The so called Edwin Smith Papyrus, a 16th century B.C. manuscript, written in ancient Egypt script,  describes the treatment of 48 traumatic injuries, like those suffered in battle and pyramid building.  Edwin Smith, an American living in Egypt, bought the manuscript in 1862, and it eventually made its way to the New York Academy of Medicine.  It details the physical exam, treatment and prognosis of various traumatic injuries.  It is logically organized, working from the head down.  (We can’t read past the torso, as the papyrus breaks off.)

Among the recommendations:

• honey and moldy bread to cure infection (?early penicillin?)
• raw meat to stop bleeding
• immobilization of head and neck injuries
• use of sutures to close wounds
• use of papyrus to document illnesses (early charting system!)
• how to set a broken jaw.

As to prognosis, the author of the papyrus categorizes  ailments into one of three  prognosis: “An ailment I will handle,”  “An ailment I will fight with” and “An ailment for which nothing can be done.”  The latter must have applied to case 31–a description of paraplegia, in which a patient is “unaware of his arms and legs” and a loss of bladder control is noted.  The papyrus notes that this is secondary to a spinal cord injury.

The papyrus is logical and organized, but if all else fails, there is an magical incantation to be used, noted in case 9.  For a look at the papyrus, and it’s translation as well as explanations and more facts, visit the National Library of Medicine.  You can actually “unroll the scroll” from start to finish, and read along.  Have fun!

Because it really, really matters from multiple stand points if the patient has an identified primary care physician.  It matters because:

• Patients that have an identified primary care physician have a place to go after discharge to get on going care.
• As highlighted in JAMA May 5 edition, heart failure patients that get follow up with in 7 days of discharge have a 10-14% lower risk of readmission or mortality.  If you don’t have a primary care physician it’s hard to get early follow up!
• Hospitals will soon get “dinged” for readmission of Medicare patients with in 30 days.  If the hospital doesn’t find out who the primary care physician is, they just raised the risk that the patient may be readmitted.  It behoves the hospital (and hospitalists/hospital physicians!) to find out, identify and communicate with the outpatient physicians regarding follow up care.
• Physicians, both in and out of the hospital care because we want practice good medicine.

So, clearly, from a patient, physician and hospital perspective, having an identified primary care doctor who will manage care after discharge is paramount for the health of the patient, and the finances of the hospital.  (Let’s call it like it is!)

So what needs to go on at the discharge process?

• Communication between “sending and receiving” physicians (the discharge summary!)
• Medical reconciliation
• Follow up plan outstanding tests and ongoing problems
• Preparation of the patient as to what to expect next
• Signs and symptoms of worsening conditions.

How well do we do with this?  PCPs complain constantly that they don’t get discharge summaries in a timely fashion, or at all. This directly effects follow up of outstanding issues and problems.   Medical reconciliation is fraught with mistakes, especially with fragmented record keeping.  Lastly, the discharge instructions to the patient are frequently misunderstood or incomplete.

So here’s what needs to be done:

• Hospitals must start by ramping up efforts to identify and document who the PCP is.
• Hospitals must identify and implement easy ways to get discharge summaries and other reports to PCPs in a timely fashion.
• Hospitals and hospital physicians must find ways to reconcile medications through out the hospital stay, recognizing the most dangerous medication hand off is at discharge.  Avenues to be explored include fax, interconnectivity of systems/interoperability of systems, phone calls, emails etc.
• Hospitals and hospital physicians must establish processes to verify understanding of patients of discharge instructions of follow up plans.

Get out there and make it happen!

Physicians must become leaders and team players.  Sometimes, when I am wearing my EMR consultant hat, I have to remind myself that I am not the boss, I’m a team member, and not necessarily the most important team member!  (I think we physicians love to be the boss–after I told my daughter what I did at work, she commented, “so basically, you bossed people around all day.”  Ouch!) Being the boss is not the same as being a leader!

So what’s a physician leader? Here are things you don’t hear from a physician leader:

• “That’s not how we do things”
• “We’ve always done it this way.”
• “I don’t have time.”
• “You can’t teach an old dog new tricks.”
• “It will never work.”
• “That’s of no benefit.” (I think this was heard at the introduction of hand washing and sterilizing instruments!)

So what are what does a physician leader say?

• “Show me the data.” (We love data!)
• “How we will do this?”
• “Does it improve patient care?”
• “How much does it cost–in terms of time, money and will power, and what resources do we have for this?”
• “Who can I work with to get this done?”

So if you really want to stop being a factory worker physician, get out of your silo. Learn to lead, not to boss, open your mind to new ways of thinking and doing things, and learn to collaborate. And lastly, listen much, speak little!

