OK .. so I turned comments back on here .. so we'll see how bad the commentspam is this time .. and in the context of Enoch's post on the topic .. we may turn off comments over at medlogs .. but I'd sure like to have something in the RSS or ATOM feed to help resolve this ..
Today I called someone who may have cancer. This is always a tough call, since at this stage, there are no clear answers yet. We often know more about what things are NOT before we know what they are.
This is usually how it goes. I always say the "C word" early in the conversation. This gives us both permission to say it .. since it's always lurking in the background if we don't bring it out in the open. Next, I need to reassure the patient that the likelihood of cancer is small. This is often calming, but of course the worry persists. Why do I say that the likelihood of cancer is small? Because it usually is. Much more often, abnormal findings are just abnormal findings.
Of course we need to do our very best to follow through carefully, do appropriate and thorough physical evaluations, etc ... and not ignore abnormal findings. Yet the fear of the "really bad" outcome can be enormous and unnecessary, since a great deal of the time, the final result is reassuring.
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Last week's billing episode now resolved .. I tackled one this morning much more promptly.
6 months ago, I removed an infected sebaceous cyst from a patient's neck. My progress note adequately described the procedure and the indications for the procedure. The insurance company denied payment - insisting that it was a cosmetic procedure. We submitted the note - and they denied it again. So billing people call patient and tell her she must pay. She says no way .. and calls insurance company and they say ... ok .. re-submit bill .. we will pay this time. Bill got re-submitted in late May .. but patient still getting bills from us .. has appointment with me next week .. and our staff now being told to get the $$ from her when she comes. Feels bad ... so I call insurance company and very nice lady tells me that check was mailed and we were paid! ... I say think you and hang up.
.. but I wonder why it took so long .. and required so much effort.
Another unfortunate reality: being paid 6 months late after three submissions and many phone calls = a success.
The medical weblogs aggregator is getting more use these days ... we're getting closer to an RSS feeed (of rss feeds) so if you want to use your aggregator to read the medical weblogs aggregator .. you can.
The other experimental addition is the addition of comments. Blogborygmi posted the other day on the expanding use of medlogs.com, and lamented:
One concern with medlogs.com is that it'll stifle reader comments -- ya can't see 'em from their site, and you're less likely to visit a blog if you've just read the latest post on an aggregator. (Something's gotta explain the dearth of opinions lately). And it seems kind of arbitrary which blogs are indexed in toto, and which get the blurb treatment.
a) Well .. I agree that comments can be useful and interesting, but they're not part of the RSS feed that weblogs publish .. so there would be no way for us to show the comments or add a method of building the dialogue. The next-best thing would be to host the comments ourselves and build a threaded discussion. Dave wants to do this .. so then medlogs would become the slashdot of medical geeks (we'll call it DaveDot). Short of DaveDot .. we've turned on Haloscan comments. IN the title bar of every post, you can post a comment about that post in medlogs. This may provide a method of maintaining comments - without the need for every weblog to host comments. As you can see .. I've disabled comments on Docnotes due to too much commentspam. We'll see how this works. Please let us know what you think.
b) Regarding the arbitrary nature of the how much of the weblog appears in Medlogs .. it's all about the RSS. Some RSS or Atom feeds provide all of the post - so we provide that to you on medlogs. Other feeds have only an excerpt .. so that's what you get. So it's not arbitrary at all ... and in fact, I'm not sure which one I like better. We would certainly be able to cut off part of the feeds (so all feeds show only an excerpt) and sometimes I think that this would be better (especially for the graphics-intensive feeds) .. but if we had only an excerpt, we'd have to be clicking on the URL for the post every time .. which defeats the "get it all here" concept of the aggregator.
From "A Chance to Cut is a Chance to Cure" This note about sending patients to the ER.
In primary care .. it's not so clear as in general surgery.
