Find Your Beach

Every time a traveler gets sick, a Coronvirus gets its Lime.

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Short-taped in the OR

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.

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.

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.

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

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Meaningless Use

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:

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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A Suture in Time

The old adage goes, a stitch in time saves nine.

Nine what?

Google is my friend, and a perusal of this site yields the following:

Meaning

A timely effort will prevent more work later.

The ‘stitch in time’ is simply the sewing up of a small hole or tear in a piece of material, so saving the need for more stitching at a later date when the hole has become larger. Clearly, the first users of this expression were referring to saving nine stitches.

Now you may be wondering what all this has to do with anything.  I’m right there with you.  Haven’t a clue.  Wait.  What?

Certain innocuous phrases can really be lies in disguise.

Robbert van der Steeg
http://www.kuriositas.com/2011/01/photomanipulations-of-robbert-van-der.html

The check is in the mail.  (I have no intention of paying you.)

That dress doesn’t make you look fat.  (You look like that no matter what you wear.)

Of course I respect you.  (But please God, I hope she leaves in the morning before I get up.)

The doctor will see you now.  (Hope you brought a Snickers . . . you’re going to be here for a while.)

Wait.  What?

On behalf of all doctors out there, I must protest.  I resemble that remark.  There are usually very valid reasons why you had to wait so long, and these often don’t involve golf or writing a blog.  Having been in practice for over 20 years, I can tell you there is no perfect schedule.  If you book light, there are cancellations and the doctor ends up sitting around idly pumping his sphygmomanometer in private.  If you book heavy, EVERYONE–and their siblings–show up and you have twenty emergencies added on as well.

I have also noticed that the patients who complain about having to wait so long to get an appointment, are often the ones who complain about how long they have to wait in the office to actually be seen.  So you want me to jam you into my schedule sooner and make all the other people simply disappear so you don’t have to wait?  I’m not a magician, and if I were, I wouldn’t use my sorcery for scheduling.  I’d be waving that wand for some winning Powerball numbers.

There is no perfect schedule and most doctors try their best not to make you wait unnecessarily.  After all, we’re not lawyers–we’re not billing you by the hour, even if it seems that way sometimes.  And if I could clone myself and be in two places at the same time, I’m sorry to say that one of us wouldn’t be here seeing you in this office–one of us would be out having fun somewhere.  Actually, if I were able to clone people I could probably just retire.  But I digress.

And blaming it all on the scheduling secretary isn’t fair either.

What most people fail to realize is that doctor time is different from non-doctor time.  It’s kind of like dog years.  One year for a dog is like seven human years.  So when the nurse tells you the doctor will be in to see you in a few minutes, she’s not really lying.  You have to multiply that number by 7.  A fifteen minute wait will actually be 105 minutes, but what’s a few minutes between friends?  If you are a subspecialist, that number might be 10 or 12 x longer.  Restaurants do the same thing, but the multiplier is generally less.  If you think your table will be ready in 20 minutes, be prepared to stand around for 40.

I have explained this phenomenon to a number of irate patients over the years.  It’s kind of like trying to explain Einstein’s theory of relativity to someone other than Einstein.

But one elderly gentleman unfortunately “got it.”

He handed me his medical bill for $70 along with a ten-dollar bill, saying that he was paying me in patient dollars.  You just have to multiply it by 7.

Payback is a bitch.  (Payback is a bitch!)

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Making Out in the OR

Most people are unaware of the myriad government regulations and documentation that goes on behind the scenes in the medical setting.

In the operating room, one of the items that must be documented are the times in the room and the times out of the room.  Time in or time out.  But, we also have to take a “time out”–actually two time outs–where we verify the patient and the procedure before starting surgery.  The terminology gets confusing.  But I digress.

Anyway, both anesthesia and the circulating nurse must document these times in different locations in the medical chart.  AND THE TIMES MUST MATCH.  I don’t know what happens if they don’t, but I imagine it would be like matter meeting anti-matter.  The very fabric of our universe would be ripped apart if these numbers are not exactly the same.

So to avoid a universal catastrophe and destroy civilization as we know it, the circulating nurse and anesthetist verify their times before documenting them in the medical record.

From http://www.shitamandasays.com/2011/12/01/she-wants-to-do-what-to-the-dog/

Now so far, none of what you have read about has actually TREATED the patient.  Apparently the government hasn’t worried about that yet.  Right now, we are spending an inordinate amount of time treating your medical record.  The outcome of your surgery is irrelevant as long as all the times match up correctly.  But, I digress again.

So a given interaction to coordinate these times might go like this . . .

Circulating Nurse:  “Do you want to make 11:13 time in?”

Anesthetist:  “Sure.”

And then they dutifully document that in their respective areas of the chart.

Today, at the end of the case, though, the anesthetist phrased the question slightly differently . . .

Anesthetist:  “Jane [name changed to protect the innocent], what time do you want to make out?”

He meant to ask what time she wanted to document for the time out of the room.  But that is not how it sounded to everyone else.

Always on the ball, she responded, “Not right now, but I’m free later.”

For the non-medical record, Jane, who really isn’t Jane, didn’t actually say that.  But she should have.  We all had a good laugh anyway.  And the universe is safe for another day as our times all matched.

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