Red Cap Society

As I was entering the surgical center where I do cataract surgery, I was greeted by a sign on the door to the locker room . . .

If you follow my blog with any regularity–or my new sister blog, The Silence Dunwell Letters–you know that I am a bit of a cynic when it comes to arbitrary regulations–rules that seem to be in place only to justify someone’s job–proof that they are doing their job, even if it isn’t very well.

So apparently these rules are designed for VENDORS.  I’ve always known them as sales reps, but tomato, to-mah-to.  Vendors makes me think they’re selling hot dogs or drinks.

SO CLOSE!  Red Cap, but not BOUFFANT!

Red Bouffant Cap.  I’ll come back to that.  You know that I will.

Badge clearly visible.  Good rule.  No problem with that.

Current with requirements.  I have to maintain my license.  I don’t have a problem with everyone else in the operating room maintaining their credentials.

Long sleeve warm-up jacket?  What about summer time?  Is it possible the coach may want to put you in the game, so you better keep your arm warm?  There may be a good reason to require this, but I have FAILED to come up with any remotely logical reason to make this a requirement.  Leave me a comment if you think of something.

NO UNDERSHIRTS.  Seriously?  How will you know if they are wearing one under the already mandated LONG SLEEVE WARM-UP JACKET?  Are you [bleeping] kidding me?  Who’s going to inspect for this?  Do they have to undergo strip searches for illegal under garments?  Can anyone show me a medical study that even remotely suggests that the undershirts of non-operating personnel worn underneath an official warm-up jacket have been shown to increase the surgical infection rate?  Anyone?  McFly?  We are just a few sieg heils away from regulating the type of socks and underwear we use.  Oh wait, I think they do regulate the type and color of socks and shoes of the nursing personnel.

UPMC stands for U People Must Comply.  We will wear only their scrubs and have no other scrubs before thee.  We are the Stepford Doctors.

Shoe covers?  Not a problem for me.  As long as I can wear whatever shoes I want underneath.

And no problem with requiring that visits be scheduled.  We don’t want the operating room to resemble a flea market or bazaar.

But . . .

What in the wide, wide, world of medicine prompted this fashion faux pas?  I searched high and low but couldn’t find the big red noses or the clown shoes to go with them.  What are they vending?  Happy Meals?

I will assume–always an unwise thing to do, but this is my blog dammit–that they want these “people” to be readily visible.  Mission accomplished.  You could pick them out from a satellite image.  I guess the ID badges are simply not enough.

Seriously, is this necessary?  For the record, we never had RED CAPS before, so now we are spending health care dollars on this fabulous headwear.  (Hashtag #whyamericanmedicineisgoingtohellinahandbasket)

In all my years as a surgeon, I have never had an instance where there was someone in my operating room that I did not know, or was not introduced to (such as a nursing student, inspector, repairman, etc.)  And if there was someone in my room and I do not know why they are there— I ASK WHO THEY ARE AND WHY THEY ARE THERE.

I don’t depend on the color and coordination of their outfit to satisfy my curiosity.

Because any idiot can put on a red cap.  I did.  I wore that thing all day!  I’m operating and I’m vending!  Oh, I’m vending, Jerry.  I’m vending!  And I hear that UPMC allowed a VENDOR to perform surgery!  (Psst.  It was just me.  In the red hat.  Don’t tell.)

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:oscopy

Get it?  😕  Colon.  Oscopy.

I was really hoping to find some humor in this procedure.  This was my first colonoscopy.  Welcome to being 50!  It is like a right of passage.  I have read many stories over the years about this procedure.  Most of the horror surrounds “the prep,” which is a nice way of saying that Satan is coming down your colon with a supersoaker from hell.  And while that was mostly true, it was not as bad as I was expecting.

Granted, having to stay within 30 feet of the toilet for most of the night was not pleasant.  The time actually spent on the toilet was not pleasant.  I did get to play a lot of games on my iPad, so it wasn’t a total loss.

