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Archive for the ‘Random Thoughts’ Category

Income Comparisons – Teacher vs. Physician

Tuesday, April 15th, 2014

Who makes more money over the course of their career – a high school teacher or a doctor?

Doctors are obviously paid more.
However, when you also consider that doctors work 1.5 times more each week than other Americans, that doctors spend an average of 42,000 to 50,000 hours (20-24 years of full time work equivalents) just to become a doctor, and that doctors pay almost $700,000 for their educational debts, the net hourly wage of doctors versus high school teachers shows that, on average, teachers earn about 3 cents per hour more than doctors over the course of their careers.

And these calculations don’t even consider the licensing fees, licensing exam fees, DEA fees, malpractice insurance premiums, continuing medical education fees, hospital staff dues, costs of running an office … and also assumes that the doctor doesn’t get hit with a multimillion lawsuit judgment.

Teacher Salary vs. Doctor Salary

Happy Doctors’ Day

Sunday, March 30th, 2014

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According to the Southern Medical Association,

Doctors’ Day was first observed in 1933 as a way to honor the profession. Initially, it involved mailing cards to physicians and their wives and placing flowers on the graves of deceased physicians.
It wasn’t until 1958 that the US House of Representatives adopted a resolution commemorating Doctors’ Day.
In 1990 several Mississippi legislators drafted a bill to make March 30 National Doctors’ Day.  George Bush signed this bill into law later that year.

A red carnation has traditionally been used as the symbol of Doctors’ Day.

Give your doctor a fist bump today.

Just Checking

Saturday, February 22nd, 2014

CT BB NoseIn one of the hospitals where I work, when we order certain tests in the computer, we have to write the indications for the test on the order sheet. I suppose this isn’t a bad idea in some cases. For example, if an ultrasound might be better than a CT scan to look for the suspected diagnosis, writing the indication may help to provide the most useful test.

The problem that has popped up recently is that the typewritten indications have now turned into a full scale interrogation by the radiology techs. What symptoms is the patient having? For how long? What is the patient’s medical history? What medications?
Apparently this all has to be written on the order form for some patient safety protocols.

I’m even getting regular calls to ask if I “really want the test” and then ask why I am ordering the test – even though the indication for the test is written on the order.
Just double checking, of course.
It isn’t uncommon for two techs to ask me if I really want a test in some cases.

The director of the radiology department approves of all the questioning. After all, it improves patient safety. I’m not sure how repeated questioning improves patient care and I haven’t been persuaded to change or cancel any of the tests I have ordered, but I am now beginning to see how the pre-authorization process would dissuade some doctors from ordering certain tests. Some doctors just get tired of dealing with the hassles involved in ordering the tests.
I’m not one of those doctors, though.

Initially, I planned to just start typing “yes I really want the test” in the order comments. Then, my better judgment got the best of me. A statement like that probably wouldn’t look too good if the charts were sent to outside hospitals or other third parties.

Although the actions of the techs are frustrating, they are just doing the job assigned to them by their boss. Not really fair to give them a hard time.

How would you address the situation? Is it even worth complaining about? Let me know what you think.

Open Mic Weekend

Sunday, February 9th, 2014

theatre curtainIt’s been a year since I last did this and I’ve had a couple of people send me questions about medical issues. Interest has varied in previous Open Mics, so we’ll see how this one turns out.

Like Reddit, you can “Ask Me Anything” in the comments section and I’ll give you the best non-binding informational answer I can give you.  I’ll be back Tuesday to answer questions and any of the other readers who want to chime in are welcome to do so.

The only rules are that there are no personal attacks and that the comments/questions have to be medically-related.

Let the show begin …

The Most Common Thanksgiving ED Complaints

Thursday, November 28th, 2013

TurkeysWhen I first saw this article in Live Science about the strangest holiday ED complaints, I was interested in what other doctors’ perceptions were, but I first sat back and thought about what types of complaints I usually see more often on Thanksgiving than during other times of the year. I’ve given up on trying to time “strange” complaints. They occur so often that I lose track of any temporal aspect to them.

