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As a routine precaution during cataract surgery, we normally tape the patient’s head to the operating bed.  Our patients are sedated (wouldn’t you want to be sedated if someone was working on your eye?) but sometimes they wake up at unpredictable times.  Everyone metabolizes drugs differently.  So to prevent them from suddenly sitting up like the Cowardly Lion and quipping, “Unusual weather we’re having, ain’t it?” we gently but firmly run tape across the forehead and under the head rest.

May be a bit low tech, but IT WORKS.

In the past, we had this big ass roll of tape to make a couple of passes around the head (or more if the patient seemed likely to be a problem child.)  A typical roll might last for eight cases.

1inchtape

More than enough tape to get the job done!

Enter UPMC (the acronym for “U People Must Comply.”)  Someone, somewhere, in the vast corporate mind of the beast decided or calculated that  “single use” rolls of tape were more economical.  Or maybe they ordered 10 million rolls of the wrong tape.  Whatever, the reason, this is what we have to work with now.

singleusetape

The picture can be deceiving.  One roll of this single-use roll just barely makes one circuit over the head, so on most cases, we are now using TWO rolls of single-use tape to protect our cataract patients from their own involuntary movements.

Never mind the insanity of making rules to govern every situation as if every situation is identical, but isn’t this terribly wasteful?  At two rolls per case, we’re using about 8 rolls for every one of the larger multi-use rolls.  Is that environmentally conscious?

Rather disgusted, I told the nurse to just order the old rolls for us to use.

I was informed that we can’t do that.  This is what we are required to use.  Silly me.  This isn’t the United States of America.  I can’t be allowed to do what I think is in the best interest of my patients.

I’m going to go off on a rant right now (and several run-on and poorly structured sentences) so you might want to grab a Snickers and an English teacher.  Okay.  Do not grab an English teacher.  Unless you are Donald Trump.  Or you are married to said English teacher.

I am getting rather tired of people telling me, the surgeon, how to do my job.  I am told that I have to mark the patient’s eye.  (That is a good idea.  We always did it before, but . . . )  I am told where I have to mark it (in the holding room instead of the operating room where my chart is and with the patient in the proper position for the surgery–I know that sounds weird but when I operate I sit behind the patient’s head so his right eye is my right and his left my left, but when I face them in the holding area, my right is his left and vice versa–for someone who had operated for years the other way, it took some getting used to and I tried carrying my charts around, but now I have two charts, the previous patient and the next patient and of course I wrote on the wrong chart shortly into this new experiment which quite frankly made a simple but important safety act more cumbersome and difficult with no definable benefit), and how I am supposed to mark it (on the cheek below the correct eye, marker that won’t rub off easily (patients have to scrub, often with alcohol, to remove my initials tattooed on their face), and I have to include THREE initials, because I might forget who the fuck I am after following all these god-damned insane regulations.)  I am basically told what medications we can use because if it’s not in the hospital formulary, it ain’t happening.  I am supposed to date and time my orders–this is an outpatient procedure that takes 10-20 minutes in most cases.  How is dating, and worse yet timing, my signature of any benefit to patient care???  Anything I sign in the chart has to be on that date and within a fairly definable time frame.  I’m not supposed to wear a watch in the OR, yet I am supposed to time everything.  What the hell did I go to medical school and residency for?  I could have saved EIGHT years of my life and just had the federal government (The Joint Commission) and UPMC tell me what to do.  Maybe Trump will wipe out the Joint Commission after he’s done erasing the EPA.  And I am done digressing.

But I heard this single use tape experiment has been so wildly successful at improving patient care and cost-efficiency that UPMC is going to roll out their next great idea:  single-use toilet paper rolls.

toiletpaper

Because you shouldn’t be pooping on company time anyway!!!!

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Apparently there is a regulation that healthcare workers wear an ID tag.  It is not clear whether this is to ensure the safety of the public, remind absent-minded workers who they are, or protect the innocent.

For 23 years, I have performed eye surgery at a number of hospitals and locations.  I have NEVER worn an ID badge at any point while operating.

For one thing, we wear sterile hospital gowns over our scrubs, which would cover any name badge.

