Catching Up

Sunday, a day of rest, a day to catch up.

I had 2 more patients on Friday, both kids. The first one I scheduled at 7:30 AM when his mother called. She probably thought she'd leave a message at the office, but instead I answered since I still had calls forwarded to my cellphone. Since I was giving a talk at the Senior Center at 10 AM, I thought it'd be better to schedule him a little later at 12 noon, just in case it ran long.

The second one was a walk-in. As I was driving back to my office at 11:30 AM, I got a call from the Ob-GYN doctor's office next door to mine, and they asked me if I was open today because a patient wanted to see me. I assumed they had referred one of their patients who walked next door, only to find nobody there. I told them that I would be there is 2 minutes, and to just ask the patient to wait. I only figured out later that they were not the Ob-Gyn doctor's patient. They had been referred by the "chemist" aka pharmacist up the street because they were looking for a doctor to check out the 4 year old's earache. (I must remember to thank Dr. Chan!) The mother and her 3 children were visiting for 7 months from England while her husband taught at a local college. I gave her the usual paperwork, which she found amusing/annoying since medical care is free in England through the National Health Service, which she loved. I quickly diagnosed a swimmer's ear and got them on their way, because my 12 o'clock patient had come early.

His mother had learned about me through my sister, who is a co-worker. He came with his father, who was worried that his son might have West Nile Virus, because he had spent time at his grandmother's who lives very close to where a lot of WNV cases were recently discovered. Fortunately, I had recently read about WNV though information provided on a CD-ROM provided by the CDC. (I don't know if every doctor is getting one, but I received two CD's in the mail. Anyone want an extra?) I reassured him that 80% of people infected with WNV are asymptomatic, that about 20% will get fever, headache, rash, and less than 1% actually needed hospitalization. Anyways, he had swollen tonsils with an exudate so I did a rapid strep test on him. Unfortunately (or maybe fortunately?) it came up negative, so I send off a throat culture and put him on Amox for 5 days pending the report.

As always with these new disease outbreaks, there is a lot of concern, but also some overconcern (hyperconcern?). About two weeks ago at Kaiser I saw a patient who works in the department of public health who developed fever and a rash. She told an epidemiologist there who told her to get tested for West Nile Virus. When I saw her she had a classic rash for shingles. But because an "expert" in WNV (who I suspect is not an M.D.) told her she should get tested for it, I could not reassure her that her symptoms were only due to shingles, and that testing for WNV would not change her management. I should try to find out what her WNV test showed.

Earlier last Friday morning I gave a talk at the Senior Center on Nutrition, Exercise and Supplements. And even earlier that morning/night, I was working on that talk. Being a chronic procrastinator, I always wait until the last minute to prepare these talks. It's hard for me to get motivated to write them any earlier. Anyways, I'm wondering if it's worth it for me to continue these talks. I've given 3 so far. This talk was attended by 9 people (but 2 left early). My last talk was attended by 4, so it's an improvement. I haven't gotten any patients from doing these so far, but one person said he is planning to see me sometime. I do enjoy giving them, plus I feel that I do learn a lot from researching the various topics. Because of the informality of the small group, there are frequent interruptions and questions, which always prolongs things. But some people ask very good questions.

I'm not signed up for any more talks so far, and I think I'll take a break for the summer. Besides my Board Recertification is coming up next month and I really should study. But, it's hard for me to get, you know – motivated.

My wife (hi honey!) and children are out of town this week visiting relatives back East. So I spent 2-3 hours yesterday scanning in papers from previous patients. For the longest time I couldn't get the scanning program to communicate with the scanner (an HP 6110 All-in-One), so I had to hold on to the papers. About a month ago, I figured out how to get it working but just didn't have time to scan papers in. Unfortunately, I had to manually scan each sheet by hand. Even though it has a automatic sheet feeder, it only works with faxing and copying, not scanning. Grrrrr! But it is satisfying to know that I can now shred all those papers (when I get around to it).

Doing the math, if I eventually see 12 patients a day, and each patient has 9 sheets of paper (2 registration, 1 financial responsibility, 1 email consent, 3 patient history, 1 insurance card, 1 statement of benefits) to scan, that works out to 108 papers to scan a day! Of course, that's the worst case scenario. Hopefully, I'll have some returning patients who won't need anything scanned. But I am beginning to see the benefits of a high-speed scanner (and high-speed shredder). At this point, I don't have the money or space so manual scanning it is for now.