Yesterday I met a patient at the office (yep -- Saturday afternoon) who called with "doc I feel just rotten." It would not have been appropraite to send him to the ER ... and some may have had him take some tylenol and come to the office Monday AM. ..
when I saw him, I was glad that I did what I did.
Temperature was 103. Exam revealed cellulitis of the right leg ("well, my leg did hurt some") and a blood sugar of 156.
(no known medical problems, by-the-way)
So now you know the diagnosis.
While I doubt anyone would argue that this would have been an abuse of an ER .. I think that most would agree that cellulitis and a new diagnosis of type 2 diabetes is more appropriately managed in the primary physician's office -- where follow-up can be arranged (he's doing much better today) and continuity is maintained.
How to bill?
99050 (rarely paid .. but we'll ask the insurer for it anyway)
A few weeks ago, I pointed to an article on billing for mental health services in primary care. I was surprised that the author suggests that primary care physicians can use 908XX CPT codes. I've never done this, and asked our medical director what he thought. His initial response:
.... many/most of our health plans will likely not reimburse us for these services because of their requirements that mental health diagnoses be treated within their mental health network. If Medicare were to pay, they would pay at the reduced mental health rates. So, it doesn't sound like a good idea any way you look at it.
My morning project confirmed his thoughts .. and then some. It gave me a little glimpse of what our billing staff attempts to deal with on a daily basis ... and is a great example of why our health system is simply broken.
Better rewind to March, 2003 to catch you up.
So it took a bit more than 90 minutes of my time this morning to get paid on a $59 balance from 15 months ago. Our billing specialist spends her days like this. We have thousands and thousands of dollars of write-offs every months ... for things that we just don't have the energy to follow-up on. The system is simply broken. Every company comes up with their own methods of trying to deal tactically with the small problems they see .. and of course, we respond with our own tactics .. such as hiring billing specialists to argue with theirs.
But what in the world does this have to do with health-care? Oy ... not much. Will I hesitate before coding for mental health ICD-9 codes? yep. Primary care of the future:
Dave installed FCKeditor into our MovableType installation. It's better than HTMLArea, but it will take a bit of getting used to. HTMLArea had been acting funky ever since we installed the new version of MT. I'm surprised that MT doesn't come with a WYSIWYG editor. There are so many available ... 
Let's see how it handles images. Not bad.
Sam's baseball team (which our practice sponsors) won the "majors" division in little league this session. See .. that's us .. Slingerlands Family Medicine .. in 1st place!
I took the picture with my Treo 600 .. and I continue to be impressed with it, though I'm on my 3rd one ... (all replaced for free by Sprint) so I can't say much for the quality control.
Still not able to get a good moblogging tool to work on it... any suggestions?
Well .. if you do have a suggestion, you'll have to post it on your weblog and send me a trackback .. or send me an e-mail. I've turned off comments on the site, since I now get over 200 comment spams a day. MT 3.0 lets me screen them before they get posted, but I just don't have time to review 199 spams to approve of one "real" comment every day. Soo ... comments are gone.
Final Geeknote: We're playing with an rss feed of rss feeds .. it's an RSS version of medlogs.com. Still in the early stages .. and not yet clean .. but here's a peek.
Another article looks at the question of whether imaging is helpful for the management of back pain.
Ever since my MRI in 1989, I've known I had an L5S1 disc herniation. (I'm not alone, of course) The MRI didn't change my treatment - indeed, I think that in the first few years after my diagnosis .. I was less active because of it.
The pressure to do something and know what it is often is blamed on the patient, but I think physicians are guilty of such behavior just as much - if not more. Patients learn from the physician .. and I can say with some confidence that patients and physicians can learn from each other to work toward healing without ordering unnecessary tests.
... and speaking of unnecessary tests, I ordered a PSA last week for a patient who had chosen (after lengthy discussions) not to have it done the previous two years.
The result was not what we wanted .. and I thought instantly of the recent JAMA paper. oy.
Next topic ...
Lyme disease is quite prevalent in these parts. I've seen a handful of very severe cases, and saw my first case of a true Erythema Migrans rash today. Impressive.
