family practice issues and general life events

Archive for March, 2012

Why your doctor is running late.

I know it is a stereotype that seems to take effect over and over in real life.  You go to the doctor, and he/she is running late.  It is a standard joke, and I have even heard of others attempting to bill the doctor for the time they waited because the patient’s time is also valuable.  Which it is, but are we talking billable hours, quality hours, life saving time.  What kind of time are we talking about?

First of all, let me say, that if you doctor gives the impression that your time is not also important, there is something wrong.  However, there are legitimate reasons why your doctor is running behind.  And rarely even though based on popular opinion is it due to talking overly much to the drug rep who comes into the office bearing gifts, golf outings and fabulous trips.  I wish that is the easy reason why I often run late.  A paid vacation would be wonderful, but those days are long gone, and were before I was ever licensed.  And if I spend time talking to a rep in my office it is so that I can get samples of a medication that might help my patient.  End of story.  I don’t collect money from them, occasionally they buy me a pizza at lunch so that they might detail me on their product and why it is better than their competitor, but if I am going to write for a medication, I will do it based on efficacy.  First in clinical trials, and then based on my patients.  So no, I am not running behind because of the pharmaceutical rep.  And if they come in, and I am running behind, often the time spent is merely to give a signature between patients.

I do meet with reps, and I am not ashamed.  I think that they help with treating my patients.  It is not that I believe their entire spiel, I am not that dumb, but they help a lot by providing samples, which allows my patients to try products before they have to pay copays or even pay for the full prescription.  And it is necessary, because despite what the people at Wal-mart tell you, not all medications have a $4 equivalent, and in the case of COPD, there is not a medication that follows the gold standards for treatment that is generic.  There might be a couple of different brands, but there are no generics.  However, they actually take up little of my day individually.

Most of the time, I am not running behind because I slept in late, or just was moving slow.  While it has happened, it is a rare day for that to happen.  Most of the doctors in my town, start their day by rounding on patients in the hospital.  My husband sees anywhere from one patient a day to 16 yesterday.  Since he usually sits around two or three on the inpatient, the 16 took considerably longer to see than normal, so he got to work about 45 minutes late.  In our clinic, most of our schedules are made 6 months to a year before, so there would have been no way to account for that amount of patients on Monday when it looked like a possibility

Much of the time, running behind schedule has to do with the patient complaint.  They take longer than the front schedules for.  This is not to say that patients are doing something wrong, but more than once I have seen someone worked in for a sore throat, only to have them say as I am walking out the door- “Oh and by the way, I have been having these chest pains.”  Well, I cannot tell you what my malpractice carrier would say, if I answered that “oh by the way” with “well stop at the front desk to schedule an appointment to find out what might be causing that.”  I guess with that complaint, I could send them to the ER, but well I have already done the exam, and gotten vitals, and most of my patients would be very angry if I sent them to the ER.  (This is not to say that if someone calls to tell me that they are having chest pain and shortness of breath, my front office has not been instructed to advice them of heading to the ER to make sure they are not having a heart attack, it is a little different after the exam)  And I would estimate that at least 10% of my exams a day have an “Oh by the way.”  Not always are they so bad as chest pain, but usually they do tend to increase the amount of time of the visit.

I might also be running behind because a patient has come in for one reason and they tell me that they have not been able to sleep since their husband died last week.  I cannot see how as a physician or a human, I can just stop them and say, “Well that is nice, but why are you here?”  Or “well that is too bad, but the patient in the next room has a sore throat, and well your 15 minutes are up.”  That is not what I do.  I am a family practice doctor, and in my mind, giving them a sympathetic ear, and any other comfort I can provide comes with my job description.  I would hope that all citizens of the human race would do the same.