For another thing, I do not operate on patients I don’t know or have never met.  I certainly wouldn’t want someone I have never met to operate on me.  All my patients have seen me at least once in my office before any surgery is scheduled.  They KNOW me.  Badge or no badge.

The staff I work with knows me.  I have operated there since 2003.  Sure, there are new people hired now and then.  They get to know me.  No badge required for that little exchange of information.  Some may regret meeting me, but that’s another story altogether.

So while this well-meaning regulation may have some use in certain situations–I fully understand that a patient or family member in a hospital setting might be interested to know who is coming into their room and for what reason–is this person a nurse, a nurse practitioner, a physician’s assistant, a respiratory therapist, or a janitor, or is it someone who just stayed at a Holiday Inn Express last night?  I still think simply asking if you are curious would be sufficient, but no one asked me.

But there is no legitimate reason on God’s good earth, why I should wear an ID badge while operating at an institution that knows me, with people who know me, on patients who know me.  And for crying out loud, they have cataracts!  They couldn’t read the name tag anyway!

slapstupid

But today, the Board of Health (Bom, bom bommm!) came to our tagless institution for the supposed purpose of evaluating and certifying the place.  Basically this means they want to make sure that we are following their rules, even if those rules interfere with basic patient care.  None of this regulatory crap has anything to do with “patient care” anymore than Obamacare has anything to do with patient care (whereas it has everything to do with the government controlling your healthcare for better or worse, but again, that is a story for another day.)

But as I prepared to give patients the gift of sight today, I was accosted by a supervisor at our surgery center who insisted that I wear an ID tag–because the Board of Health (Bom, bom bommm!) is coming.

“Did we check the lights in the old north church?”

One if by land, and two if by sea.

The Board of Health is coming!  The Board of Health is coming!  (Bom, bom bommm!)

IDtag

Seriously?  Are you freaking kidding me?

And this serves what purpose in the treatment of my patients today????

The healthcare system in this country is sinking, and apparently the Board of Health is rearranging deck chairs on the Titanic.

I was not the only doctor wearing these make shift labels today–we all were.  Misery stupidity loves company.  None of us routinely wear ID badges. WE DON’T NEED THEM.  Doesn’t improve patient care.  And what’s to keep some criminal on the street from stealing a pair of scrubs and using a Sharpie pen to make his/her own name tag?

BTW–the Penn State badge is there because I am not allowed to wear my PSU scrubs anymore–only hospital issue uniforms.  Another brilliant regulation dreamed up by someone who doesn’t have a real job, doesn’t do my job, but knows they can do my job better, and has to justify their existence on this planet by enforcing said regulation.  The PSU badge does improve patient care–it makes me a happy doctor to wear it, and happy surgeons are BETTER surgeons.  Trust me on that one.  (Really, would you want someone unhappy to be putting sharp objects in your EYE!)

At least after I was done pounding my head against a wall in frustration, I could look down and remember who I was!

 

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Money4Nothing

That ain’t Twerking . . .That’s the way you DO it!

And my chicks for free!

The Daily Post asks . . . If you’re like most of us, you need to earn money by working for a living. Describe your ultimate job. If you’re in your dream job, tell us all about it — what is it that you love? What fulfills you?

For those of you who follow my blog, you know that I am, by profession, an ophthalmologist.  An eye doctor/surgeon.  And while I do like my job–I really enjoy giving cataract surgery patients the gift of better sight–there are certain things about my job I do not like.

I really do not like our government and its bureaucratic intrusion into my practice.  I wish they would just leave me alone to do what I was trained to do.  Dealing with insurance companies makes me want to stick needles in MY eye!  Obamacare is just worse and more of it!

I loathe computer medical records.  Electronic Health Records.  EHR.  Errrrr!  Meaningful use = meaningless abuse.

I really don’t like having to get up at a set time every morning and living my life to a schedule.  Didn’t bother me years ago, but as I have aged, I really look forward to sleeping in on weekends!  I could get used to doing that every day.

I don’t like call.  As I have turned 39 for more than a few years, the ER calls in the middle of the night really bother me.  I no longer can fall back to sleep right away which affects my next day’s performance.  I already work a very busy schedule and additional add-ons are just additional stress right now that I could do without.  It is what it is, though.

