Tuesday, December 17, 2013

Can't win for losing

The Washington Post recently decided to demonize doctors, with a headline trumpeting, "An effective eye drug is available for $50, but many doctors choose a $2000 alternative."  The article tells the story of a miracle drug treatment for wet macular degeneration, which is one of the leading causes of blindness.  Avastin was approved in 2004 for treatment of colon cancer.  It targets a protein called VGEF, thereby decreasing harmful blood vessel growth in cancer.  This same protein is linked to wet macular degeneration.  The company that makes Avastin, Genentech, has created a slightly different molecule and development process to make Lucentis, which is FDA approved to treat macular degeneration.  For all intents and purposes, the drugs are the same.  Both target VGEF.  Both are effective for macular degeneration, according to several independent trials.  However, Genentech has only sought FDA approval for Lucentis to treat MD.  It does not produce Avastin in the proper size to treat MD.

Despite this, many ophthalmologists still use Avastin to treat MD.  They have to have a compounding pharmacy separate it out into the proper dose, which does introduce a risk of contamination, though the risk is slight.  However, using Avastin this way is certainly considered off-label, meaning using a medication in a way that is not FDA approved.

The newspaper clearly implies that doctors should use Avastin, and that there is no good reason not to. It implies that doctors who chose not to take the risk of using an unapproved drug are greedy, stating that the medicare reimbursement of 6% of the cost of the drug (a whopping $120) is driving their decision.

And yet, just a few months ago, The Washington Post published this article.  It decries the lack of oversight of pharmaceutical drug use in the elderly, specifically targeting the off-label use of drugs in Alzheimer's patients.

So, which is it, Washington Post?  Am I a saint or a sinner?  Is off-label use good or bad?  Or maybe, just maybe, doctors are using their clinical judgment in individual situations to guide their decisions.


h/t to Overlawyered.com

Sunday, December 15, 2013

ICD-10 Crazy Codes

Medical coding.  It's an entirely separate language that distills all medical problems down to a "code."  Currently, ICD-9 is in use.  Every time you receive medical care, your diagnosis is translated to a code which is then used for billing purposes, among other things.   Your hypertension and high cholesterol? 401.9 and 272.4.  Your hypothyroidism? 244.9.

And so on.

ICD-10 is going into effect next year.  It will increase the number of possible codes from 17,000 to 141,000.  No potential for confusion or complications there.

Now, has medical practice become so much more complicated over the past 30 years that there are now 124,000 new diagnoses?  Of course not.  ICD-10 is just more specific than ICD-9.  Much more specific.

For example, if you were to present to your doctor now after getting bit by, say, a squirrel, the code would be E906.3 (bite of an animal other than an arthropod).  But under ICD-10, your doctor can actually code that it was a W53.21XD (bitten by squirrel) to make sure that it is not confused with a W55.42XD (bitten by pig).

Or, after that ill-conceived ocean swim, your doctor can bill appropriately for W56.01XD (bitten by dolphin) vs W56.11XD (bitten by sea lion) vs. W56.21XD (bitten by orca).

Do you see the importance of these distinctions??

There are other codes that I'm sure are crucial.  V9733XD (sucked into jet engine, subsequent encounter).  Got that?  Subsequent encounter.  They made a code to cover someone who got sucked into a jet engine, not once, but twice.


For those of you that worry about worst-case scenarios, there are also codes for you.  For example- T71224A (asphyxiation from being trapped in a car trunk).  This is to be distinguished from T71234A (asphyxiation from being trapped in a discarded refrigerator).  There are also codes to clarify if the fridge asphyxiation was accidental, assault, attempted suicide, or "undetermined."  If you're really unlucky, you might have to use V9020xA (drowning or submersion due to falling or jumping from a burning merchant ship- initial encounter).

By the way, I apologize for any typos.  I have a big bandage on my index finger, having done a W920xxA this morning (contact with powered kitchen appliance).

Actually, there's one ICD-10 code that probably covers this whole coding thing quite nicely- K62.89 (pain, anus).

Wednesday, December 4, 2013

If you give a patient a chest x-ray...

It's probably the rare parent these days who hasn't read If You Give A Mouse A Cookie, an adorable book by Laura Numeroff.  In it, a little boy gives a cute mouse in overalls a cookie.  This one little act sets off an exhausting chain of events that eventually comes full circle.

I was recently reviewing old records on a new patient.  I noticed that he had had an awful lot of tests over the previous couple of years, which struck me as odd, given that he was a pretty healthy person. Looking a little further, it seemed that a cascade of events had been set in motion that had started with one innocent little test- which was not even indicated.

This patient was a former smoker, having quit many years ago.  His previous doctor ordered a chest x-ray to screen for cancer.  This was unnecessary in  the absence of symptoms as it's a category D recommendation by the USPSTF.  Nevertheless, the doctor ordered it and the patient had it done.

