Monthly Archives: April 2012

A Modern Country Doc–The EMTALA end run and more

 –Tom Bibey

Over the ensuing decade, I did learn how to circumvent EMTALA (Emergency Medical Treatment and Active Labor Act). I call it “the EMTALA end run.” If by chance a doc has a patient who wound up in the wrong facility and can’t find anyone to accept a transfer, you do “the EMTALA end run”: tell the family to check the patient out AMA (Against Medical Advice—I try not to use abbreviations). Arrange for an ambulance to take the patient to a facility that has the specialist they need, such as neurology or cardiac surgery. Once there, the family can demand their loved one receive the specialized care not available at the first institution. This is an insider country doc trick, and it works every time. Oversight of medicines would be even more humorous, if not so sad.

One elderly patient came to see me and complained of being weak, nervous, and dizzy. Being the smart doc I was, I figured the three diuretics she was taking had something to do with it, so I changed her regimen to one that reflected current clinical rationale. In short order, she spun out of control, and became incoherent and combative. She was hospitalized for an intensive evaluation, only to find the resolution to the problem to be the urgent reinstitution of her old regimen. She returned to normal in a few days and again was weak, nervous, and dizzy. I knew the chart jockeys would come around in six weeks, and no one would understand, so I arranged a nephrology consult. (This guy was one of the smartest docs on our staff—the cats that get acid/base are always quick.) I’ll never forget the nephrologist’s thorough review of the entire medical record, and that poor woman doing her best to answer all those questions again. In the end, he told me it made no scientific sense, but he would continue her antiquated regimen. We all do our duty, I guess. I am still the patient’s doc; the patient is still weak, nervous, and dizzy; the nephrologist left town for a big-city practice where he can make some real money; and the chart jockeys still send letters. Some things never change, and all these government folks who believe they can morph these country people via legislation are naive as to medicine and human behavior.

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

I love Dr. B’s cynicism and humor. What he says is often quite true. #1 Despite the high technology and money we spend on health care in the US, the system is broken. This is evidenced by the need for Dr. B’s EMTALA end run. It won’t take you much time on the wards or in the clinic to see what does not work about our health care system. This is one of the reasons we need energetic, young students interested in advocating for their patients and working for change.

#2 All the science doesn’t explain why some things work for certain patients and not for others. Sometimes they just do. Our scientific studies look for the average, but some patients are beyond the standard deviations of the norm. I don’t want to diss science, it helps me take better care of patients, but at times there is no rational explanation. This reality keeps one humble and also reminds me to see each patient as an individual.

A Modern Country Doc–alphabet soup

Inside the Mind of –Tom Bibey

COLA, CLIA,OSHA, HIPAA, EMTALA. I’ve heard the powers that be are going to start up the NBEMAA (National Bureau for the Elimination of Medical Abbreviations Agency) to question everyone’s integrity for use of nongovernment approved abbreviations. Now if they do, I guess I’m gonna call it a day. The hypocrisy would just be too much.

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

 Modern medicine is an alphabet soup of acronyms. It can be quite overwhelming to the student. With the turn of the 21st century we’ve added EMR or EHR –electronic health or medical records, HCH or MH—health care home or medical home, but MH can also mean mental health. You may encounter NCQA and JCAHO, both efforts to improve and monitor the quality of care in the US. The ACA, Affordable Care Act, which some folks call Obama care, the national health reform passed during President Obama’s first term and now under attack, also brought us ACOs—accountable care organizations, which are supposed to be different from the HMOs-health management organizations of the 1970s and 1980s. I know that was a run on sentence, but one acronym seems to give birth to others. You can probably add some others to this list. The bottom line is that medical care in the US is complex. All the efforts try to guarantee quality, affordable health care for the patient, but often seem like barriers between the doctor-patient relationship.

A Modern Country Doc–chart jockeys

–Tom Bibey

In the early 1980s, I made almost all my decisions in conjunction with my patient, together with the specialists we deemed appropriate in a given case. It wasn’t but a few years before modern medical “oversight” or “management” began to assert itself. This started first with government programs, soon followed by big business. Docs were forced to learn a new set of skills to overcome these obstacles to the delivery of care.

Early on, it was a benign process. Every once in a while I’d get a call from old Doc Smith who’d ask about a case. I knew him from State Medical Society meetings. Retired, he’d never made all that much when he was in practice, so I understood his need to supplement his income. I’d even taken over some of his patients, so Doc Smith knew me well. He wasn’t going to scoop me on much over the phone. I had the advantage of being the doc who saw the patient, and we both knew he wasn’t in a position to compete with that. Doc had to call every so often. I understood. He’d call and ask a few questions, and I’d tell him in doctor terms about where to go, and we’d laugh.