Because Thanksgiving obviously occurs on a Thursday and because many doctors offices usually aren’t open the Friday after Thanksgiving, the holiday often presents patients with difficulty in obtaining medical care. Office schedules are booked in the days leading up to Thanksgiving, few offices are open during the holiday or weekend, and the schedules are again packed the following Monday and Tuesday with patients needing care. So patient volumes in the EDs usually increase, and I typically see more patients with routine problems than I do during “normal” weeks.

Thanksgiving is also one of the times where families get together – many times when they haven’t seen each other since the last holiday season. When busy adults haven’t seen the steady decline in the health of their elderly family members over the prior year, they will sometimes bring in their family members for an evaluation of what they perceive is a sudden change in their family member’s health. Then, instead of spending time enjoying the company of their families during the holidays, many elderly patients are admitted to the hospital to rule out old age.

Thanksgiving is also a time of food and drink intake. The excesses of alcohol often result in reduced inhibitions and oversedation. So there are always the injuries from fights over such things as whose football team is better and who got to eat the turkey neck. Later in the evening, it isn’t uncommon for families to bring in family members whose excessive alcohol intake has made them difficult to arouse.

Getting back to the Live Science article … the strangest complaints for visits to the ED include burns from turkey preparation, lacerations from carving accidents, food contamination, overindulgement in alcohol and food, sports injuries, anxiety, and performance pressures. I wasn’t even close.

Lacerations and stab wounds, sports injuries and hurt feelings, heart attack and heartburn, anxiety and isolation – we’re there to take care of everyone so that hopefully families can reconnect next month to enjoy more of each others company. If you happen to be in the ED today, remember that the person taking care of you or your family member is probably giving up time with their family so that they can be there for you.

Safe and happy holiday wishes to everyone and their families.

And go visit a family member or friend you haven’t seen in a while. Bring a picture and a card. It will be worth a lot more to that person than will a “Doorbuster” you got by standing in line in the freezing cold waiting for a store to open up on Black Friday.

Dragonisms – Voice Misrecognition Contest

Thursday, November 7th, 2013

I like the Dragon NaturallySpeaking program. I like tequila, too. But I try to use both with caution.

Dragon’s speech recognition is good in that it saves a lot of time and costs in transcribing medical records, especially in complicated patients where it would take a long time to type out the patient’s history and the patient’s course.
The problem with Dragon NaturallySpeaking is that it isn’t perfect. Sometimes the difference between a doctor’s dictation of “no murmur present” and the Dragon transcription of “murmur present” can make a big difference in a patient’s workup. Other times, Dragon will misinterpret a dictated phrase for a similar-sounding but inappropriate phrase.
I’ve tweeted about a few of them.
For example, in the patient with GERD who was having repeated exacerbations, I dictated “bland diet” in the discharge instructions. Dragon apparently didn’t like the patient too much because it transcribed “plan to die” onto the chart. It’s fortunate that I didn’t miss that error while I was multitasking. Imagine those discharge instructions showing up in a patient complaint to an administrator.
Another patient was recently looking for a prescription for oral contraceptives. The Catholic hospital in which I work doesn’t allow prescription of contraceptives from the ED, so I have to recommend that patients follow up at Planned Parenthood. Dragon translated my instructions as “Follow up plan paranoid.”
And then there’s the colleague who dictated his findings that “examination of the patient’s breasts with a chaperone showed no lumps, masses ….” Dragon transcribed “semination of patient’s breasts with a chaperone showed no lumps, masses ….”
Dr. Grumpy regularly documents the foibles he has with his Dragon software as well.

Then I thought to myself … Self, you haven’t had a contest in a while.

So we’re having a contest for the best “Dragonisms.” What have you seen or read in a medical record that was misconstrued by voice recognition software? Add it to the comments section. Best Dragonism wins a free copy of Mark Plaster’s critically acclaimed “Night Shift” book (affiliate link). We’ll also try to find some EP Monthly swag for runner up prizes. I think I have an old coffee mug somewhere in my closet. Or perhaps a couple of Amazon gift vouchers.
Contest ends at 12AM on November 15.
Let’s see what shoe grout you’ve got.

 

UPDATE NOVEMBER 21, 2013
It was very tough to pick a winner from all of these great entries. We smiled at almost all of them and laughed out loud at a few. The winner is …
#6 Ashley for the metaphorically true mistranscription about a referring facility transferring a patient because it had no testicles.
Ashley will receive a free copy of Mark Plaster’s new book “Night Shift.”