I might be running late, because frankly I over-booked.  As terrible as that might be to say, but I do it frequently.  Why?  Well first of all, I have patients that have chronic conditions that need to be see frequently.  Those appointments are set up at intervals between a month to three months in advance.  So they have been there.  Next there is a group of appointments that are following up from an illness, ER visit or hospital stay.  These are set at intervals between one to two weeks.  Now while we try to cap those visits at a certain number, there are also appointments made available that day for work ins/sick visits.  And truthfully, I would rather fit as many in that day for a sick visit that I can, than have my patients wait, or visit the ER or the urgent care.  I am possessive about my patients.  They are mine.  I know their allergies, I know their history, and I know them better than any other doctor.  So I want them to see me whenever possible.  And truthfully it is easier, if I take care of their sick visit, because then I don’t have to figure out what someone else did.

And that leads me to another delay.  The other patient went and say a specialist, went to the ER, discharged from the hospital, etc.  In the future when interfaces are seamless and electronic records are readily available, I will not have to figure out what happened where.  It is very common for an ER follow up, that the patient tells me that the ER gave them some white medication that didn’t seem to help.  If it is the Emergency Room here in town, I can get access to the records, otherwise I have to stumble through and figure out what treatment they received and whether they need to see another specialist, and whether there are any medications that need to be changed.

Then there is the various exams that are required for work, medical equipment, school, and/or various other agencies which all take time and have requirements that have to be met.  And often these are brought up during the routine medication refill.  Seriously there is no winning in these instances, because few patients are happy if you make them come back for the paperwork and rarely is the paperwork merely one or two pages.

Additionally, there is a seemingly endless requests for medication refills, lab results, and radiology results which all must be reviewed and determined what needs to be done.  This includes consults from specialists (some of which are not legible) and management of more referrals.

All of these reasons contribute to why, I often run between 30 minutes and an hour behind.  I am not crazy about running behind, and I do apologize.  Because I am sorry, and I don’t want to keep you waiting, but I have between 30-35 patients on an average day, that I want to give personal time and attention.  I want to give them the care that they deserve.  I would like your visit to be as personal and comfortable as possible as it is to go to the doctor, but at the same time, I want to give the consideration to everyone.  One of the biggest complaints you see about doctors is that they don’t listen.  Well maybe I don’t want to be that doctor, and maybe I listen for too long.  So maybe your doctor is running late because in an attempt to make sure that your problem can be addressed, they take the extra time to listen and address concerns.  Maybe they are trying to teach better nutrition, making sure that you are receiving quality care.

So the next time you are annoyed that your doctor is running late, ask yourself do they take the necessary time with you?  Do they spend time listening to your problems and concerns?  And if the answer is yes, realize that maybe they are trying to do it for all of their patients



It’s been awhile since I talked about my grandmother.  Those of you who are not dog lovers might find this silly, but with the recent departure of my three Golden Retriever guests my thoughts have been drawn to her.  Both these wonderful puppies and my grandmother showed me nothing but their complete love.  I miss all four of them.

When I began this blog my very early entries revolved around the life lessons that she taught me.  For those of you who missed it, she came from Czechoslovakia at the age of nine without any knowledge of English.  She began as a scullery maid and taught herself a new language with the aid of her aunt and a dictionary.  She never had any real formal education – but in my view, was one of the wisest women who ever walked on Earth.

She married, raised two children on her own…

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Soda intake and health

Throughout my day, I spend a lot of time trying to counsel patients on how to lose weight, eat healthier, decrease their blood sugars.  And it has not ceased to surprise me the amount of people that don’t seem to realize the problems with drinking large amount of sodas.  We will focus on the non-diet variety to start with.

Empty calories, no benefit

Sodas are terrible for diets because of the amount of calories that have no nutritional value.  Now Coca Cola likes to advertise that they contain 100 calories per serving.  I guess that helps to go with the fad of the 100 calorie packs, but are you aware of what a serving size is?  It is not the 12 ounce can nor the 20 ounce bottle.  It is 8 ounces.  How many of you stop at 8 ounces when you drink a can.  I know I don’t, and I admit I am a coca cola addict.  (well actually cherry coke or cherry Dr. Pepper) But I have had to force myself to cut down, and most days to remove it completely out of my diet.  And most of the sodas are similar in calories.  There is some differences in the amount of sugar and caffeine neither of which in high amounts are great for the diet.