By the mideighties the minor nuisance grew to a downright disruption of patient care. I remember a fellow I had followed since I started my practice. I inherited him when a local doc retired. The patient was elderly and had multiple medical problems: several heart attacks, a pacemaker revised several times, bad kidneys, bad lungs, but he was a heck of a nice guy.

My first hospital admission for the patient was for an episode of syncope (they call it “falling out” around here) and the situation was complex, so an extensive workup was undertaken. Both carotid arteries had partial blockage, but the surgeon said that the literature showed that only the worst side of a 70 percent blockage warranted intervention. (Here is a country doc tip for you: if a surgeon doesn’t want to operate, I would take that advice very seriously.) I talked it over with the local cardiologist, we ran everything by the big boys at the Medical Center, and everyone agreed to a treatment plan. With some adjustments in medication, we sent the patient home. Surgery, at least at that time, was not indicated. A week later, he had an unanticipated TIA (near ministroke), which thankfully resolved. Due to the change in circumstances, the surgeons changed their minds and proceeded with surgery to correct his right carotid artery blockage.

The patient did well, and he went home satisfied with the outcome. For him, it was the end of that chapter of his story. For me it was the beginning. Six weeks later, I got a letter from one of the Medicare review boys, who determined the first admission to be unnecessary. I knew my patient could get stuck with the tab, so I began to compose a letter of explanation. Before I could complete it, I had a second letter on my desk from a different review bureaucrat (I call them chart jockeys). This jockey determined the second hospital stay was due to a premature discharge from the first admission. I have a fair amount of education, but I was confused. How can one be discharged too early from an unnecessary admission?

I found it a silly demonstration of the lack of medical sophistication on the part of the reviewers, but I did not anticipate the intense effort required to win this battle. However, I lost the war. Years later I noticed reviewer number one had his name on a government medical complex, and I assure you I will labor in obscurity until the end. I’ll consider myself lucky if I just stay out of trouble. I was the doc for my patient until the end, when he died of plain old, very old, age. Every so often we delighted in laughing at the incompetence of those chart jockeys.

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Dr. B talks about the chart jockeys. Today they come in many forms. If the clinic is part of a health system, the chart jockey may be the quality review folks who review patient charts for each clinician looking for patients who are lost to follow up or are out of compliance with recommended treatment. They can be helpful. Thanks to electronic health records (EMR or EHR), we can pull up lists of patients based on diagnosis codes (ICD-9, soon to be ICD-10). As a result, I can look at all of my diabetics and know who has been in the clinic in the last 6 months and what their lab values are.  With diabetics we aim to keep their HGBA1C under 8. (Glycosolated hemoglobin-the measure of sugar molecules on a red blood cell gives us an idea of how well a patient’s diabetes is under control over three months, the life of a red blood cell.) Then the nurse and I can figure out which patients we need to contact and ask them to come into the clinic. In the old days, we waited for patients to come to us. Today we make more efforts to reach out to patients, especially patients with chronic health problems. With diabetes we know that certain medications and checks actually keep patients healthier and prevent or delay kidney failure, loss of vision and amputations.

The chart jockeys can be a nuisance when I have to jump through hoops before I can order a treatment or medication–often call a prior authroization, especially if it is what I know I need to do for my patient. On your rotations you will hear lots of clinicians complain about the paperwork or phone calls that accompany this. It is all an effort to avoid unnecessary treatments, identify fraud and to manage cost. Often it consumes time and energy for staff that interferes with caring for patients.

Inside the Mind of a Modern Country Doc

–Tom Bibey

I have seen a lot of changes in my three decades of practice. Technological advancement offers new treatments, and I am grateful for them. Heck, I have partaken of this myself. Last fall I had a retinal detachment, and with modern ophthalmology I was back to 20/20 in no time. Don’t get me wrong, I’ve nothing against being modern.

Computers have improved our ability to compile data, but also have rendered privacy obsolete. Sure, I know the Government enacted the HIPAA privacy rules, but that was only to keep everyone else from cutting in on their business.