From STI:
Here's the abstract. It's an interesting idea .. though I doubt the local HMO would cover it.
Zafirlukast for severe recurrent vulvovaginal candidiasis: an open label pilot study
D J White1, A Vanthuyne1, P M Wood3 and J G Ayres2
1 Hawthorn House, Department of Sexual Medicine, Birmingham Heartlands Hospital, Hospital, Bordesley Green East, Birmingham B9 5SS, UK
2 Department of Respiratory Medicine, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham B9 5SS, UK
3 Department of Clinical Biochemistry and Immunology, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
Correspondence to:
Dr D J White
Hawthorn House, Department of Sexual Medicine, Birmingham Heartlands Hospital, Hospital, Bordesley Green East, Birmingham B9 5SS, UK; David.white@heartsol.wmids.nhs.uk
Background: Recurrent vulvovaginal candidiasis (VVC) has been linked to allergic disease, particularly allergic rhinitis.
Objective: A pilot study to assess the possible use of the leukotriene receptor antagonist zafirlukast as a treatment for recurrent VVC.
Methods: 20 women with six or more symptomatic attacks of VVC in the past year (at least four proved microbiologically). Clinical atopy determined by the International Study for Asthma and Allergies in Childhood (ISAAC) questionnaire assessed blindly. Monitoring by daily symptom diary and self taken vaginal swabs. Treatment with zafirlukast 20 mg twice daily for 24 weeks or until three microbiologically confirmed episodes of VVC. Response assessed by daily symptom diary and self taken vaginal swabs. Subjective response scales for improvement, side effects, and change in other allergic disease completed when stopping treatment. Semistructured telephone interview 1 year after stopping medication.
Results: 14 patients (70%) reported a subjective response on the improvement response scale. Six (30%) showed a complete response with no further symptomatic attacks of VVC or negative swabs when symptomatic. Seven (37%) remained symptom free 18 months after entering the study—that is, 12 months after stopping therapy. 11 (58%) remained symptom free for at least 3 months after stopping therapy. This does not include one patient who remained symptom free but continued on zafirlukast because of an improvement in her asthma. There was no clear relation between response and atopic status. Six of nine atopic subjective responders reported improvements in other allergic symptoms. Side effects were minimal; one seemed clearly attributable to the drug.
Conclusion: Zafirlukast offers a potential new treatment for recurrent VVC that requires confirmation in controlled studies.
I read Dave's post on when he quit smoking to a patient in the office tonight. I was trying to break through the iron wall of denial. No dice. "Doc, I'm not gonna quit .. I like smoking." How many physicians does it take to change a lightbulb? (answer)
JAMA:Is This Child Dehydrated? Here's a pdf of the article .. just for my own personal use ;-) .. it's an excellent review of a complex yet very common topic.
From FDA.GOV: A Primer on Summer Safety.
It's hard to miss the posts from Mercola.com on medlogs.com.
Dr Mercola's frequent posts are often enhanced with graphics - so they stand out from the crowd. He does a good job sharing his opinion .. but today's post on mercury in vaccines is quite misleading. He suggests that readers/parents "read more on the link between autism and vaccines before deciding whether to vaccinate your infants."
Huh?
He may not know that thimerosal is not in any of the commonly used pediatric vaccines - nor has it been for several years. Dr Mercola: please update your weblog to reflect a more accurate picture of pediatric vaccines circa 2004. While there may be reasons for some parents to have questions about vaccines .. thimerosal is not one of them.
The Primary Care Companion to the journal of clinical pscyhiatry has a good article called Billing for the Evaluation and Treatment of Adult Depression byt the Primary Care Clinician. (pdf)
It's a good overview of a challenging topic. It's well documented that primary care physicians are poorly reimbursed. It's hard to be appropriately reimbursed for our time - which of course is are most valuable commodity. Funy that I can remove a toenail in 10 minutes and earn several times what I can earn to listen to someone for 45.