After sending 5 claims through Medrium, I have gotten back 5 rejections. Hmmm. The reasons for rejection are all the same: "NETWORK ID:REQ: LCNSE # IN NETWK ID FOR PAYER". I think that means they are rejecting the claims because I did not give them a network ID#. That's because I don't have one. I clearly checked off that I was not a participating provider - yet. But I hope to be soon. I hope this doesn't mean that I have to wait until I'm approved as a participating provider before I can submit ANY claims. There has to be a way for non-participating providers to bill the insurance companies. I'll call Medrium on Monday to see if they can help me figure this one out. I knew it wouldn't necessarily be easy to get a claim paid, but why can't I ever be wrong about these things?

Finally, last week I received an email from Dr. Bob Nelson, a pediatrician stationed in Afghanistan, who is thinking of opening his own solo practice after he gets out of the army. I connected him with Gordon Moore's Practice Improvement Group, and told him about this blog, which he has found helpful. I hope he doesn't mind me posting his comments. He wrote: "On 14 FEB you wrote that if your blog helps one person start a solo practice, you'd be happy. You should be happy." Thanks, Bob. I hope we'll both be happy. Godspeed and good luck!

See One, Do One, Teach One

One patient so far this week, a young woman with anxiety disorder who wanted to be reassured that her shortness of breath wasn't a sign of impending asthma. And it wasn't. I was able to see her at 8PM after she initially called in the afternoon for an appointment, but changed her mind. Twice.

I spent some time discussing anxiety disorders with her, and encouraged her to consider trying anti-anxiety medications as her psychiatrist suggested. Hopefully, she'll get better. And even though she didn't have any insurance (because she is a graduate student), she told me she would come back and see me when she got insurance coverage.

I hope I get some patients in my practice in the next 3 weeks since I am precepting a 2nd year medical student as part of the California Academy of Family Physicians' Summer Preceptorship Program. It pairs an practicing family physician with a newly minted 2nd year medical student who is interested in family medicine as a possible career choice. They spend 4 weeks shadowing the physician, and at the end, get a $1000 stipend. Having done this many summers over the past several years, it is always fun for me and hopefully inspires a student to go on to FP. This year's student is from USC, and even though I am a UCLA alumni, I am treating him like any of my other past students. I'm just that kind of guy. (For those of you who have no idea what I'm talking about, read this.)

For those of you who have not tried teaching medical students or residents, I highly recommend it as the experience can be quite rewarding.

I started inputting data into Medrium yesterday and have submitted 5 claims so far for a net total of $780. Of course, I don't expect to get all of that, but even some of it would be helpful seeing as I'm down to about $2000 in my checking account. We'll see how long it takes to process these electronic claims, or whether any claims get kicked back to me. Even though entering the info is kind of tedious, I can see myself getting faster as I learn what needs to be entered. I was one of the faster coders in my medical billing class, after all. I even toyed with the idea of trying to get some work as a medical coder (incognito, of course) just to see if I could code as well as a "real" coder. But before I got the chance, the instructor found out I was a physician, so that blew my cover.

But I am a believer in learning new things and doing things myself. And after I learn them, then I can teach someone else. Knowledge is power. A medical records file clerk has power over me as long as I don't know how to find a chart. A medical assistant has power over me if I have to wait for her to get vitals on the patient before I can see him. A medical coder has power over me if he can take 8% of my charges in return for writing some numbers on a piece of paper. Now, I am getting some of that power back, as I learn my way around the business end of medical practice. It may not be a pretty end, but it's the end that makes this beast called Medicine go.

Moo.

Use a Pen, Go to Jail

Back to a slow week, just 2 patients. That's the way it's going to be: unpredictable. It's been 4 months since I opened my solo practice and I've seen 36 patients so far. I've got a long way to go...

I signed up for an online billing service today called Medrium. It's about time I got paid for seeing some of these patients. We'll see how easy (or difficult) it is to use.