So, in a nutshell, right there is my dream job . . . making the same amount of money I currently make (more would actually be better since I still live paycheck to paycheck with my doctor’s salary) but not having a set schedule, no call, and still do what I enjoy doing.

I enjoy running.  Can’t see anyone paying me what I make now to simply run.  And I am certainly not an elite/Olympic runner.  If I have to compete to get paid, I will starve.

I enjoy golfing.  And while I could make more than I currently make being a great professional golfer, I am not a great golfer.  I’m not really a good golfer.  I’m not worthy of playing with Tiger Woods.  I’m not really worthy of playing with Tiger’s woods, or even carrying his clubs.  I have probably lost a few balls in Tiger’s woods and if not, I certainly could manage that.

I also enjoy bowling, but I don’t think my current 192 average is good enough to keep my salary level where I am.  Nothing more pitiful than a starving bowler.

I’ve always dreamed of being the head coach at Penn State, and that would certainly pay better than my current gig.  But as passionate as I am as a fan, I do lack the X’s and O’s to actually be a football coach.  And looking at the hectic schedule that our new coach is living–travelling on the recruiting trail–I don’t think I would enjoy that schedule.

I am thinking Penn State University president.  The job may still be open, but I think they will be announcing a new president shortly.  I have not the experience nor qualifications, but there would be no bigger promoter of the University that I know of.  I can cut a ribbon without cutting myself.  I think.  I could ask people to donate money.  I’m not sure how I could handle dealing with our State Legislators, since my opinion of monumental idiots lawmakers in general is not very high.  The schedule probably isn’t as flexible as I’d like, so I think this is a no-go as well.

I could be a professional blogger if somebody wants to pay me what I’m currently making.  Yeah, I don’t see that happening.

Professional lottery winner?  I’m so there.  I just need to win the freaking Power Ball!

I’ve always thought stand-up comedy would be great.  I’m currently the entertainment for our annual office Christmas party, but that’s a once a year gig.  Not sure I could pull it off on a regular basis.  Maybe if I had a team of joke writers.  But the whole stand-up thing is not my style.  One of the things that drew me to eye surgery in medical school is that you can do it sitting down.  I guess I could be a late-night show host–a little actual standing followed by sitting behind a desk drinking coffee.  I could drive around like Jerry Seinfeld and drink coffee with other comedians.  I could drink coffee with just about anybody, especially if I’m getting paid well to do it.

I do dream of being a “professional” writer some day.  I have several novels in very stages of completion.  I blame my day job for the lack of time needed to actually finish and publish these projects, but we all know that is just an excuse.  And I have heard that publishers can be downright nasty with deadlines which would annoy me.  Sometimes the muse inspires me; sometimes the muse perspires me.  You just never know when the words will come.

It looks like for now, I’ll have to stick with taking out cataracts.

That’s not working.  That’s the way I do it.

Lemme tell, eye docs ain’t dumb.

Maybe get a blister on my little finger.

Maybe get a blister on my thumb.

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Has your eye doctor asked you to disrobe and bend over for a prostate exam?  You might want to think about getting a new eye doctor if your answer was yes, but that scenario might not be as absurd as you think.

The United States government, in all its infinite wisdom and good intentions, is changing the way your doctor takes care of you.  Now this is a government that can’t adequately fund or run the Social Security System, Medicare or Medicaid, but they know what is best for your health.  They can’t run the Post Office without a loss, but they know the best way to deliver your health care, and starting in the near future, in addition to no mail you likely won’t be able to get health care on a Saturday.

After all, what would a doctor know about delivering health care?  They went to medical school instead of business school!  They weren’t elected to protect your rights!

Enter Electronic Health/Medical Records (EHR or EMR).  Physicians are “mandated” to computerize medical records.

According to Michelle Malkin:

Buried in the trillion-dollar stimulus law of 2009 was an electronic medical records “incentive” program. Like most of President Obama’s health care rules, this top-down electronic record-sharing scheme is a big fat bust.   Oversight is lax. Cronyism is rife. The job-killing and privacy-undermining consequences have only just begun.   The program was originally sold as a cost-saving measure. In theory, modernizing record-collection is a good idea, and many private health care providers have already made the change. But as with many government “incentive” programs, the EMR bribe is a tax-subsidized, one-size-fits-all mandate. This one pressures health care professionals and hospitals across the country into radically federalizing their patient data and opening up medical information to untold abuse. Penalties kick in for any provider that hasn’t switched over by 2014.