Look at it this way: HIPAA was enacted by the same crowd who invented the Social Security number. I don’t know about you, but that scares me a bit. As a small businessman for years, I know the importance of the bottom line. Years ago, the staff and I agonized about increasing office visits from fifteen to eventeen dollars. We were very concerned as to how a two-dollar increase might play in the local circles. My aunt would hear about it and talk bad about me in Sunday school. In small towns, you have to be careful about a bad PR rep at church or in the beauty shops. A local restaurant owner who got greedy and went up a full dollar on a perch plate was out of business in a month. When you live with people, your decisions tend to be conservative, and we were sensitive to local economic issues.

Our bottom line was how our patients fared. If they were happy, and we cleared enough to go another year, we counted it a success. It was like one of my patients said, “I want you to make enough to retire, Doc, just not in a few years.” I agreed and found it good counsel.

Somewhere along the way, medicine evolved into big business. Once the bottom line became a stockholder report, the rules began to change. An old doc, Dr. William Gray, had the same answer for every problem. “I don’t know what’s wrong here, but it’s got something to do with money.” Well, old Doc is long gone, but I think he’s still right.

(Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

You may encounter gray-haired physicians like Dr. B on your rural rotations. They are often nostalgic about the “good old days of medicine” as portrayed by Barnard Hughes in Doc Hollywood (1991), a movie that starred Michael J Fox as a hip plastic surgeon headed to LA, long before his Parkinsons manifested. You catch the same flavor in the TV sitcom Marcus Welby MD.  In the good old days, little came between the physician and the care of the patient. Most physicians were in solo practice or in small groups and ran their own businesses. They had a lot more autonomy. As with everything, there are pros and cons. In the next blog posts we will explore Dr. B’s take on the good old days meeting modern high tech medicine where lots of “Chart Jockeys” monitor the care that is provided to patients. Dr. B also blogs about blue grass, has written a novel and has another in the works. 

As you shadow and talk with these practitioners who have seen the changes in medicine over the past three decades what do they see as the losses and gains? What changes do they imagine that you will witness over the span of you own career?

Asking the Right Question

–Therese Zink

“Two blocks into my paper route and I can’t peddle my bike,” Joe complains. He tells us the pain started when he was playing Hacky Sack. He rotates his hip out and balances on his left foot, his right knee protrudes from his denim shorts like a doorknob. Ankle-high red tennis shoes squeak on the linoleum floor. I marvel at his flexibility considering all the pain he describes.

“Sometimes my knee locks up and I have to massage it to release it,” Joe says and demonstrates. “Twenty Ibuprofen in two hours doesn’t touch it!” His blonde ponytail flips from one shoulder to the other.

Joe and Doug, the patient and the medical student, are in their early twenties. Both are tall; their clothes hang on them like a dress shirt drapes a hanger. Doug listens intently, making notes on his clipboard from his post on the exam room stool. Near the end of a nine-month rural rotation during his third year of medical school, he has seen patients at the local hospital, clinic, and nursing home and learned about the community’s health issues. He’s rented a trailer home in the town’s trailer park. As faculty in the Rural Physician Associate Program at the medical school, I am here for one of six visits to assess his progress, observing his interactions with patients and doctors, the professor monitoring the student.

Doug methodically uncovers the how, when, why, where, and what about Joe’s pain, what makes it better and what makes it worse. Shifting his focus between his notes and Joe, he pauses and runs his long fingers through his short brown hair. I hold my tongue during the pregnant silences and Doug always comes through with the appropriate next question. I quietly applaud him. So far, Doug has documented Joe’s history of present illness, past medical history, and family history and is working through social history. As Doug concludes the interview and prepares to conduct the physical exam, I decide to interrupt and ask Joe where he lives.

“In my van,” he responds.

At this, Doug’s gaze locks with mine and he settles back on his stool, crosses his legs and begins a new line of questioning, probing where Joe gets money for food and cigarettes.

Reprinted from The Country Doctor Revistied (KSU, 2010) with permission.

Doug had done a good job of understanding Joe’s problem–the PQRST of pain, but he and I broadened our understanding of Joe’s situation when we asked about where he lived. Homelessness is an issue in rural areas. Because it is often more hidden than in urban areas, we forget that it is a problem. Rural homelessness, like urban homelessness, is the result of poverty and a lack of affordable housing. In 2005, research shows that the odds of being poor are between 1.2 to 2.3 times higher for people in nonmetropolitan areas, than in metropolitan areas. (National Coalition on Homelessness) The current mortgage crisis hit rural areas across the US. The challenges in rural areas are magnified because resources are more limited.

As you spend time on rural rotations, think about poverty and ask who and what organizations create the safety net in the community.