Wednesday, May 6, 2009

The Worried Well

During this recent H1N1 flu scare, I know many of us physicians have been swamped with patients, both sick and well. It has been a definite challenge, I think for all of us! I am used to seeing a certain number of patients for minor illnesses, and I have come to know which patients tend to be quite ill when they come in versus those who tend not to be. However, this past week or so has been quite different. Although I often find it annoying when parents bring in their children for very minor illnesses, such as a comedone on the nose of a teenager, I have been much more understanding the past few weeks! I had one child come in who was very worried that she was going to die from the swine flu. She had no symptoms, and therefore I didn't use one of our precious few viral swabs to test her for the virus. I tried to reassure her and explain to her the different methods she can use to protect herself from the virus. But I truly felt sorry for her. Her anxiety was palpable when I walked in the room, and I couldn't do anything concrete to assuage her worries. How very frustrating!! She was just old enough to understand the news, but not old enough to fully understand it. I do hope she was able to go back to school and focus on the last few days of the school year, however, I have my doubts.

Do we have a way to help these kids besides education? We have mental health providers, but they are usually swamped with patients... I am hoping that next time an illness like H1N1 comes around, we are more prepared either with better training for medical providers to deal with such patients and/or with mental health providers that are dedicated to providing this specialized care.

Friday, April 24, 2009

turmoil at home

I have had quite a frustrating, sad week. It seems there was a lot of strange medicine being practiced at my local emergency room, including prescribing antibiotics for viruses. But what really wore me down was a family with several girls and boys. All the children came in this week for well-child exams. They are charming, bright, and cute. However, they have been in and out of foster care as their parents have been in and out of jail. I know kids are resilient, but what kind of chance do these lovely girls and boys have of becoming successful adults? They have role models at school and in the community, and, granted, their parents try hard at times, but they don't have much going for them. We are fortunate to have good mental health services here that I've accessed for them; the teachers at the schools do their best to care for them; and protective services is continually involved. I just look at them now and hope and pray that they can overcome the obstacles in their path.

Tuesday, March 31, 2009

Surprise costs

OK, I haven't written in a while, mostly because I've been swamped at work and preoccupied. I'm going to have minor surgery tomorrow, and I'm nervous even though it's no big deal. But now I have to vent.

A little background: I'll be having the surgery done at a large hospital which has a busy outpatient surgery center that handles thousands of patients per year, a well-oiled machine. So here's my gripe: I received a phone call today from the billing department of the hospital where I'll be having my surgery, exactly 24 hrs before the scheduled time of surgery. I was told that I needed to pay approximately $1000 tomorrow before I have surgery, the "facility cost" that is not covered by my health insurance, payable by check, cash, or credit card. Now, even though I'm not thrilled about it, I am fortunate enough to have a steady job that provides me with a solid income; I also guessed that I would have to pay something so I was somewhat prepared mentally. What stunned me was that I received so little notice. The surgery was scheduled more than two weeks ago, and I gave the hospital my insurance information at that time. Presumably, I could have been notified shortly thereafter about the fee or even given an estimate of the fees at the time of scheduling. I know many people who would have a hard time paying this large fee. Perhaps the hospital arranges payment plans for those who can't afford a lump sum payment, but I do feel that advance notice is critical and courteous. For those who have a hard time paying, advance notice gives them a chance to speak to family members or their bank about borrowing money, or to put aside money from a paycheck or two specifically for the surgery or to put off making another big purchase. I wonder if it's done like this everywhere. I do know that the same 24 hr notice was given to a member of my staff who had surgery at another hospital just a few weeks ago, which added a lot of stress to an already stressful situation.

I think that especially in these challenging economic times, all of us need to be considerate of each other's needs. There, that's my piece. I'll be back online in a day or two to let you know what it's like being a patient, a good reminder for all of us docs around who sometimes forget!!

And by the way, GO TARHEELS!!!!!

Wednesday, March 18, 2009

Will EHR become a reality?

I am very excited at the thought that I will eventually have EHR at my office. Sadly, knowing my organization, it will be at midnight on the night of the cut-off, probably in 2015. I have been clamoring loudly for EHR since I started at this job in 2005, as have other physicians in the organization; however, our administration has been resisting, stating start-up costs as the main reason we haven't moved ahead. Now, with money in the national budget set aside specifically for achieving the goal of universal EHRs, perhaps we can start thinking about options.