Here's an article from today's WiredNews.com site on doctors and computerization, appropriately title: "Dragging Doctors to the Info Age" that suggests a topic for a rant:

Since 1999, then, hospitals have slowly brought in more computers, focusing largely on so-called Computerized Physician Order Entry systems that force doctors to type in prescriptions instead of writing them on paper. Not surprisingly, some deadly errors occur when pharmacists misinterpret physician handwriting. In one 1995 case, a Texas man died because a pharmacist thought his doctor had ordered the high-blood-pressure medication Plendil instead of another drug called Isordil. The patient got eight times the safe dose of Plendil. (Wachter showed the handwritten prescription to 158 doctors and only a third thought it was for Isordil.)

"Only" a third? That's not very reassuring. And this:

Computers, of course, have limits. Notwithstanding computerized physicians on Star Trek, technology won't turn an incompetent doctor into a competent one or provide the intuition that nurses rely upon when they treat patients.

The point, Wachter said, is to provide backup systems to warn hospital employees before they make mistakes. "We're not going to fix these sorts of screw-ups by advising people to be more careful. They'll just blow it again," he said.

Computerization may help, but typos happen to (sic).

You'd think that highly educated doctors could learn to be more careful. But I agree that that is not likely to be the answer.

As studies (here, here and here) have shown, doctors as a group do have bad handwriting. I have personally known a select few whose penmanship was so illegible that even they have trouble re-reading what they wrote. So, as a profession, it's our own fault.

While some think the solution is forced computer entry, preprinted prescription pads or "aggressively educating" patients what medications they take and why, I think a simpler solution is at hand, yet one that will rarely be followed: handwriting classes. It is such a simple and low tech idea and addresses the root of the problem. As an English major, I have always prided myself in my handwriting, or rather my printing (I haven't used cursive writing since high school). One of the nicest compliments I get is from patients who look at their prescription and say, "Gee, you sure don't write like a doctor. I can read what you wrote."

Admittedly, my handwriting has gotten worse through the years. Plus I realize that lack of time plays a role in how quickly doctors scribble their notes and prescriptions. But are careful doctors also more careful about their handwriting? Or vice versa, are doctors who are careful about their handwriting also more careful in their medical practice?

I confess that I have a prejudice against bad handwriting. I sometimes feel that, rightly or wrongly, a doctor's handwriting correlates with his or her competency, or more specifically, their attention to detail. Whenever I read a consultant's report or progress note that is illegible, I think, "This doctor didn't take the time to give me a comprehensible note, so he probably didn't take the time to do a good job evaluating the patient either." I realize that this is probably not true, that there may be excellent doctors with chicken scratch handwriting. But it is certainly not something that bolsters a lot of confidence for me.

So write neater or the alternative is this.

A Good Week

This has been an unusually good week so far. So good, I'm finding it hard to post an entry. A quick summary:

Last week: 0 patients
This week: 9 patients (so far)

My ad appeared in The Quarterly, a locally distributed magazine that is mailed free to all residences in the area. I believe it goes out to about 30,000 households. But none of the 9 patients called because of the ad.

I met with the local Kiwanis group, and there are a lot of local business leaders. Seems like a good way to network.

I did 45 sports physicals on Tuesday at the local high school in 3 1/2 hours. It was the assembly line model, with me and a physical medicine doctor doing the doctorly duties. Quite exhausting! But I got paid $15 for each physical. With this week's income, I actually generated enough income to pay for my office rent this month. Whoopee!

Did my first pap smear today in my office. The patient did not want to bring along anyone she knew to chaperone, so I enlisted our children's nanny to step in for chaperoning duties, which she cheerfully performed. I also paid her $10 for 15 minutes of work, which is worth it to me.

I think I'm going to have to start sending out bills soon. Most patients I've been seeing lately have insurance, but I haven't gotten around to filling out those HCFA-1500 forms. Should I do it by hand, or sign up for Medrium at $25 a month? Hmmm...

I have to finish my talk on Anti-Aging for tomorrow's Senior Center lecture. Plus I have been continuing to work half-day shifts at Kaiser (12 patients in 3 1/2 hours). Busy, busy, busy. I hope it stays this way.