We also chose a couple of runner up winners who will each receive EP Monthly coffee mugs.
#14 Mati whose discussion about an advance directive turned into a discussion about an advanced rectum
and
#1 ndenunz whose patient’s warm feet turned into warm other body part

If the winners e-mail me at whitecoat-at-epmonthly-dot-com, I’ll get your swag to you. Thanks to everyone for their comments. Hope that the entries at least brightened your day a little.

ACEP 2013 WhiteCoat Recap

Thursday, October 17th, 2013

ACEP 2013I arrived at ACEP’s 2013 Scientific Assembly a day early to attend the Council Meeting and to meet up with some old friends.

The venue for the gathering was good. Transportation, hotels, dining, and shopping all within easy walking distance from the Convention Center. The Convention Center itself was rather oddly situated. Had to take escalators up four floors to get to lectures. Staff was uniformly pleasant and helpful.

Some of the issues at the Council Meeting that had the most vigorous debate seemed tangentially related to emergency medicine. If I hear one more proposed resolution about marijuana, I’m going to go postal on someone. We’re the American College of Emergency Physicians, not the American College of Emergency Potheads. If the “Joint” Commission wants to smoke marijuana during their days off, that’s their business. Don’t smoke it directly before or during your shifts and stop with all the resolutions about it. If you were in court and submitted the same topic for judicial consideration half as many times as it has been submitted to the ACEP Council, you would have been sanctioned a long time ago.
And a 25 minute debate followed by an emergency physician Council vote on breastfeeding? I’m a breastfeeding advocate and my wife has breastfed all of our kids, but how are breastfeeding rights relevant to emergency medicine? A resolution to follow state laws relating to breastfeeding is a waste of Council time. I’m just hoping that next year someone doesn’t submit a Council resolution asking that ACEP declare Britney Spears more popular than Nicki Minaj. Then again, maybe someone could submit a resolution that the ACEP Council will not consider any other resolutions relating to marijuana for the next 10 years.

ACEP Opening SessionI enjoyed the opening session. Shawn Achor was informative and entertaining. He summarized predictors of success in life including: Optimism, strong social connections/social bonds, perception of stress as a challenge and not a threat.
To create positive change, he had these suggestions:
1. Write down three new things each day for which you are grateful. Don’t have to be major things. The idea is to train your brain to look for positive things in life.
2. Doubling. Sit down for a half hour and write everything you can remember about a positive experience. Doing so helps you relive and “double” the positive experience. This trick improves ones positive outlook the fastest.
3. Exercise. Helps improve our health and shows us that intervention matters. Fifteen minutes of exercise each day is as effective as taking an antidepressant.
4. Meditation. Meditate daily for just a few minutes. We are all into multitasking. Meditating forces us to “singletask.”
5. Perform one conscious act of kindness each day. Doing so increases our social consciousness and improves our social connections. Strong social connections have a significant positive effect on our longevity.Top ACEP 2013 Influencers
His parting words were that “happiness spreads – create a ripple effect.”

Classes first day were informative. Tried to tweet pearls as much as possible. Made the top 10 list for most influential tweets, but left in the dust by @GruntDoc and @mdaware. Shout out to Team Health that provided wi-fi coverage for the meeting. The connectivity was usually quite good, although it sometimes lagged a little during peak times. My tablet kept having problems connecting which made keeping up with @GruntDoc and @mdaware even more difficult. Here are my WhiteCoat tweets from the ACEP 2013 conference.

Enjoyed the secret ED blogger dinner meeting Monday night. Always good to see old friends and catch up on the arguing and poking fun at each other.
10-17-2013 11-57-56 AM
Tuesday involved more lectures and also gave me a chance to visit the exhibits. Lots of interesting gimmicks to draw interest including the Deer Hunter video game, indoor golf, and a Chewbacca/Sasquatch emergency physician spokesperson … or perhaps it was a gruntsperson. Probably the smartest gimmick was fresh-baked cookies. A functioning oven on the exhibit floor was perhaps a little bit of a fire hazard, but the smell of cookies wafting through the air created a natural draw to find out where the smell was coming from.