I recently received communication about a website that reviews electronic medical records. I was intrigued, so I checked it out. Software Advice, a website that reviews electronic medical records, makes some interesting points about the future we are facing, with late adopters joining in the fray at the last minute. Will these providers (and organizations):

  • Truly believe in the value of an EHR over traditional paper charts?
  • Take a leadership role in advocating adoption of the new EHR in their practice?
  • Change their old work flows to match the best practices in leading EHRs?
  • Take part in intensive training to learn the new system?
  • Ride out the difficult stages of new software adoption and change management?
I think that these are valid points, and I will answer each question from my perspective regarding our organization. I think that some of the physicians and mid-level providers do see the value in EHR, but the administration does not. In terms of leadership in advocating for implementation, we have two leaders, our Medical Chief of Staff and our head pharmacist. I think those of us who believe in EHR will be willing to change the way we work, train to learn the new system, and keep working with it until it runs smoothly. I don't think this split will be by age, but rather by comfort level with computer technology. I had the advantage of growing with computers from before they were common (and the hard drive was a cassette player), and although I'm not an expert on computers by any stretch, I enjoy learning new programs. Having worked as a transcriptionist, I'm also a fairly quick typer, so I'm not slowed down by having to use a keyboard vs a pen.

They offer a five point plan to help smooth the transition which relates to the five points above. The organization should have a project manager to coordinate the transition from start to finish. I propose that there be two managers, one medical and one technical, because I think that both perspectives are necessary for successful implementation. Next, the team of doctors needs to be rallied, as well as the patients. The transition will hit bumps, and all team members, from the front desk staff to the patients themselves, need to be prepared and understand that EHR will be an excellent solution, eventually. Training will obviously be key. The better the training provided on the program, the more likely the transition will be smooth. So far, I think this will be one of our biggest obstacles, based on the training the staff have received on other new electronic programs, which is none to be exact. Their fourth point is to keep it simple. Amen to that. The transition may need to be gradual, and the EHR will likely evolve as the process goes forward. Finally, the practice will change, be it by medical staff carrying around tablets PCs or by having PCs in the exam rooms. This will require adjustment by medical assistants, nursing, providers, and families. I happen to strongly believe that EHR will be a safer, more efficient way to practice medicine, but I am bracing myself for the transition.

I do, however, disagree with the authors of the website on one main point. They feel that EHRs should not be free, that people only value what they pay for. While I see their point, I think that for certain organizations like community health centers, the cost of establishing an EHR is absolutely prohibitive. I know that the money will eventually be re-couped by improved billing and improved efficiency, but the start up capital is a real challenge. In addition, if this is something that is going to be required, at least a subsidy needs to be available to help. Maybe there can be a basic form of EHR which is available free-of-cost to all providers, and then practices that can afford a version with more bells and whistles can pay extra. I don't know if this is the right solution, but it's just a suggestion.

Friday, March 6, 2009

Subspecialist shortages

The news is full of stories about an ever-shrinking group of pediatric specialists, rising average ages of these specialists, and the overall critical situation we are. I also happen to work in a state with a tremendous shortage of doctors, both primary care and specialist care. Needless to say, I spend a fair amount of time thinking about the predicament we are in.

The first things that comes to mind as a solution to this problem is to re-examine the current fellowship curricula. It used to be that different fellowships were different lengths, varying from one year to three, depending on the specialty. About fourteen years ago, the American Board of Pediatrics (ABP) made the decision to standardize the length of all pediatric fellowships to three years. I often wonder how much of an impact this has had on the number of graduating specialists. Please don't get me wrong, I think that certain fields require three years of training in addition to the three years of residency, i.e. pediatric intensive care, but others may not. Research plays into this length, I realize, and I know that research funding is very important to post-graduate education programs. When I was checking out the ABP website, I did learn that there is a way to do a fast-track fellowship for those people who already have documented research or other time in the field they're going into. For example, I might be able to do a developmental pediatrics fellowship in two years because I have a master's degree in early intervention. However, this only applies to a small pool of physicians.

As a resident, a pediatrician makes approximately $50,000/yr. During this period of training, one is also required to start paying off college and medical school loans; some residents also have families to support . In the current economic crisis, buying a house may not be an option anymore as it has become so much more difficult to get a loan, so one may be paying large sums in rent. Salaries increase a little bit during each additional year of training but not significantly. Then, finally when fellowship training is complete, depending on whether one chooses academic practice vs private practice, one may end up earning less than a private pediatrician and working more hours, and certainly earning less than almost any other type of physician except for family practice. This, after four years of college, four years of medical school, and six years of training. If one were to think of this as an investment, it is not a very high-yielding investment (then again, what is these days?). I know that it's "not all about money," but I feel strongly that time and money are realistic factors that medical students and residents take into consideration. I know this is going to sound cynical, but although passion is wonderful, it doesn't put food on the table.