And people who drink high amounts of sodas tend to have increased risks of urinary tract infections and fibrocystic breast disease.  The greater amount of caffeine increases the risk for both.

For those of you who are drinking a 2-liter (or more) a day, well since you don’t want to have a massive caffeine withdrawal for about 5 days (Been there done it, got the t-shirt) I would recommend cutting down. by 8 – 16 ounces every three days.  But seriously consider cutting down.

Diet Sodas

With the studies that have come out over the last several years it is important to know that there are significant health issues that have contradicted previous theories on diet sodas.  Initially I used to advise patients to change from regular soda to diet to help with their weight loss.  We told diabetics that diet sodas were ok.  They aren’t.

About 3 or 4 years ago, studies first came out showing that there was not a significant difference in weight gain between drinking diet and regular sodas over the long term.  There is a belief that it is something in the soda itself that triggers the appetite.  In fact, diet soda might even be worse with the artificial sweetener increasing the desire for a sugary snack.

For years, there have been reports from individuals that diet sodas and aspartame with headaches, abdominal pain and cancer in rats.  The last is probably the least worth discussing.  For one thing the amounts introduced in rats is more in quantity than a human would intake in actually amount, increase it to the size of a human body would be a ridiculous amount.

As for the headaches, it can trigger migraines, whether it is the aspartame or the caffeine well in those cases it is best to avoid all together.

The most damning of all came out in the journal Circulation about 2 weeks ago, linking diet sodas to increased risk of heart attack.  This was done in a study of 42,000 men over a period of 22 years.  One serving a day increases the risk for a heart attack 19%.  19% this is incredible.  People get upset about a 0.1% risk in vaccines for side effects, or a 1% increase risk in breast cancer.  This increase risk is that out of 5 people that drink diet sodas, 1 person will suffer a heart attack.  And this was after controlling for factors that include smoking, age, exercise and family history.  Twenty percent.

A similar study came out 2 years ago which illustrated the same changes and risks in woman.  These drinks both sodas and diet sodas have adverse risks on HDL (good cholesterol), triglycerides, and c reactive protein (which is a marker for inflammation in the body)  Elevated C reactive protein is found in disease states such as cancer and heart disease.

As a side note, I would also like to mention fruit juice, while one cup a day can provide some nutrients and vitamins, making them slightly better than sodas, they are packed with sugar.  And giving your child more that 8-16 ounces in a day is not any better than the coca cola in a bottle.

I would also like to discuss that sports drinks are not necessary for anyone who is not actively competing at the time of intake.  If you have just run a marathon, it is an ok way to help replace vital nutrients lost through sweat.  However, sports drinks are not healthy.  They are packed full of sugar and carbohydrates and if you are trying to eat healthy and lose weight or maintain, routine intake of these drinks will not help you.  They will actually increase calories because many who are drinking them are viewing them as a health drink and therefore free.  But they are not.  Gatorade has 50 calories and 14 grams of sugar for an 8 ounce serving.  G2 is better with 20-30 calories and about half the carbs.

The brand names selected are examples of their group.  I am not saying that pepsi is better, it is not.  And none of the other sports drinks are better than gatorade for the calorie and nutritional information.

Let’s be honest, any excessive amount of calorie intake will cause you to gain weight.  So limiting these drinks are better, and just cutting intake in half will often help.  But these are sneaky calories, they tend to be overlooked during the day, because they are liquid.  Fruits are better than their juice counterparts.  The initial fruit is healthier and allow for fiber without sugar added.  So for health reasons alone, try to limit if not eliminate them from the diet all together.

Convention woes

There has been a delay from my posting, and I will blame it on being at a convention last week.  That sounds like a good excuse.  It is for the very minimum true.  This year, my husband (also a physician) has to take recertification exam to maintain his board certification in family practice.  Which is a process in the osteopathic world which includes a practical exam with manual medicine and a online computer exam about medical knowledge.  The manual medicine exam occurs only at conventions twice a year.