ACEP 2013 Exhibit GimmicksSeveral neat innovations at the InnovatED. New Stryker wheelchairs are easy to maneuver, comfortable, but run about $2500 each. Also had some Lost in Space freaky robot chasing me around the exhibit. Neat idea, until some ticked off patient knocks it over. Not sure that this would be cost effective in many emergency departments, but if some rural areas could use it to screen suicidal patients and discharge without having to hold them in the ED for days at a time until a psych bed opens up, it may pay for itself over the long run. Monthly lease cost reportedly averages $1500 to $3000+ including IT support. Jason Wagner was also doing some demonstrations with Google Glass. Lot of hiccups in the demonstration. Have to nod your head to activate. People were doing this so often while trying out the glasses that I can see docs developing subconscious tics from using the glasses too much. Also, there can’t be any delay between verbal commands or the software resets itself. Shows some promise after you get past the HIPAA issues but I agree with @theSGEM that Google Glass just doesn’t seem ready for prime time use in emergency medicine.

InnovatED picturesOne complaint I heard from several vendors was the placement of the displays. With the exhibit floor separated by a skybridge, few people seemed to know about the other half of the exhibits. One vendor said that his company would not be back because of the low foot traffic. ACEP might consider providing vendors on the far side of the exhibit floor with some give backs to maintain goodwill with those vendors. Just a suggestion.

Got to see a couple of short “flashmob” type talks while wandering the exhibits. Angela Gardner gave an excellent synopsis of the benefits of tort reform in Texas. Quite knowledgeable on those legal topics, she is. Jason Wagner was back discussing useful apps for emergency physicians. Unfortunately many of the apps he reviewed were exclusively for Macs and iOS. Wandered away mid-lecture since I’m not a Mac fanboy anymore. Would like to have seen suggestions for Windows, Android, and even Linux (which I also use).

ACEP 2013 Lectures
Snagged a copy of Mark Plaster’s new book Night Shift – Stories from the Life of an ER Doc – a collection of his columns over the years. While visiting at the EP Monthly exhibit, Mark told me that many people stopping by the exhibit have just assumed he is “WhiteCoat.” I’m again dispelling that myth. We are not the same person. He’s much shorter and better looking than I am.

Sea-Tac Airport TSA Lines Around AirportThe trip home was a little trying. Both Sea-Tac Airport and the TSA in Seattle fell asleep at the wheel. It isn’t like they don’t have the ability to predict the volume of passengers based upon the number of flights leaving during a given time frame. Yet with a huge passenger surge and lines queuing across the entire airport (literally!), there were only two TSA lines open. But there sure were a lot of supervisors running around with walkie talkies and clipboards, though. Too bad they couldn’t have opened up another screening lane and helped move the passengers through security. I felt bad for the agents doing the screening. They maintained grace under pressure. Oh, and during the surge, the airport also shut down a runway for “inspections”. Don’t know the details of why, but the airport experience was definitely the worst part of the trip.
By the way, if you ever fly into Seattle and don’t want to pay $50 for a cab, there is a train that will take you right into the heart of the city and that costs a whopping $2.75.

Seattle ACEP 2013 Summary:

Pros: Location, Wi-Fi connectivity, courses, impromptu lectures and “genius bar”
Cons: Exhibit layout, cost ($770 is getting to be too expensive)
Overall Grade: A-

Looking forward to next year in Chicago October 27-30. Should be lots of fun.

Still Don’t Use These Abbreviations

Friday, October 4th, 2013

Remember all of those “do not use” abbreviations?

I wrote a post about them a loooong time ago, but since then things have changed.

We went from written medical charting to almost exclusively computer [hack hack] generated medical records.
So the whole Joint Commission issue about a “>” looking like the number “7″ or the notation “cc” looking like two extra zeroes is – or at least should be – a moot point.
And I still believe that if someone can’t tell the differences in dosing between “MSO4″ and “MgSO4″ then they shouldn’t be prescribing or administering those medications. Again, it should be a moot point since orders have to be made from dropdown lists.
But some organizations don’t understand the concept of “moot.” Rules just keep

At the start of my shift, a very pleasant member of the chart review team was waiting to talk to me. This same member of the chart review team had reportedly chastised a nurse because she hadn’t completed a “medication reconciliation” on a young multiple trauma patient that was flown out of our ED to a regional trauma center less than 30 minutes after arriving. Because obviously whether the patient medication list states that he took Motrin and Zyrtec on an as-needed basis was going to have a profound effect on whether he would survive his rib fractures, hemopneumothorax, and open femur fracture. In fact, wasting time documenting nonessential information such as ASA scores and medication reconciliations will very likely have a detrimental effect on patient outcomes.