I guess what I'm arguing for is that the ABP reconsider it's decision to standardize all fellowships to three years; what fits one specialty may not necessarily fit all. I would love to see a dialogue on this topic with specialists and generalists alike weighing in. Sadly, I don't know that this is going to happen, as there is so much else going on during these tumultuous times, and hopefully all of us will be focusing on helping President Obama revamp our health care system.

Monday, February 23, 2009

1961 electronic medical records

nearly 50 years later, and where are we?!

Feeling a little old

This past weekend, I started working as a hospitalist, with the goal of working about one weekend per month. I chose to do this to maintain this unique set of skills which I worked very hard in residency to obtain, to see different problems from the ones I see in my outpatient clinic, and to spend some time with other pediatricians. As I was hoping, it was a lot of fun, and it was interesting to see the variety of patients on the pediatric floor. Of course the majority of patients had respiratory problems, it being winter, but even among them, there was some variety. I found my sea legs fairly quickly, to my great relief.

I did feel a bit out of touch, however, like I had been passed by father time. When I did my residency, which was not very long ago, we had some parts of the medical record computerized; we were able to look up lab and radiology results online. Every morning, all of us had to walk around the wards, finding nursing notes with vitals, finding charts to write in, and signing verbal orders. This was a great time to check in with patients, parents, and most importantly, nursing, but it was certainly tedious and inefficient! At the hospital where I worked this weekend, most of the medical record has been computerized, and they are in the process of making the ordering process electronic. Needless to say, I was very excited and intrigued to try this new system! It was wonderful to have access to labs, radiology, dictations, and nursing notes on the computer, and actually, on any computer with internet access! What a change! I was pretty slow at using the system since it was brand new to me, but I'm sure that I'll get used to it. But, what was shocking to me was that I missed walking around looking at paper vital signs flow sheets... I was able to talk to the nurses and patients, but it was just different, a little less social. Some aspects were much better, like the graphs with the fever curve and computer-calculated ins/outs which eliminate relying on my math skills (a positive), and the previously hand-written narratives which were now legible! Yet, it made me feel a little old that I missed the old paper system. I can't imagine what it would be like for someone to learn this system without any experience with electronic records! Obviously, electronic health records are the future (in some places, the present!), and this change will likely change the medical culture, just as mp3s have changed the music culture. And, I suspect, just like LPs have a strong following even now in 2009, I suspect paper charts will have a strong following in 2020, but I, for one, will be relieved when I get EMRs in my office and the hospital EMR continues to progress.

I found an amazing video on YouTube from 1966 that I posted on my next blog. Please check it out!

Wednesday, February 4, 2009

You want passion? Let's talk food!!!

I can't stand it anymore. I read my own blog, and I fall asleep... Health care, costs, access, blah blah blah. I like to write about things I'm passionate about. And I generally am passionate about my job, except for this time of year, when I feel like I'm drowning in boogers. Although some of my patients happily eat their little green boogers, I'd rather dine on other snacks!

I was raised in a family where we ate dinner together every night, we had a salad every night, and we had dessert usually when we had company. Dinner was a fun, chatty event, and we kids helped cook and clean up afterward. Our father cut the bread, and, I believe, that was it for him! But my mother was an excellent cook. I learned to taste unusual foods that my parents enjoyed, including pig brains, mountain oysters, and tripe. I didn't necessarily like them all, but I did acquire a taste for at least trying anything once. Some things, like avocados, I hated as a kid and learned to love as an adult; others, like tripe, I still don't like. Yet, my parents' love of food and dining with family and friends was definitely passed on to all of us kids.

These days, I travel to eat. I exercise to eat. I dream of food. When I go somewhere, I try to research where I can eat interesting food. Sometimes, the best restaurants are ones we find by accident. Ethnic food is my preference, although this past Sunday, I had one of the best hamburgers I've ever eaten in my life in Coronado, just across the water from San Diego, at The Burger Lounge, I didn't think I was hungry when I entered the restaurant, but I didn't have any difficulty eating my burger and some outstanding fries. When it comes to eating ethnic food, Ethiopian is probably my favorite. I still remember the first time I ate at an Ethiopian restaurant - it was called The Blue Nile, as many are, and it was in Durham, NC. We ate at a traditional table with the woven basket, drank some delicious tej, and ate a wonderful variety of vegetarian dishes on the traditional bread, injera. From then on, I started to seek out such restaurants on my travels. One of my all time favorites is in Berkeley, called FinFine, The kitfo, an Ethiopian-style steak tartare, is outstanding, if you enjoy raw meat.