The ED visit was a complete disaster.  We waited for an hour and a half in an empty ED  before being seen.  I looked at the Xrays with the ED doc, and we both noted the fracture.  The radiologist at the hospital called while we were there and confirmed the break.  The ED doc sent her home in a sling, with an instruction sheet on “sprains”!  No splint was applied, no pain medications given, no warmth to a young girl whose entire season concluded with a misplaced hand on a vault table.  The nicest person to us was the lady who took our registration information and handed us some warm blankets as we waited in the cold, empty lobby. 

The next day I came to my senses and called Tweenager Daughter’s pediatrician. By some miracle, he was in the office on the Saturday after Thanksgiving.  He told us to come right in.  The good doctor applied a splint, gave a prescription for pain medication, and applied a soothing balm to the soul. 

Tweenager Daughter is still horribly depressed about missing the state championships.  However, she is in less pain, and actually slept last night.  Thank you Dr. W. for that!

• Lay in a supply of alcohol based hand sanitizer and surgical masks.  Have signs on your office door along with a supply of both, advising patients with flu symptoms to use them.
• Remove non-essential items such as toys and magazines from the waiting areas and exam rooms.  These can serve as a mechanism to transmit the viruses.
• Have a place were symptomatic patients are separated from other patients.  Some practices triage over the phone and have symptomatic patients enter through a different door and go directly to an exam room.
• Encourage staff AND their families to get influenza vaccines.
• Have a plan so employees can work from home if possible.
• Cross train employees to cover for each other.
• Have a defined sick policy.  The federal government is recommending those with suspected or confirmed H1N1 stay at home for seven days or until they are well, whichever is longer.  (See flu.gov.)
• Physicians should develop a plan of what to do if they are sick.  (My group, ExtraMD, has already been called in to fill in for one doc out with the flu.)
• Have a plan of how your practice will handle extra patients.  Consider finding an extra practitioner temporarily, or sending patients to another office.
• Current recommendation on treatment: (verify this for yourself, please) tamiflu for those hospitalized with suspected or confirmed influenza, those with high risk from complications, e.g. children younger than 5, adults 65 and older, pregnant women, those with chronic medical/immunosuppresive conditions. Start monotherapy with tamiflu within 48 hours of onset of symptoms.

Hope that helps.  Take good care of yourselves–doctors are people too!

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If you are one of those, I suggest you think about an important concept: you can’t practice medicine if you can’t keep the doors of the practice open.

If on the other hand, your practice is so well run that patients run in carrying cash for the copays and insist on leaving a tip at the front desk, read no further.

Here’s the deal: you must get paid for the work you do, you must meet the financial obligations of the practice, and you must take home some sort of paycheck to keep bread on the table, a roof over your head and clothes on your body.  Your dependents would probably appreciate this as well.  Health insurance and retirement funds are optional.

So what to do:

1. Set the expectation from the get go that a copay is  expected at the time of the visit.  Have a sign to this effect, and train your staff as to the importance of collecting the copay from the beginning.
2. The front desk should check the insurance card for the amount of the copay every time.  (I was at my ob/gyn office, and they tried to convince me to pay the “specialist” copay of $50.  Since when is a gyn visit for a pap smear a “specialist” visit?!)
3. The front desk person should ask, “how will you be paying the copay today?”  (Notice: not “will you be paying the copay today?”)
4. Take credit cards if your office can afford it.  Credit card companies take a 2.5 -3% of each transaction.  When your margins are really tight, this can be significant!
5. Ask for partial payment.   Getting even some of the copay and billing the rest is better than getting none at all.
6. Be diligent in following up on missed copays with billing.  Again, have the option of putting it on a credit card when you send out the bill.
7. Make sure you have a system for logging copays. 
8. Keep the goal in mind: doors open=practice medicine. 

Good luck out there!

I bring it up because of two things: 1) in this culture of health care reform, we need to look at the low lying fruit and 2) the accompanying editorial is ridiculous.

The New York City Board of Health mandated in 2006 that artificial trans fats be removed from restaurant food.  By November, 2008, use of trans fats in restaurant foods had fallen to 2%.  Trans fats are largely manufactured or modified fats, but naturally occur in small amounts in foods.  Initially, restaurants were urged via an educational campaign to voluntarily remove trans fats from use. Trans fat use in restaurants remained unchanged in spite of the educational efforts.  (Please see my post on “Influencer” as to why education as a mode of behavior change doesn’t work.)

However, once the mandate (and accompanying fines for non compliance!) went in to effect, use of trans fats fell to less than 2%. Now, long term effect on lipid profile has yet to be seen, but it seems a relatively painless step in creating a healthier population.