This year the spring convention falls during our kiddos spring break and is in Orlando.  A tax deductible trip to Disney World?  Well sign me up.  Well ok, the trip to Disney World itself is not deductible, but the airfare, hotel and some of the food do qualify as business expenses.  And the amount of time is not out of the realm of normal.  He tested on Tuesday and we arrived on Sunday.  The convention started on Thursday.  (well there were some extra hours on Wednesday, but that would have interfered with our day at the Magic Kingdom)

So this is where the woe comes in.  First of all, topics did not seem to be very interesting.  While I can understand one lecture of disasters- 5 seems like a little bit of overkill.  And sorry to tell you, I don’t care what HIPPA says, but if Armageddon hits tomorrow, I don’t give a damn about my electronic medical record system.  I will be taking the kids, and heading to some place safer.  And besides are we really buying this terrorism is coming, and the floods, tornados and hurricanes.  What the heck?  While there might be a legitimate risk, this overwhelming fear is the reason that a poor child with a broken leg in a wheelchair had to be patted down by security over the weekend.  If everything is high alert you will manage to make everything less.

Then apparently HIV takes center stage.  Again, I understand one lecture.  I have HIV patients, I don’t treat their HIV.  Why?  Because it is too complicated.  I talked to oncologists who treat CANCER who don’t want to treat HIV.  Why?  Because of the complexity, it needs someone who treats HIV and maybe little else.  As a family doctor, I need to know about treatments, side effects and diagnosis.  It is overkill to make it take such precedence at a family practice convention.  

And what actually made this all worse- seating.  Whoever decided how to arrange the rooms needs to be replaced.  Why for a lecture hall would you arrange tables in a circle.  First of all, it puts about 1/4 of the people facing away from you naturally, and additionally it also takes up more room, allowing for less to be in the room.  Either rectangle tables should have been used, or none

I was asked to leave during a lecture for sitting in a corner of the room with my boys.  We were not making any noise, but apparently we were a fire hazard.  We were not near the door, but merely by sitting on the floor in the back.  There were no seats available, despite being told there were seats in the front of the room.  However, I couldn’t see seats in the front, talk about rude weaving ones way through the seats to the front, for there maybe to be seats.  I don’t think that is good.

Anyway, if I am going to pay for a convention, pay for the travel and room it should have worthwhile lectures and have seating room.  Add to that parking at the hotel that was selected cost more than it cost at Disney World, the days we were there cost $14 a day to park.  While this is not cheap, it is still less than the $15 a day at the Gaylord Palms.  This is a nice hotel, but seriously?

Additionally, at 10 AM the coffee allowance and coke allowance for the day had been used on Thursday morning.  I understand trying to save money, but go to a cheaper hotel for the amenities and room- don’t try to be cheap on the coffee and drinks.  It really looks bad.  Paying that rate for the hotel (which I didn’t) is not easy for everyone.  Anyway, this convention was poorly planned or it seems like it.  It would discourage me from going next year, except that I have to recertify myself next year.  Unless the lectures are more interesting, I probably will consider not staying for the lectures.  And as of right now, my husband will be staying at home with the kids while I go and take my test.

Anyway this is my excuse for not being online and blogging for over a week.

My 5010 nightmare- maybe coming to a close?

It has been a little longer than normal since I have posted, and my excuse is that I have been busy.  Not that everyone else hasn’t been, but well work life seems to have been busier than normal.  Previously, I have written blogs about a firewall that was blocking payments and how I could not get through, and that maybe things were finally getting better and they are.  This week we finally got our first check from Medicare for claims since 12/19/2011.  It was for $12.45.  Woohoo, I can finally retire!

I laugh because I actually think that it is hilarious, all this time and work, and complaining about not getting paid for almost 3 months, and when we finally get through, the amount is not quite the amount you expect, because the deductible started over on January 1, and most of the claims on that sheet went to deductible.  All this work and time waiting, listening to the crickets chirp.  Or wishing their were crickets chirping, because it would be something better than silence.

