All doctors get angry/frustrated/exasperated about the things we have to do that take us away from the practice of medicine. I have read and heard many of their complaints in my various capacities, and I am listing a few of them. The complaints deal with the states, the federal government, and of course the patients.
1) The patient who asks you to renew a prescription, but doesn't know the pharmacy phone number.
2) The patient on vacation who forgot his/her medicine, and has the local pharmacy number, but doesn't know the dosage or frequency of the medicine (and sometimes not even the name, just the "blood pressure medicine").
3) The patient who calls up with an anxiety attack, but can't come in right now to be seen because he/she has an important appointment.
4) The spouse who asks you to convince the patient to do something you know full well the patient has refused to do.
5) The spouse who asks you to call him/her on the telephone and keep the line open so it acts as an intercom and the spouse at home can see if the spouse in the office is telling the "truth".
6) The patient who comes into your office with the printed cure for his/her disease cut out of the National Enquirer.
7) The patient who skips his/her blood pressure medicine for 24 hours before your appointment and then triumphantly announces this fact after the blood pressure has been found to be normal: "You see, I really didn't need the medicine". Then you have to try to explain the concept of the half-life of a drug, and how if the drug is taken every 24 hours, there is still at least half-strength left in the bloodstream.
8) Doctors are not supposed to treat their family, because of possible emotional interactions, but the state gives the children the power of "pulling the plug" on a comatose parent---terribly cruel for the children.
9) Arguing with an HMO that you know that their preferred drug (i.e. cheapest for them) for suppressing stomach acid is Prevacid, but only Aciphex works on this particular patient.
10) Trying to explain to an HMO that in this particular patient generic Ativan does not work, and only the brand name does.
11) Trying to explain to an HMO that although the allowed (i.e.paid for by them) dose of a medicine is 40 mg/day, your patient needs 80 mg/day to control symptoms.
12) Trying to understand why all HMO's will only pay for 8 Viagra/Levitra/Cialis a month. I guess they figure that no married couple should have intercourse more often that once every 3 to 4 days. I always ask the HMO rep how often he/she has sex, just for the heck of it.
13) How Medicare can review 10 office charts at random, decide that you overbilled (i.e. your notes did not justify a fee of $75.06, but only $53.45) on 2 of the charts, and therefore you have to refund (2/10) or 20% of ALL the Medicare fees you received in the past 12 months, or allow them to do a chart by chart audit of all the visits by Medicare patients in the past 12 months, with you there to answer their questions.
14) How Medicare part D suddenly decided they would pay only for generic drugs, and not brand name, unless the doctor can convince them to make an exception for this particular patient. (Lots of luck with this one!)
15) How you have to call a central number to get permission for certain Xray studies such as CT scans and MRI's on HMO patients, and sometimes they insist on speaking with me rather than my secretary.
16) The fact that in a one-man office I should need only two staff: a receptionist and a lab tech/chaperone. But I have a third employee who does nothing but call HMOs all day long for various permissions.
17) The fact that most HMOs only allow a 30-day supply of medicine to be dispensed, so if a patient is going on vacation someone has to call up for authorization for a 60-day supply.
18) The fact that Medicare annually threatens to balance its budget by cutting fees by 23% to primary care doctors. The government always relents at the last minute (does anyone out there remember the TWU president in NYC, Mike Quill, threaten a midnight New Year's Eve strike of subway motormen?) but this pattern is not a way to generate enthusiasm for a primary care practice in medical students.
19) The spouse who not only comes into the consultation room, but also into the examination room, so as to hear anything the patient says to me.
20) The spouse who calls up to ask: did you tell my spouse "........" and you have to reply that that answer is confidential.
Showing posts with label Doctors. Show all posts
Showing posts with label Doctors. Show all posts
Thursday, February 16, 2012
Tuesday, September 14, 2010
Basic Care by Doctors for Patients
There have been articles (and even books) written about what a patient should expect from a doctor, but I have found none of them to be of practical use. Let me tell you about the basic behavior I expect from my medical residents. Some if it is what I call "good housekeeping", some of it is common sense, and some of it is based on over 25 years of experience of taking care of ward and office patients. This list is not complete, and it is not a check list of what the doctor should do, because check lists are mechanical, and are not insightful for the doctor. Rather, if your doctor does NOT do several of my suggested actions, it may be time to find a "luckier" doctor for you, i.e. one who is more thorough with his/her patients.
Every patient should be asked about past transfusions (most usually occur during childbirth, so ask specifically). If any transfusions before 1985, do blood test for Hepatitis C antibodies, and, if positive, for Hep. C. RNA.
Ask about blood donations (immediate check for Hepatitis A,B,C, syphilis, West Nile disease, etc.).
In the appropriate neighborhood or background, skin test for TB on high risk patients. Always skin test on admission to a hospital, rehab center, assisted living, or nursing home. Patients from the Caribbean, especially the DR, have usually had BCG vaccine to protect against bovine TB, but the PPD should still be planted. Ask about prior TB skin tests, + or -.
Check on last Tetanus booster (at least one every 10 years), and Pneumovax and cervical herpes vaccine if appropriate. Offer flu vaccine.