Here I sit and dream of glory, alone inside the lavatory.  (An obscure reference–leave me a comment if you know the source.)

Personally, I thought that drinking “the prep,” a concoction called Suprep that comes in two 6 ounce bottles of cherry flavored hell, was actually worse than getting rid of it.  I’m not a big fan of cherry to begin with, and that is probably a good thing.  My dad underwent a colonoscopy a number of years ago.  He mixed his prep at that time with Squirt, a citrus soda.  From that day on until the day he died, he could not bring himself to drink Squirt again.  And that name is kind of ironic, doncha think?

So if taking this prep turns me from cherry flavored anything, it is certainly not the end of the world.

It looks so innocent!

And it was god awful.

Yeah, there was cherry.  With bitter undertones and a hint of maybe seltzer–or mineral water.  I think I detected some acetone or benzene, if my senses have not failed me from biochemistry.  The bouquet was nonexistent–it didn’t even smell like cherries.  And it was crystal clear, so you could almost convince yourself you were drinking water or vodka, until it actually touched a single taste bud on your tongue.

You see, you had to dilute this wonderful prep into 16 ounces of clear but vile crap that you must choke down before you have to run to the bathroom.  Twenty minutes.  That’s all it took.  And I had to down two more 16 ounce cups of water afterwards, or it would have sucked the water out of my brain.  I would have ended up a pile of dust floating in the toilet.  The beast had to be fed water.

So after choking down the cherry shit, alternating forced gulps with some coffee or white grape juice (you can’t drink anything with red or purple dye!) to try and save my taste buds, I then had to down 32 ounces of water over the next hour.  I’m not sure I drink that much water in a single day!  I drink–coffee, tea, soft drinks, wine, beer.  But only occasionally do I ever drink plain old water.

The first bottle came out explosively but without any accidents I am happy to report.  I did get baby wipes as recommended since toilet paper could be “irritating.”  By the time I was ready for bed, I was no longer living on the seat.

Unfortunately, bottle two had to be taken seven hours before my scheduled time, with another 32 ounces of water in the hour after that.  Then, no more liquids until after the procedure.  With a 9:00 appointment, I had to get up at 2:00 am to force another cherry jubilee down my esophagus, and through my intestines.

I was hoping that being half asleep, I wouldn’t mind the cherry crap so much.  I was wrong.  It was worse.  I have never drank gasoline, but if you throw some cherries in it, I imagine this is how it would taste.

Boom!  I’m back in the bathroom.  Cholera without the actual disease.

In the morning, I looked longingly at half a cup of coffee left over from the previous night’s escapades.  I carefully took a mouthful, swished it around my mouth to tantalize my taste buds and maybe absorb some through my mouth’s mucosa, before spitting it out in the sink.  I watched as the coffee went down the drain.  I was devastated.  But I didn’t drink anything!  I did not swallow!  (That’s what she said!)

So I arrive at 8:45, and I am back in the holding area with all my clothes off except for my socks, a hospital gown and a sheet to keep the young women from laughing at me, or at least, not laughing at that.  At 11:00 o’clock, they finally come to take me for the procedure.  Waiting that long was more irritating than the toilet paper.  And I’m a doctor!  There had better have been an exploding colon somewhere to delay me getting my damned coffee.

Anyway, I’m all ready to take notes about the actual procedure for this blog, to bring the colonoscopy experience alive for my readers my reader  the person who stumbled here by accident.  They ask me to lay on my left side.  And  . . .

Then I woke up.

What a disappointment!  This is the closest thing to a sexual encounter I’ve had in years and I missed it!

And in case you care, my colon is just fine, thank you very much.  Not even a polyp.  Come back in 10 years.

And I finally got my coffee.

Seriously . . .March is Colorectal Cancer Awareness Month.  And if you are over 50, don’t be like dead-from-colon-cancer Rob Lowe–get DirecTV and a colonoscopy today.

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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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