However, if we're talking passion, I need to talk about barbecue in North Carolina. Now, when my family moved there from New Jersey, I thought that the word barbecue was a verb or an adjective, but definitely not a noun. So, needless to say, when I was offered barbecue at our school cafeteria, I asked, in all innocence, "barbecued what?" The lunch lady looked at me strangely and answered, "barbecue." I politely repeated my question, and she politely repeated her answer. Just as an aside, there weren't many northerners in Winston-Salem at that time, and I think she thought I was as strange as I thought she was. Eventually, when I asked what kind of meat it was (remember, it was a school cafeteria, so color is meaningless, it's all the same shade of brown, even the chicken), she said pork, so I happily ate it. Not long after, our next door neighbor invited me to go with her to Lexington, NC, home of "western" barbecue and the famous Lexington Barbecue festival, This type of barbecue uses a ketchup-based sauce and only the pork shoulder; eastern barbecue uses the whole hog and a vinegar-based sauce. Both kinds are cooked over an open pit, traditionally with wood fires. Anyway, we ate at one of the famous old restaurants, and I liked the hush puppies, but I wasn't crazy about the barbecue. So, at this point in my young, naive life, I simply thought I didn't like barbecue much because I didn't like the tomatoey, sweetish sauce. Then, about four long years later, I saw the light, and it was in Goldsboro, North Carolina, home of Wilber's, The pulled pork was out of this world juicy, tasty, smokey, and had a wonderful zing from the vinegar-based sauce. That was it! I done been converted that very day, as some people around there might say. The restaurants along US 70, starting with Ken's in La Grange, going all the way to the coast, are all pretty safe bets, with some, like Ken's, being better than others. If you get a chance to go, remember to ask for "outside brown," which means the pieces of meat that are closest to the fire and have a crispy side. Better yet, try to get in on a real pig pickin' at someone's house. And ask if you can get there at 4am when they start the hog cooking. It is a slow, careful process, with lots of basting and stoking of the fire, and, as often happens when men stand around a fire for many hours, a fair bit of beer gets consumed! If I've managed to pique your interest in this delicacy and in the debate between the east and the west, check out this website: And please, as bumper stickers in eastern NC say, keep your maters off my pig!! I now have to wipe the drool off my keyboard and go and plan my next culinary adventure. Bon appetit!!!

Thursday, January 29, 2009

Economics, job losses

Last week, I had the pleasure of watching the inauguration of our 44th president. I felt optimistic about our future, even though President Obama's speech was not full of the optimism he expressed during the campaign, rather full of realism. I know the economic disaster we have on our hands, as well as the diplomatic one, the wars we are fighting and some might say losing. Yet, I am basically a glass half-full kind of a person!

However, I am really starting to see the effects our economy. On the news this morning, there was more disturbing news about record job losses, record company closures, etc. In my community, there always seems to be a recession with few good-paying jobs, expensive gas and groceries, and a lot of elderly people with limited incomes. But now, we are seeing an influx of people from elsewhere in the country who have lost their jobs. They move here because housing is still inexpensive, and the weather is nice. I guess if you're going to be unemployed, at least it's nice to sit in the sunshine. But really, it's shocking to realize the numbers of people moving from industrial cities like Detroit, Minneapolis, Pittsburgh. The problem is that there are, like I said before, few good jobs.

I was speaking with a drug rep who survived large cuts at his company, only to be given a larger area of NM to cover. He is very grateful that he has a job, even if it means he doesn't see his family. I also now see several fathers in my clinic who are back home, having lost their jobs in the oil fields, suddenly becoming reacquainted with their wives and children, but jobless. I'm also seeing a rise in kids entering the military after high school because college is unaffordable.

It's just very different when you know people directly who are suffering from our economy, rather than only hearing about it on the news. I hope that our new president and congress can come together to create jobs, to improve education, and to improve our health care system. Sadly, I don't think there is a quick fix, even a great big economic stimulus package. I know that I'll just continue to take care of the families in the community; at least I can do that to a degree, whether they have health insurance or not!