Ask about any foreign travel in the past 5 years, and any illnesses while traveling or shortly after return home. Ask if took malaria prophylaxis, if appropriate.
Over age 50, one test for Vitamin B-12, as well as 25-OH Vitamin D. Also test for Vitamin D and Calcium after any bone fracture.
ANY patient put on steroids for longer than one month should be placed on Fosamax or its equivalent to help prevent steroid-induced bone loss.
If patient requests Viagra or its equivalent, check free and total testosterone level as swell as prolactin level. If either testosterone test is low, check the pituitary FSH/LH.
In irritable bowel disease, always check for lactose intolerance and celiac disease/malabsorption. Both can occur at any age.
There are only two acceptable reasons for not doing a rectal exam at the annual physical: no rectum, and no finger.
If no mammogram in the past year, examine breasts.
In hospital visit, always SIT DOWN. The patient should not feel rushed. You should always at least take the patient's pulse for physical contact and reassurance.
Ask about allergies, and request copies of written Xray reports and all past operative reports.
Ask about any veneral diseases, specifically herpes.
Last ophthalmology, dental and GYN visit, and any abnormalities. Can the patient read street signs at night when he/she drives?
Birth control used, sexual satisfaction with partner, and sex of partner.
Any stresses in life. Children or parents with mental or physical problems. Do you like your job?
When was your last vacation? Do you exercise regularly? Do you fall asleep easily? Any pets at home?
Check blood pressure in both arms. If over 50 (or 40 with certain medical conditions such as diabetes), listen for murmurs in the carotid arteries in the neck.
Do NOT tell the patient your own problems. You are wasting their time, because you are there to help them with their problems.
Keep a shadow chart in code of embarrassing facts the patient does not want released, and NEVER copy the shadow chart (OK to verbally give info to treating doctors with secrecy caution): e.g.; adultery, uses cocaine, prior pregnancy and surrender for adoption or abortion, bisexual, hole in nasal septum, lax anal sphincter.
Only try to diagnose treatable diseases (e.g. atrial fibrillation due to hyperthyroidism, and not atrial fibrillation secondary to cardiac amyloid).
The test may not be the patient's, so always repeat any abnormal blood test before you alarm the patient.
If the patient has syphilis and you suspect neurosyphilis, send the spinal fluid only for a VDRL, and never for an FTA, because no one knows what to do with a positive CSF FTA. Remember that Lyme disease is also caused by a spirochete, and is the cause of many false positive VDRL/RPR screens for syphilis.
Ask about orgasms. Ask about suicidal thoughts or attempts or plans. If sex drive low or sex with partner infrequent, ask about masturbation.
Undiagnosed Addison's disease can kill, and you won't make the diagnosis if you don't think of it.
If you have been on prednisone or other oral steroid in the past year, ask the doctor about stress doses of steroids if admitted to the hospital with an acute illness or infection, or for surgery.
If there is a dog in the house, the dog should get the monthly drop on the neck to keep Lyme ticks off.
If the patients says 2 drinks/day, ask how big the drinks are. (In some groups "two beers" means "two six-packs".)
Last menstrual period, and consider pregnancy test (must be done on every hospital admission.).
Ask the patient (1) what he/she thinks is medically wrong, and (2) if there are any other questions.
Most important: try to deduce the patient's model of disease, because any prescribed treatment that is in conflict with this model will not be properly applied.
(Trivial) if patient is low in serum potassium, check urine potassium, and serum magnesium; serum PTH usually not needed.
If kidney stone, 24 hour urine collection for Ca++, urate, and Ox-- so can treat to prevent further recurrences (if untreated, 50% have recurrent attack in 5 years).
Ask about unprotected sex (there is always some), and berate patient appropriately.
ALWAYS skin test for TB (and strongoloides as well?) when immunosuppressing with steroids, imuran, etc.
You may not be worried about lung cancer, but if you are a smoker your doctor should tell you that you are 100% guaranteed to develop emphysema, and spend the end of your life on an oxygen tank if you live long enough.
Why does the dentist go into the other room when taking dental Xrays if they are so safe?
Your doctor should never complain to you about his/her personal problems, but bitching about Medicare, HMO's and Electronic Medical Records is perfectly appropriate.
Never be afraid to leave a doctor because you don't want to "hurt his/her feelings". You should always find a doctor with whom you are gemutlich. I always tell my patients that my ego is not on the line: I give them my best professional advice, and they take it or not.
50% of our current medical knowledge will be obsolete in 5 years, but we don't know which 50%.
Leeches for high blood pressure, anyone?: (They did work , which makes it all the more surprising that the Red Cross will not let anyone with high blood pressure donate blood!)
And finally, do you feel "good" about your doctor?
Every patient should be asked about past transfusions (most usually occur during childbirth, so ask specifically). If any transfusions before 1985, do blood test for Hepatitis C antibodies, and, if positive, for Hep. C. RNA.
Ask about blood donations (immediate check for Hepatitis A,B,C, syphilis, West Nile disease, etc.).