Published tomorrow: For-Profit Hospitals are Costlier Than Non-Profits. This is from the "duh" department. But while we would intuit that this is the case, this article provides clear evidence that profit clouds healthcare decisionmaking.
A year ago I posted about many commercial nasal sprays and how they may contain preservatives that can actually destroy neutrophils.
Since then, I've told patients to make it at home. Here's the secret formula:
The solution can be squirted up the nose from a squeeze bottle .. or you can just dip a teaspoon in the solution, place it under one nostril and hold the other nostrol closed ... and snort it up. Yep .. if feels like you just went bodysurfing on a big Atlantic wave .. invigorating. Nasal saline is now a mainstay of my treatment for nasal complaints. I rarely use antibiotics. This article reviews the use of nasal saline and concludes:
"Summary: Nasal irrigations should no longer be considered merely adjunctive measures in managing sinonasal conditions. They are effective and underutilized. Some of the persisting unanswered questions will only be answered by further research."
Zed Med in N. Zed is a wonderful weblog written by Chuck Zelnick. He's on sabbatical in New Zealand:
I'm now in my 22nd year of practicing Family Medicine, and feeling its time for a change. So I'm taking my family (wife, youngest daughter) with me to New Zealand for 6 months, where I will be working in a small town medical clinic in the South of South Island
A Simple, Accurate Method to Confirm Placement of Intra-articular Knee Injection
Glattes RC, Spindler KP, Blanchard GM, Rohmiller MT, McCarty EC, Block J.
Department of Orthopaedics and Rehabilitation and the Department of Radiology, Vanderbilt Sports Medicine Center, Nashville, Tennessee.
BACKGROUND: Intra-articular knee injections are routinely performed in clinical practice without documenting intra-articular placement. HYPOTHESIS: A small amount of air to an intra-articular knee injection produces an audible "squishing" sound with range of motion. STUDY DESIGN: Prospective nonrandomized clinical trial. METHODS: The study group (20 knees from 20 patients) received an intra-articular injection with a mixture of local anesthetic, corticosteroid, contrast dye, and 1 to 2 cc of air. The control group (10 knees from 5 patients) received extra-articular injections of a mixture of local anesthetic, contrast dye, and 2 cc of air. All knees were examined immediately after injection for a squishing sound with range of motion. Postinjection arthrographic radiographs were taken to verify the actual placement. RESULT: All study group knees and no control group knees had intra-articular contrast by radiograph. Clearly audible squishing sounds were heard in 17 of 20 study knees (sensitivity of 85%). Squishing sounds were audible in none of the control knees (specificity of 100%). CONCLUSION: Adding 1 to 2 cc of air to knee injections provides a no-cost, reliable, sensitive, and specific method of confirming accurate placement. Clinical Relevance: This simple method is easily reproduced, can confirm accurate placement, and can eliminate extra-articular injection as the reason for clinical response failure.
PMID: 15150053 [PubMed - in process]
This project at the AAFP received grant funding - $100,000 from the the federal government this month. It's actually not much money, and the project is quite small. I have mixed feelings about it all - in part because I've been doing my very best to help AAFP understand why they should join NAPCI. NAPCI is a collaboration of primary care specialties. No one is in charge and we all work together to work toward the same or similar goals. Yet AAFP seems to think that NAPCI is going to slow down the work that AAFP is doing, and I simply don't get that. Ugh.
From eCMAJ
Recommendations
- Given the balance of harms and benefits, the Canadian Task Force on Preventive Health Care recommends against the use of combined estrogen–progestin therapy and estrogen-only therapy for the primary prevention of chronic diseases in menopausal women (grade D recommendation).
- For women who wish to alleviate menopausal symptoms using hormone replacement therapy (HRT), a discussion between the woman and her physician about the potential benefits and risks of HRT is warranted.
This is a clear and compelling review of this complex topic. I must admit that I was never much a fan of HRT to begin with.