Friday, January 16, 2009

Lab fees

As winter is progressing, I am getting busier, as are most pediatricians. It's amazing the difference between June and say, January or February, numbers. I appreciate my slower days in the summer, but I have to say that winter days in the office simply tend to fly by!

However, this winter is going to be a bit different. I've mentioned in a previous blog that our clinic now requires patients to pay for labs at the time they're done if they don't have any health insurance. This is awkward and annoying to me to have to explain that I want a particular test done, and, by the way, that will cost you ten bucks! I have the power to waive the fee if the family cannot pay, and I document exactly why the test is required. Yet, when I do this, there are many phone calls back and forth between our main office and my office to find out exactly why the fee was not paid. I could go on about this, but I've already complained about it in a previous blog.

Today, what brought this back to the forefront of my thoughts was that I had to ask a family to pay for a test, and I also happened to read another blog about lab fees:
I was shocked to see the prices he posted for labs. I had been told by the powers that be that we got a special rate for our labs and that we did not have to charge the administrative fees. So, just to show the stark differences, here is a list of some our fees, without the additional administrative fees: (admin charge is approx $10.)
  1. CBC (complete blood count with differential): $2.70
  2. BMP (basic metabolic panel): $2.70
  3. CMP (comprehensive metabolic panel with BMP): $2.76
  4. PSA (prostate specific antigen, a test for prostate cancer): $7.20
  5. TSH (thyroid stimulating hormone, a test for monitoring thyroid disease): $ 3.60
  6. Lipid panel: $2.58
  7. Urine culture: $6.00
The most expensive test on our basic listing is a hepatitis C RNA PCR for $181.20. Now, you can see an enormous difference in the costs I've listed versus those listed by the Country Doc. Why is there this difference? Admittedly, one needs to add $10 to the fees I've listed, and the rates I've listed have been negotiated for a large group of 8 health centers. In addition, the lab company is willing to accept some loss with uninsured patients, but this cost gets passed on to those with insurance. On a side note, it would be interesting to see what that particular lab charges insured patients for the same labs. But why is there so much difference between the two labs? Again, it brings to mind the problems we have with our health care system. Imagine saving $12 on each CBC that is drawn throughout the US - if 1/3 of the US population of ~305 million received one CBC per year, that would add up to 1.2 billion! I'm sure it's the same with the pharmaceutical companies and saving $12 per script written in the US would also add up.

I'm just hoping, come January 20, that the debate on healthcare will start up with actual results this time. I do know that SCHIP is already being re-addressed and will not be vetoed by the new president, so I have hope.

Monday, January 5, 2009

New Year's Resolutions/Wishes

Happy New Year to everyone!! Now that the holidays are over and school is back in session, my life is returning to it's usual busy wintertime schedule. It's also the time of year when people discuss their resolutions for the new year, and I see a lot more people walking on the track after work! I've often been tempted to ask if they are there to lose weight in the new year, but instead I just see how many days they seems that two weeks is about the maximum. All this aside, it's also a special January this year, as we will be inaugurating a new president in a few short weeks. I hope things will start to change quickly.

In light of the potential for change, I have come up with a list of my top 10 wishes for our health care system which I am hoping will be targeted for change early in this new administration. I know that some of these wishes are not free, and I don't know where the money will necessarily come from, but a wish is just that, a wish! I could also go on with many more wishes, but I think ten is a good start.

1. Renew and increase funding for SCHIP. Perhaps with more Democrats and more progressive Republicans in Congress, this will happen.

2. Increase reimbursement for pediatricians giving vaccines.

3. When considering universal health care, examine what other countries have done and perhaps create a system which combines the best from the different approaches being used world-wide. Having waited this long to do what most other first-world countries have already done, we might as well turn this to our advantage and learn from the mistakes of others.

4. We, as physicians, need to practice medicine responsibly. We need to accept that we are contributing to the skyrocketing costs of medical care in the US, and we need to do something about it.

5. Continue to encourage medical students to go into primary care with increased emphasis on programs that already exist, such as the National Health Service Corps. As costs for higher education continue to escalate and funding for student loans is cut, informing pre-med college students about the availability of scholarship programs may be more effective than in the past.

6. Continue to study pharmaceuticals specifically in the pediatric population.

7. Continue to promote the safety of vaccines. The American Academy of Pediatrics is working diligently on this effort.

8. Strive to continue research efforts with stem cells.

9. Provide adequate reimbursement for obesity counseling, nutrition education.

10. Let's get daily physical education back in schools!!