gives me a chance to tarry with the folks and chat about what's been going on over the past 85 years.

I regret the attitude I had in my younger years when I viewed the elderly as burdensome. They'll teach you a lot, or at least entertain you, if you just take a few (poorly reimbursed) moments and listen to them. Funny how aging does that to you. I suppose old age is like the Republican Party: you go through your life thinking very little of them, and then one day you wake up and you ARE one of them.

Peace be with you.

Thursday, August 18, 2005

I wish I could feel guilty about this...

Early in my career I volunteered to be a Reviewer of my Peers, one of those citizens who reviews medical records to determine if appropriate medical care was delivered to Medicare beneficiaries. As an upper echelon reviewer I would get cases that had attracted the attention of a screener, then a nurse practitioner, then perhaps a physician generalist. After careful review, I would venture an opinion as to the quality of the care delivered. This feedback would reach the physician or hospital, and could have led to a variety of sanctions and punishments.

My motivation for participation was simple. I wanted to improve the delivery of healthcare in my region. I wanted to do my part. I wanted world peace.

The review organization changed hands and I received no more cases to review, which was fine. They took a lot of time to do well, and the pay was shabby. Then in the past year the medical charts began to reappear on my desk.

Before I left on vacation I had a little pile of charts for review on my desk. These charts sat untouched by human hands until earlier in the week when I received an urgent letter: "Doctor, we really need those charts back. Will you get off your duff and review them?"

In my fatigue I sat down and opened the first. A physician had hospitalized a patient who had been puking his guts out. The patient was a diabetic and a bit frail. The doctor kept him in the hospital for three days, giving him IV fluids and anti-nausea medication. He left the hospital in a greatly improved condition.

The review organization asked me to review the case to see if he merited a "good citizenship award". The doctor's writing was legible, his orders appropriate, and his intervention prevented, say, the patient from going into renal shutdown which would require very expensive dialysis.

In a parallel universe. What the screener was bringing to my attention was this:

  • Did this intervention justify admission?
  • The patient was in the hospital for three days. Could he have been discharged in two?
  • The patient in his history reported fever and chills leading up to his hospitalization. Why were there no fever and chills documented while he was in the hospital?
  • The patient's history listed "frequent urinary tract infections". Why was this used as one of the discharge diagnoses?
  • Are there any other violations that we did not spot?

I've always been a person who does his best to honor his commitments, but this was the wrong case at the wrong time. I'm not going to be party to institutionalized harassment of physicians who are out there trying to do a good job.

So I sent the charts back. "I'm sorry but the time demands of my practice prevent me from giving the attention that these charts deserve. Please take me off your list of reviewers".

And I brace for the onslaught.

Sunday, August 14, 2005

The benefits of low dose aspirin

All bleeding stops, sooner or later.

I was reminded of this aphorism earlier in the week as I stood in the operating room watching a citizen do his best to bleed to death. The gent turned up in the ER with a low blood pressure and had barfed up a very scary-looking amount of blood, so we made the decision to take him into the OR and have the anesthesiologist intubate him. I would then run an endoscope down and see if I could identify the bleeding site, and, if we were all lucky, get the bleeding lesion to stop. I didn’t think this was likely to succeed, and the surgeon stood at my shoulder, ready to take matters into his hands when I failed.

As I was waiting for the anesthesiologist to do his thing, I was struck by the marvelous efficiency of the American healthcare system. The whole OR was filled with folks doing exactly what needed to be done: the anesthesiologist figuring out how to put the fellow to sleep while keeping him from bleeding to death, one of his aids holding the hand of the frightened citizen assuring him that he had nothing to worry about, the endoscopy team setting up my equipment, the OR nurses setting up the surgical trays, and the surgeon and I trading aphorisms.

“All bleeding stops, you know, sooner or later.”

As I pondered this, I realized that with just a little modification this would be the perfect epitaph for my gravesite:

“All problems go away, sooner or later.”

And it’s true, if you’re willing to wait ‘em out. It may take Eternity to dispose of some problems, and that can be a little impractical, such as the time I developed biliary colic and collapsed in my office. Eternity would have taken care of that one, to be sure, but Eternity can be a long time, especially towards the end of it (per Woody Allen), and having a surgeon fix me up seemed like a better approach.

It isn’t necessarily a good thing to elevate one’s avoidant tendencies to an art form, but that’s what I’ve done. Biking has been my means of escape lately, and although I’m grateful that I’ve avoided the lesser diversions such as alcohol, women, etc, I’m not sure my current obsession is any safer.

Yesterday my son and I went back to our Boonieville bike trail, but we didn’t get out early. This time we waited until late morning, with the temperature gauge pushing 90 and the humidity running around 80%. Any child of Ma Gaia with a nanogram of sense to it stayed out of the heat. No deer or chickens, not even the giant goat-eating spiders were to be seen. It was just too flaming hot.

That didn’t deter us initially, but it caught up with us very quickly. My athletic performance is shabby to begin with, but when I get overheated my body goes into frighteningly random motion, which can be very inconvenient on a mountain bike. Before long I had ridden off the trail and into a tree, the bark of which felt like a cheese grater as it tore into the tender flesh of my left forearm. I dragged back to the trail, looking like I had been savagely raped by Mr. Mestofeles (Trey Parker and Matt Stone).

“Lucky!” my son exclaimed. “You always get the cool injuries!”

I looked down and noticed that a cut on my arm was bleeding profusely, thanks to the low dose aspirin I had put myself on. It looked like I might bleed to death, although the blood loss probably didn’t exceed one ounce. It provided a great excuse to call it a day. And the bleeding stopped, as it always does.

My patient’s bleeding also stopped, courtesy of some metal clips I was able to attach to a blood vessel in the base of a stomach ulcer. I was glad I could help him, especially as I had to send an office-full of patients home without being seen in order to free me up for the procedure. Did I mention free? The patient had no insurance (he was in town on a job interview) so I don’t plan on getting paid. No money could replace the satisfaction of saving a person’s life, especially when the Federal penalty for refusing to see patients in the ER is up to $2 million per infraction.

Thursday, August 11, 2005

Putting off procrastination

Hard work may pay off later, but laziness always pays off now.

Sometimes blogging is like flossing teeth: you know you should really do it, but you just got other things to do. Vacation in North Carolina was great, and, frankly, it's getting easier and easier to put the Internet off limits and do weird things like read books and talk to heretofore unidentified family members. Coming back home I encountered the usual Total Chaos that I expect from a week's absence, along with discovering that I'm on ER call and that I'm covering for another GI guy.

When faced with this brutality, I did the only thing a reasonable person could: go mountain biking.

Not the entire week, mind you. We went Wednesday morning, waking up at 6AM and getting an early start, before the suffocating heat and humidity of the Ohio Valley came on.

My son and I went out to a place so remote that we were seized by the urge to hum the theme song from "Deliverance" on our way out. Being amidst Nature's Wonder, communing with Gaia Herself was a special treat: we were surrounded by six very angry-looking deer who looked like they were holding us personally responsible for the death of Bambi's mother. We saw a giant spider drag off someone's goat. My son was almost killed by a chicken who darted in front of him while he was screaming downhill on a Ride of Death.

The whole thing was pretty cool.

So rather than discuss the malpractice crisis or explain why emotivism is killing our culture, I'll leave you with these infinitely more helpful thoughts:

  • A cheater wheelie is just as good for the most part as a real wheelie and is a heck of a lot easier to do.
  • The farther you stick your hindquarters back, the less likely you are to go endo.
  • You don't have to be faster than the attacking spiders. Just be faster than your son.