Like so many federal programs, the EHR incentive is advertised as an optional program.  I don’t have to convert to medical records if I don’t want to.  But, oh, by the way, if I don’t convert by 2014, Medicare is going to penalize me.  The federal government has a long history of such extortion–think of the 55 mph highway speed limits that were enforced in the 70’s and 80’s.  States could legalize higher limits, but then they would lose federal funding.  You don’t have to participate . . . but we know you will!

I don’t have to participate in Medicare, but here is the reality:  80-90% of my ophthalmology practice is Medicare.  If I don’t participate, my waiting room will be empty.  The vast majority of Medicare covered patients can’t afford to pay for services out of their own pockets, so they will go to physicians that do accept the coverage. I can’t blame them–I would too.  So I participate because I have to–not because I want to.

And such is the case with EHR.  I can’t afford to collect less from Medicare.  Seriously.  The reimbursement for a cataract surgery today is 1/3 what it was when I started in practice in 1994 and about 1/4 of what it was in 1986 (I now perform THREE surgeries to get paid the same as I used to get paid for ONE!)

Think about that for a moment.  If you are a farmer, you must now plant and harvest three fields to make the same profit you used to get for farming one field.  If you are a salesperson, you must now sell three times as much to keep your salary the same.   Or keep it even more simple–if you are paid an hourly wage, you must now work three hours to take home the same pay you used to work one hour for.  That sounds fair, doesn’t it?  And that is without taking into account inflation and the fact that a 1986 dollar is worth more than a 2013 dollar, not to mention the fact that cataract surgery today is safer and more predictable than it was in 1986.  When you factor in inflation, it is criminal what the federal government has forced upon physicians.  And now there is the 2% sequestration loss on top of all that.

The worst part of the whole thing is that I spent 12 years of my life (four years of college, four years of medical school and four years of residency) and well over a $100,000 for my education, and I am only trained to be an ophthalmologist.  It’s not like I can take my training and skills set and join another company.  I’m not qualified to do anything else, except consulting in some capacity or teaching ophthalmology.  Judging by the page views on this blog, I couldn’t make a living doing this!

So the government dragged me into EHR kicking and screaming, but I have not yet seen one cent of any “incentive” that was promised.  Why?  It’s not because we aren’t using EHR–all of my new patients and 90% of my old patients are now computerized.  It was a long, arduous and frustrating process.  It was expensive.  Anyone in our office that needs access to a chart–from technicians, schedulers, phone operators and insurance filers–must now have a computer and each computer has to have a rather expensive software license.  And every time we submit to get our incentive, there is a new reason why we failed to meet the criteria. No soup for me!

And if the computers go down–I can not access a new patient’s information.  It’s backed-up somewhere, but I can’t get to it until IT figures out what the Hades is wrong with the software or server.

The whole process of computerization and data collection sounds nice on the surface.  This site outlines the process like this:

EHRoverview

Improved communication, quality measures, patient access and efficiency are all wonderful buzz words that make it sound like a fairy tale come true.  But it’s the details of the process that are horrendous. It’s the “meaningful use” of that technology that is problematic.  The fine print for meeting these criteria include 15 CORE objectives for physicians, apparently regardless of specialty (“one size fits all”):

1.  Computerized provider order entry (CPOE)
2.  E-Prescribing (eRx)
3.  Report ambulatory clinical quality measures to CMS/States
4.  Implement one clinical decision support rule
5.  Provide patients with an electronic copy of their health information, upon request
6.  Provide clinical summaries for patients for each office visit
7.  Drug-drug and drug-allergy interaction checks
8.  Record demographics
9.  Maintain an up-to-date problem list of current and active diagnoses
10.  Maintain active medication list
11.  Maintain active medication allergy list
12.  Record and chart changes in vital signs
13.  Record smoking status for patients 13 years or older
14.  Capability to exchange key clinical information among providers of care and patient-authorized entities electronically
15.  Protect electronic health information

If you are a non-physician and you look at this list, you are probably thinking to yourself that physicians should probably be doing these things anyway–and in fact, good physicians have been doing most of these things on paper for years.