NOT SO, according to an accompanying editorial by Julie Louise Gerberding, MD, MPH, former director of the CDC.  She states that implementing a nation wide ban on trans fats (as they have in Denmark) is “impractical if not impossible” for several reasons. She claims:

1. Consumers will “inadvertently” substitute foods with saturated fats or higher carbohydrate loads
2. Corn oil is limited secondary to the “strong biofuel market”
3. There is not enough healthy oils and development is too slow to make this viable
4. “Pushing too quickly could do more harm than good, if producers are forced to resort to products high in saturated fats…”

Dr. Gerberding suggests instead that physicians inform and encourage patients to avoid trans fats.  She states that the FDA “urge clinicians to encourage awareness of the important influence of diet on heart health.”

Bull pucky.

Patients do not change their habits because of a once a year “physical” in which physicians urge them to eat better, exercise more, stop smoking, wear their seat belts, wear sun screen, get a colonoscopy, get a mammogram, get a flu shot, get an H1N1 shot, get a tetanus shot, get a bone density, eat calcium, and make sure the guns in the house are stored safely.  They are NOT going to eat less trans fats because I tell them it is bad for them.

Please Dr. Gerberding, use your considerable influence for the common good.  Eliminating trans fats is an easy fix.  Stop pushing it off on clinicians, and stand up for the American public, and for appropriate public health care.

Sounds good on the surface.  However, I think the law of unintended consequences will come in to play.  Here’s the gig: if specialists are reimbursed less for patients visits, they will make fewer patient visits and do more procedures.  They are not stupid.  The money is in the procedure, not in the face to face contact with the patient!  What this will do is reinforce the fact the specialists do procedures.  They will have no reward to see and THINK about what is wrong with a patient–instead we will have more cardiac catheterizations and endoscopies.

How many times have you called a specialist because you need help diagnosing or managing a patient, and they tell you over the phone what tests to order, and then tell you they will see the patient before the endoscopy?

No, the CMS has it wrong.  We need to decrease the amount specialists are reimbursed for procedures.  We need to reward time spent with patients, not time spent with the endoscope.

By the way, you must click you way to Medical Marginalia and her take on specialists pay.  Especially poignant are the ending paragraphs where she describes how the hospital made a decision to shed primary care physicians to bring in a cardiologist.  Undoubtedly, the cardiologist will pay for himself/herself through more procedures.

(Apologies to specialists: I’m not picking on you, really! I think we need to get paid for taking care of patients, even if it doesn’t include a procedure!)

It took me an hour and half to go through them, sign them, make the appropriate dispos: e.g. patient needs follow up  appointment, needs phone call etc.  Of course, that one and half hours isn’t paid for.  I tried to make it quick, making piles of charts to file, piles of charts of patients to be called, piles of those needing follow up appointments etc.  I racked my brain for ways to make this more efficient, but couldn’t come up with much.  It just needed to be done, and it required a physician to do it.

In keeping with the guidelines on abnormal labs I just blogged about, I had the patients notified on every test if it was normal, and scheduled appointments for those that weren’t.  Same with x-rays etc. An EMR may have helped as results could have routed through the EMR, but it would still require review.

I don’t have a solution for how to wade through the endless paperwork.  Maybe this is why we desperately need to reform how we give health care, and how it is reimbursed.  Thoughts on improving efficiency?

“Based on current data, CMS is projecting a rate reduction of -21.5 percent for CY 2010. 

CMS is also proposing to stop making payment for consultation codes, which are typically billed by specialists and are paid at a higher rate than equivalent evaluation and management (E/M) services.   Practitioners will use existing E/M service codes when providing these services instead.  Resulting savings would be redistributed to increase payments for the existing E/M services.  

CMS is proposing to increase the payment rates for the Initial Preventive Physical Exam (IPPE), also called the “Welcome to Medicare” visit to be more in line with payment rates for higher complexity services.  The IPPE benefit was mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 to pay for an initial assessment of key elements of a beneficiary’s health status within six months of the beneficiary’s enrollment in Medicare Part B.  Subsequently, Congress extended the time period for the IPPE benefit to within one year of the beneficiary’s enrollment in Part B.

In addition, CMS is proposing to refine how Medicare recognizes the cost of professional liability insurance in its payment system.  While these changes would have a modest impact, they will promote payment equity by redirecting the portion of Medicare’s payment for professional liability insurance to those physicians that have the highest malpractice costs.

 Taken together, refining the practice expenses, eliminating payment for the consultation codes and revising the treatment of malpractice premiums would increase payments to general practitioners, family physicians, internists, and geriatric specialists by between 6 and 8 percent (before taking into account the proposed update and other proposed changes to the fee schedule).”

Wow.  I foresee a big fight on our hands, but hopefully the “thinking” specialties will finally be rewarded as well as the “doing” specialties.  Stay tuned!