After this time, arguing with the clearing house about their responsibility only to be told to look at their website, which for the longest time said absolutely nothing, and then eventually outdated and somewhat misleading information.

First it was my fault, no, it wasn’t.  I did all the steps, I was told were required for a smooth transition.

Then it was my EMR vendors fault.  Well,. they sent me a new update on January 1, which was downloaded within that week.  Followed by one more update the end of the month.  So maybe slightly- though I did send them a not so nice email as well during my frustration, to which they replied within 10 minutes intially, and then 5 more times within 30 minutes and able to fix the problem by the next morning, and considering it was 5 pm when I sent the first email, I was happy enough with their response.

So that takes me to the end of January, where the clearinghouse has yet to notify me of any problems, or to answer why I have not heard anything in a month from ANYONE (insurances included) to looking at my balance sheet saying “Holy (insert profanity here)!  Why haven’t I gotten paid.  How am I going to make my bills, pay my employees, …”  To only get told I am 1700 in line with a waiting time of 7 and a half hours.  Well that was when their system did not cut me off and hang up on me.  And after all that time I was on hold what was their answer.  “Well you should look at our website daily.”  Well at least they are consistant.  Though they continue to refuse to answer my question “how can you take my money without at least warning me that there is a problem?”  Their answer is still I am sorry for your difficulties and your disatisfaction, but we post things on our website daily.  You should read that.  And when I threaten to leave them, it isn’t any better.  Still with the damn website quote, and does not answer my question, and that I am required to give them 30 days written notice.  Which I will, as soon as I know I am up and running with the new group.  Just have to wait for Medicare approval.

Finally, the clearing house appears to have gotten their job done (only 60 days late, and not willing to take any responsibility).  However, that day Trailblazer crashed.  Nice.  It takes them about 4 or 5 days to get back up and going, and then we get messages that we are not an eligible provider.  Apparently even though Medicare claims that our contract is still good so far this year (we will have to renew this year, it is just not our turn yet) Trailblazer has forgotten to tell us, we need to sign a new form.  OK done.  Now for the new denials- all of our claims are duplicate claims.  Seriously?  It is a wonder, I haven’t gone postal yet.  All of this, filing and refiliing, denials and everything else to get the anti-climatic check of $12.45.  Awesome

However, I have gotten in contact with some great people that have helped.  Apparently, I helped my professional organization find out there was a problem, and they narrowed it down to Trailblazer having the biggest issues.  They determined that the physicians in Oklahoma and Texas appeared to be having the biggest problems.  Talking to some billers across the country, those using a clearing house seemed to have more problems than those that didn’t.  So guess what?  I had both issues.

And in the middle of this all, apparently Trailblazer is installing new software to help fix the problem (which apparently started last year)  I have heard from my congressman and Senator and one state Senator, but since things are improving we are hesitant to have them do anything.  Because there is no desire to cause further stalling on the issue, especially now that payments (did I mention $12.45) are finally slowly coming in.

As for my relationship with my clearinghouse- Well it will come to an end when I receive approval from Medicare for my new billing company to file how the prefer to do it.  After 6 years, I think it is time, and my loyalty apparently means little to them.  But I did let my colleagues in the area know that their clearinghouse was at least partially responsible for them not getting paid.  Helpful website indeed.

But I had good news on Thursday, I finally had enough money to catch up all of my bills.  I didn’t have to take out a loan.  I still didn’t get to take home a paycheck, nor did my husband, but maybe next month.  It is really sad that Wednesday, I saw 40 patients, and my hubby saw 33 patients in the office and 7 in the hospital, and we were longing for the days that we saw 17 and took home a paycheck.  But maybe as things start rolling, we will be able to see some of what we have worked for.  I hope so, because I didn’t go to medical school hoping to support 6 other people and not get paid myself  (we are now down 2 employees, after one dying at the beginning of the month, and the other being fired).

Anyway, as the computer glitches resolve, we will move foward.  Looking ahead to the crashes and glitches that will come with the conversion to ICD-10.  Oh happy days ahead/

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