In the appropriate neighborhood or background, skin test for TB on high risk patients. Always skin test on admission to a hospital, rehab center, assisted living, or nursing home. Patients from the Caribbean, especially the DR, have usually had BCG vaccine to protect against bovine TB, but the PPD should still be planted. Ask about prior TB skin tests, + or -.
Check on last Tetanus booster (at least one every 10 years), and Pneumovax and cervical herpes vaccine if appropriate. Offer flu vaccine.
Ask about any foreign travel in the past 5 years, and any illnesses while traveling or shortly after return home. Ask if took malaria prophylaxis, if appropriate.
Over age 50, one test for Vitamin B-12, as well as 25-OH Vitamin D. Also test for Vitamin D and Calcium after any bone fracture.
ANY patient put on steroids for longer than one month should be placed on Fosamax or its equivalent to help prevent steroid-induced bone loss.
If patient requests Viagra or its equivalent, check free and total testosterone level as swell as prolactin level. If either testosterone test is low, check the pituitary FSH/LH.
In irritable bowel disease, always check for lactose intolerance and celiac disease/malabsorption. Both can occur at any age.
There are only two acceptable reasons for not doing a rectal exam at the annual physical: no rectum, and no finger.
If no mammogram in the past year, examine breasts.
In hospital visit, always SIT DOWN. The patient should not feel rushed. You should always at least take the patient's pulse for physical contact and reassurance.
Ask about allergies, and request copies of written Xray reports and all past operative reports.
Ask about any veneral diseases, specifically herpes.
Last ophthalmology, dental and GYN visit, and any abnormalities. Can the patient read street signs at night when he/she drives?
Birth control used, sexual satisfaction with partner, and sex of partner.
Any stresses in life. Children or parents with mental or physical problems. Do you like your job?
When was your last vacation? Do you exercise regularly? Do you fall asleep easily? Any pets at home?
Check blood pressure in both arms. If over 50 (or 40 with certain medical conditions such as diabetes), listen for murmurs in the carotid arteries in the neck.
Do NOT tell the patient your own problems. You are wasting their time, because you are there to help them with their problems.
Keep a shadow chart in code of embarrassing facts the patient does not want released, and NEVER copy the shadow chart (OK to verbally give info to treating doctors with secrecy caution): e.g.; adultery, uses cocaine, prior pregnancy and surrender for adoption or abortion, bisexual, hole in nasal septum, lax anal sphincter.
Only try to diagnose treatable diseases (e.g. atrial fibrillation due to hyperthyroidism, and not atrial fibrillation secondary to cardiac amyloid).
The test may not be the patient's, so always repeat any abnormal blood test before you alarm the patient.
If the patient has syphilis and you suspect neurosyphilis, send the spinal fluid only for a VDRL, and never for an FTA, because no one knows what to do with a positive CSF FTA. Remember that Lyme disease is also caused by a spirochete, and is the cause of many false positive VDRL/RPR screens for syphilis.
Ask about orgasms. Ask about suicidal thoughts or attempts or plans. If sex drive low or sex with partner infrequent, ask about masturbation.
Undiagnosed Addison's disease can kill, and you won't make the diagnosis if you don't think of it.
If you have been on prednisone or other oral steroid in the past year, ask the doctor about stress doses of steroids if admitted to the hospital with an acute illness or infection, or for surgery.
If there is a dog in the house, the dog should get the monthly drop on the neck to keep Lyme ticks off.
If the patients says 2 drinks/day, ask how big the drinks are. (In some groups "two beers" means "two six-packs".)
Last menstrual period, and consider pregnancy test (must be done on every hospital admission.).
Ask the patient (1) what he/she thinks is medically wrong, and (2) if there are any other questions.
Most important: try to deduce the patient's model of disease, because any prescribed treatment that is in conflict with this model will not be properly applied.
(Trivial) if patient is low in serum potassium, check urine potassium, and serum magnesium; serum PTH usually not needed.
If kidney stone, 24 hour urine collection for Ca++, urate, and Ox-- so can treat to prevent further recurrences (if untreated, 50% have recurrent attack in 5 years).
Ask about unprotected sex (there is always some), and berate patient appropriately.
ALWAYS skin test for TB (and strongoloides as well?) when immunosuppressing with steroids, imuran, etc.
You may not be worried about lung cancer, but if you are a smoker your doctor should tell you that you are 100% guaranteed to develop emphysema, and spend the end of your life on an oxygen tank if you live long enough.
Why does the dentist go into the other room when taking dental Xrays if they are so safe?
Your doctor should never complain to you about his/her personal problems, but bitching about Medicare, HMO's and Electronic Medical Records is perfectly appropriate.
Never be afraid to leave a doctor because you don't want to "hurt his/her feelings". You should always find a doctor with whom you are gemutlich. I always tell my patients that my ego is not on the line: I give them my best professional advice, and they take it or not.
50% of our current medical knowledge will be obsolete in 5 years, but we don't know which 50%.
Leeches for high blood pressure, anyone?: (They did work , which makes it all the more surprising that the Red Cross will not let anyone with high blood pressure donate blood!)
And finally, do you feel "good" about your doctor?
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