A change in plans

Last Thursday night I was all set to stay up late working on my talks ("Anti-Aging and Longevity" for the local senior center and "The Musculeskeletal System" for my daughter's 5th grade class) for the next day, when I got a call from my dad. From the emergency room. It turns out he'd been having melena for the past 3 days, and the doctor thought he should stay overnight and get scoped in the morning. He was feeling fine and was more worried about getting a hold of my mom so she could pick up his wallet and car keys.

To say the least, I was surprised, as my dad has been the epitome of good health even at age 75. He liked to brag about how he continues to play basketball 3 times a week with men who are 1/3 of his age. I spoke briefly to the admitting doctor and learned that my dad had only a mildly decreased hemoglobin count. I told my dad what to expect and apologized for not being able to be there with him tomorrow because I had to give these talks.

After I hung up, I thought about it. Even though I knew that the odds were more likely for a stomach ulcer, this could be really serious if it turns out he has an esophageal or gastric cancer. I decided that I really didn't need to give those talks tomorrow, and I would request that my afternoon shift at Kaiser be cancelled the next day. I decided it was more important for me to be there with my father when he got endoscoped, and when the doctor explained what he saw. This was about realizing where my priorities should be, similar to what led me to go solo in the first place. I was disturbed that I didn't see this immediately.

Fortunately things turned out as well as could be expected. My dad was diagnosed with a gastric ulcer, probably brought on by daily aspirin which he had been taking for the past few months. The senior center rescheduled my talk for next Friday. The 5th grade teacher said I could give my presentation on the musculoskeletal system next week. I assumed Kaiser managed to find someone to take my place for the afternoon shift.

It's funny how life works. I hadn't had any appointments all this week. But while I was sitting with my dad in the recovery room, I got two calls for appointments. I had to quickly step out of view of the nurses because the first time I used my cellphone, one of the nurses yelled at me to turn it off because of hospital rules. I ended up calling patients back using the phone at the desk. I got a call to schedule physicals for a family of three while I was sitting by my dad's bed back in his hospital room. I kept hoping that the patient wouldn't ask me about that loud snoring sound in the background and luckily she didn't.

I'll end with my opinion that the wholesale ban of mobile phones in hospitals is ludicrous. This article calls for a loosening of mobile phone restrictions in hospitals.

Mobile phones (cell phones) are a source of irritation for some but undeniably useful for many, and over 50% of the population of the United Kingdom possess one. Their use in hospitals, however, is mostly banned as they are considered potentially hazardous in medical environments. But the evidence for serious harm is flimsy, and the hysteria that surrounds the use of mobile phones in hospitals is unjustified.

So how dangerous are they? The evidence for harm is limited. Anecdotal reports exist of interference with medical electrical equipment, which led to a study by the Medical Devices Agency in the United Kingdom. In this study, 4% of medical devices suffered from electromagnetic interference from digital mobile phones at a distance of 1 metre. This compared with 41% from emergency services' handsets and 35% from porters' handsets. Most of the interference related to disturbance of the signal on monitors, such as electrocardiographs, confirmed by data from the United States.

It does seem hypocritical for hospitals to tell patients and visitors not to use their mobile phones, while the nurses and transporters are free to use theirs. It seems to be one of those rules that nobody follows anyways, like how the speed limit is 65 mph while everyone on the freeway is going at least 75 mph (in Southern California, that is).

The one situation with cellphones that drives me nuts is when I walk into an exam room and the patient is talking on their cellphone. And they keep talking. And keep talking. I use to wait until they were done. Now I just say, "I'll be back." and see the next patient in the other exam room. Of course, this only happens now when I'm working a shift at Kaiser. Because in my solo practice, nobody waits. Nobody but me, and that's only because these registration forms take at least 15 minutes to fill out.

A Shot in the Arm

Today I gave the 2nd shot of my new practice to a 14 year old boy whom I saw for a check-up last week. I saw from his shot records that he had only had one MMR and advised his mother that he needed a 2nd one. I have not been stocking vaccines until I have a need for them, mainly because . . . have you seen how much vaccines cost???

A 10 dose order of MMR vaccine from Besse Medical costs $416.63. I figured I could use up 10 doses before they expire next summer. If not, I'll be wasting a lot of money. My other choice would have been to order a single dose vial of MMR for $51.49, but that's $10 more per dose. Anyways, I ordered it the same day I saw the boy, and it arrived on ice 2 days later.