As a side note, it is rather sad that government regulations force hospitals to hire multiple full-time employees – mostly trained nursing staff – whose sole job is to comb through the work of those caring for patients in order to pick minute errors making no clinical difference in a patient’s treatment or outcome from a document that is likely thousands of words long. Then, instead of just making the changes themselves, they have to find whomever failed to properly document this nonessential information, interrupt them during their clinical duties, and stand over their respective shoulders while they correct their “errors.” Again, the documentation changes rarely if ever have any beneficial effect on patient care and often cause delays in patient care due to all the requirements for extraneous information. If the chart reviewers instead were able to use their time to provide care to the patients, hospitals would be safer places.
Enough ranting.

My chart review error was heinous. I wrote “cc” instead of “ml” in one of my notes. It wasn’t even an order or a prescription. It was a notation of how much medicine a child was taking prior to coming to the emergency department.
“Dr. WhiteCoat, you’re going to need to change this in your note. It says “cc” and should say “ml.”
“I can’t change it in my note. The note has been finalized and can’t be edited.”
“You’ll need to put an addendum clarifying the notation, then.”
“What?”
“It is on the Joint Commission’s ‘unapproved abbreviation’ list. The notations can be confused. In this case, the ‘cc’ could be confused with ’00.’”
“You’re kidding me.”
“No. It has to be changed.”

Then that little gremlin whispered something in my ear.
“I’m not sure what the problem is. The notation says ‘ml.’”
She stopped and read through the chart.
“No. Right there. It says ’15 cc’. See it?”
“Yes. I see where you’re pointing. It says ’15ml.’”
She started getting frustrated and raised her voice.
“No, Dr. WhiteCoat. It clearly says ’15 cc.’”
“OK. If it clearly says ’15 cc’ then there’s no chance of people confusing it with ’1500′ – which by the way would mean that the child was taking a liter and a half of medicine every day. So remind me again what the problem is.”
She gathered her papers and left in a huff.
The nurse who had been chastised earlier gave me a thumbs up sign.
Fifteen minutes later I get a phone call from the head of the medical staff.
“Will you just make the change, please?”
“OK. Fine.”

All in the name of patient safety.

CLEAR!

Monday, July 29th, 2013

Defib paddlesI got a few e-mails asking whether I’m still blogging.

Short answer is “yes.”

The number of posts has been a lot less than usual, which sometimes is a sign of a blog on life support.

Have had several things that have required my time over the past couple of months but now most of those things have … stabilized. I’ve got a few days off now that I’m dedicating to putting all the scraps of paper on my desk into posts. Even have a few guest posts that I’m looking forward to putting up.

For the few of you out there who are still reading, thanks for sticking around.

Now to get back to having some fun …

Dragonisms

Sunday, June 30th, 2013

Surprised Morguefile.comI’m not sure if I’ve had a stroke and am slurring my speech or if the Dragon NaturallySpeaking voice recognition engine is just messing with me, but lately I’ve had to triple check my charts to make sure some bad transcriptions don’t get finalized into the record.

Earlier this month, I tweeted about one case where part of my discharge instructions to a patient suffering from GERD symptoms included: “Bland Diet.”
The Dragon NaturallySpeaking program translated that to: “Plan to die”.I could only imagine those instructions hitting the front page of our local newspaper if I hadn’t caught them.

The latest Dragonism was during a recent physical exam of a patient who fell.
He fell down some stairs and injured his ankle. I examined the rest of his body to make sure that there were no other injuries.
I dictated: “Left lower extremity with no pain to the hip or knee …”
Dragon transcribed: “Unfortunately with no pain to the hip or knee …”

Another one that probably wouldn’t look too good while blown up on a courtroom exhibit or in front of a state medical board.

I suppose typing has its advantages sometimes.

 

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