Who wouldn’t want an electronic prescription as opposed to a scribbled, illegible one from the doctor?  Or an office note that is typed and legible rather than scrawled by a dyslexic platypus?   Have you ever used a computer?  Have you ever mis-typed a text message or email?  Clicked the wrong icon?  Have you ever tried to submit an on-line form that was refused because you missed one of the starred items or entered something incorrectly?  Have you ever sent a text or email that someone didn’t get?

In the short period of time we have been adhering to the eRx mandate, we have had multiple calls from pharmacies where patient’s are waiting to pick up their eye drops but no prescription was received.  Our computer says it was sent.  I know you probably find that impossible to believe because computers are perfect and people are not, but how many essential prescriptions do you think might be lost and the patient not realize they didn’t pick up all the meds they were supposed to?  Or what if the doctor clicked the wrong medication in the drop down menu by accident and didn’t pick up the mistake because he was trying to save encounter time so he could ask you about smoking (see below)?

It’s not as though folks couldn’t forge or change their prescriptions before to get controlled drugs.  They did.  But how long do you think it will take hackers to figure out ways to illegally transmit prescriptions for controlled substances, if they haven’t already?  (Actually, I think controlled substances still need a paper Rx, but as an eye doctor, I haven’t written for a controlled substance in 21 years, so don’t quote me on that.)

We are on the Titanic chugging along here folks, and this is only the TIP of the iceberg.  Medicare is telling us to move ahead full speed!

Number 12 mandates that we “record and chart changes in vital signs.”  Sounds like a good idea, doesn’t it?  Why didn’t a doctor think of that?!

Here is what your hard-working government–and I swear they employ people to stay awake all night thinking up ways to screw all of us–is doing for you:

Record and chart vital signs: height, weight, blood pressure, calculate and display

BMI, plot and display growth charts for children 2-20 years, including BMI

So you show up for your eye appointment.  Your doctor’s assistant asks you to step on the scale.  They calculate your BMI (body mass index) and determine that you are overweight.  Wait a minute, you came here for glasses, didn’t you?   Or a cataract?

Your podiatrist now is asking you about smoking.  And they are handing you materials about smoking cessation.  All you had was an in-grown toenail.  WTF?

How long will it be before I have to put my patient, who is getting glasses, into a paper gown and ask them to turn their head and cough?

Or better yet, “I’m sorry Mrs. Jones, but before I can take out your cataract, Medicare requires I document a rectal exam!”

Don’t laugh!  They are changing these rules as we speak.  And I’ll give you a hint–they only make it worse.  The Academy of Ophthalmology fought the Centers for Medicare Services (CMS) for relief from having to buy scales and waste clinical time discussing your weight instead of your eyes, but I am still being forced to ask my patients about smoking.  And while that does have a modicum of relevance for macular degeneration patients who are at higher risk for the wet type as smokers, for the vast majority of patient encounters, it is just one more thing we must document for no other reason than to make Mr. Obama and his merry band of legislators happy.

We are treating the computers (and legislators)–not our patients.

Seriously, if you are a smoker, you probably know already from the media and lawsuits that smoking is bad for you.  Your general medical doctor, lung specialist or cardiologist should discuss that with you.  But if you are being checked for cataract or getting contact lenses, is that really necessary?  How many people are really going to stop smoking because their eye doctor or foot doctor or proctologist told them to do so?

But wait!  There’s a pamphlet for that!

Vital signs should be appropriate to the specialty–blood pressure and pulse for the cardiologist, respiratory rate for the pulmonologist, vision and eye pressure for the ophthalmologist, etc.  But the government system won’t allow for individuality or common sense.  There are universal protocols for everything, from infection control to marking a surgical patient, regardless of what the infection or surgery may be.

And it only continues to get worse.

So maybe you don’t care if your eye doctor is making less money as you sit in the over crowded waiting room (because I now have to see three times as many patients to maintain my income AND pay for this new computer system I don’t want.)

But if you have to disrobe and bend over, you might just start to care.

I just hope it isn’t Obamacare.

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