Never having needed to give MMR shots before, I learned that the MMR vaccine comes in a powder inside the vial, and needs to be reconstituted with diluent (sterile water) before giving the vaccine. Fortunately, the order came with 10 bottles of diluent, too, so all I had to do was draw it out with a 25 gauge 5/8 inch needle and syringe and squirt it into the vial of MMR vaccine. The MMR vaccine has to be refrigerated between 36-46 degrees Fahrenheit, which is not a problem –– for now.

I got a mini-refrigerator with a separate freezer (even has a door lock!), just so I could keep vaccines. I got min-max thermometers for the separate refrigerator and freezer compartments and have been keeping a log recording the temperatures. That's kind of a pain to keep track of, since I have to make a special trip to the office to record the temperature even when I don't have any patient visits. I've read about low-tech ways to monitor the freezer, put a cup of ice with a penny on top in the freezer and check it daily. If the penny starts to sink down, you may have a problem. But I decided to go high-tech.

My problem is, when the refrigerator is just right, the freezer is too warm (meaning goes above 5 degrees, the maximum temperature for Varivax, the only vaccine that needs to be frozen). And when I turn it down so that the freezer is just right, then the main refrigerator gets too cold for the other vaccines.

I think my solution will be to do "just-in-time" ordering of Varivax, in case I ever need it. One dose costs $71.21, and I'm sure I can convince a parent to come back in 2-3 days for their child's shots. This way, I won't have to worry about a bunch of Varivax going bad. $71 dollars a shot! Still, that's not as expensive as the meningococcal vaccine ($84.77 per dose). Yet another reason college is so expensive.

Then there's the Vaccine Information Sheets (VIS) that you're required by Federal Law to hand out to parents/patients before they get the shot. I did remember to give the mother that. Plus you have to record the lot number and expiration date of the vaccine you gave, just in case it turns out later to be recalled, for some reason, like the Hep A vaccine was a few years ago.

This site has other helpful info on good immunization practices.

As for the actual administration, he was cooperative and didn't flinch when I poked his left deltoid. I'm sure they won't always be this easy and I'm anticipating with dread my first toddler shots. I plan to try using the Shot Blocker or maybe just using topical EMLA cream.

That reminds me. I should eventually get some lollipops and stickers, too! Adults get stickers like this and this. Then again, maybe not.

I've been busy (and sick)

Haven't posted in a while because:
1) I got sick with a virus (cough, cough)
2) Got busy with a PowerPoint presentation to my daugher's 5th grade class on the respiratory system (hooray for snot!)
3) Was busy writing an article for California Family Physician magazine about practice transformation

I'm up to 26 patients seen so far, saw 3 last week. My last 5-6 patients have all had insurance (Blue Cross) for which I can bill later on, hopefully as an in-network provider. Business seems to be picking up a little.

I met with a marketing/PR guy for the 2nd time today, and he gave me a bunch of ideas on how to grow the practice. He thought the solo practice idea was unique and would be attractive to a lot of people. When I told him that I expected to get to a point in my practice where I would be busy enough to not have to do any more marketing, he laughed and said that I was dreaming. In his experience, you have to keep marketing to maintain business. He likened it to a patient saying "I'm done seeing doctors." after getting a one time check-up.

But he did have some interesting ideas on how to get more people to know about me, such as contacting the local PTAs and offering to give talks to them, or getting to know local real estate agents since they would be the ones to know about any new residents in the area. He also suggested direct mail, which I had considered before, and that I could offer to take local doctors out to lunch as a way of generating referrals. While probably true, it seems a little heavy-handed to me. But maybe that's what doctors do when they're trying to build up a practice.

Recently on the Practice Improvement listserv, there have been worries about the viability of Alteer, an EMR company that many of the doctors on the listserv have purchased. It is an impressive system and I considered getting it, too, but quickly decided that it's $25000 price tag was too rich for my blood. Given how unstable the market is for EMR systems, I was worried that I might still be paying off the loan to buy it after the company went out of business. Instead, I went with SpringCharts, not so well known, but much more affordable at $500 plus another $500 for annual support. One of these days, I'll write a little review on it. It's not a perfect EMR, but for me it gets the job done.

I also bought a domain name to make it easier for patients to find my website. $18 for 2 years is a pretty cheap deal.