And, with apologies to Laura Numeroff:

If You Give a Patient A Chest X-Ray

If you give a patient a chest x-ray, the radiologist will see some tiny nodules.
The radiologist will call you and recommend a chest CT.
When he gets the chest CT, which is otherwise normal, the radiologist will note some calcifications in his aorta.  This will make you nervous, and you will refer him to a cardiologist.
Because this is a cardiologist, in addition to ordering an aortic ultrasound, he will also order a stress test, echocardiogram and carotid ultrasound.
All of those studies will be normal, but the ultrasound tech will notice a thyroid abnormality.  This will cause you to send the patient for an endocrinology consult.
The endocrinologist will redo the ultrasound.  Then he'll order a thyroid uptake scan.  This will show an active adenoma, which is benign, but he'll recommend follow up ultrasounds every six months after that.  He also notices that the patient is slightly hypothyroid, and starts him on levothyroxine.
The medication elevates the patient's blood pressure, so you start him on an ACE inhibitor.
The patient comes back to you two months later with an ACE inhibitor-induced cough.
And if you see a patient with a cough...you're probably going to want another chest x-ray.

Tuesday, November 19, 2013

Disease Mongering

Disease Mongering.  The act of turning a normal ailment into a serious illness.

This phenomenon is rampant today, and it drives me nuts.

It seems that the first step in disease mongering is to create a scary, official sounding acronym.  ED.   RLS.  GERD.  Sounds a hell of a lot more impressive and official than impotence,  restless legs, and heartburn.

I recently had the thrilling experience of seeing disease mongering at its finest.  The latest ailment to afflict Americans? VVA.  Vulvovaginal atrophy (said in a deep, important voice).  Otherwise known as vaginal dryness and thinning of the membranes due to menopause.  VVA (said again in a deep, important voice) sounds much more serious and impressive.

This is not a new entity.  Post-menopausal women have been experiencing vaginal dryness and pain with intercourse since...well, since the first woman ever went through menopause.  I don't think it's a deep, dark secret.  It's even a question on the checkoff list that I give all my patients at their annual physical.

Shionogi Pharmaceuticals would have us think otherwise.  They have started a marketing blitz to convince Americans of the seriousness of this new condition, VVA.

They have a new drug on the market- Osphena.  It's what's called an selective estrogen receptor modulator.  This means that it binds to certain estrogen receptors (in the vaginal mucosa, in this case) and not to others (like in the breast).  It's kind of similar to Evista, an osteoporosis medication that selectively binds to estrogen receptors in the bone.  As a matter of fact, Osphena was originally developed as an osteoporosis medication.  When it didn't work to treat that, it became a drug in search of a disease.  And thus, VVA was born.

Shionogi is working really, really hard at marketing this.  One of their reps snuck a box of these into my waiting room.

Snazzy pink bracelets.   Just what everyone wants to see after a month of pinkwashing.  These say, "Break The Silence."  What silence?  The shameful silence of VVA, of course.    I cleared that box out of the waiting room as soon as I found out about it.  My office manager braided the bracelets into a long, pretty pink chain.  We're going to use it to decorate the office Christmas tree.

The medication comes in these discreet little totes.

Why?  I don't know.  Why would someone need to carry the pills in this special little bag?

Here's the brochure about the medication.

I love the off-the-shoulder sweater.  Post-menopausal women are still sexy, see!

Here's the main thing that I dislike about this.  Atrophic vaginitis, otherwise known as VVA (in deep, important voice!) has always been around.  There are multiple excellent, safe medications to treat it.  Topical estrogen, in cream, tablet, or vaginal ring insert works great.  I've NEVER had it not work for a patient.  It has a long safety record.  Whereas Osphena in a new drug.  It carries a risk of endometrial proliferation, which can lead to endometrial cancer.  And it actually increases hot flashes.

No wonder they have to work so hard to market it.

The moral of the story is: disease mongering exists.  It's marketing at its finest, as it preys on our fear of disease.  Be aware of it and be wary of it.  And just because a drug is advertised on TV doesn't mean it's the best choice.  Find a doctor whose expertise you trust, and take his or her's advice rather than an advertising agency's.

Tuesday, October 29, 2013

Three Years of Medical School?

I read an interesting article in the New York Times the other day.  Called, "Should Medical School Last Just Three Years?" it outlines a movement by some medical schools to compress the current four year schedule into three years.

To give some background for this, let me outline the typical current medical school curriculum.  The first two years are the "basic science" years.  The first year (at least when I went to school)  typically covers anatomy (including cadaver dissection), physiology, microbiology, biochemistry, histology, and statistics. The second year covers pharmacology, pathophysiology, neurobiology, and epidemiology.  Years 3 and 4 are the "clinical years."  Third year students spend their time on six-week rotating clerkships through the core areas of medicine- internal medicine (this one was 12 weeks), pediatrics, OB/GYN, surgery, psychiatry, and family medicine.  Fourth year is an elective year, used to explore subspecialty areas such as dermatology, plastic surgery, and ophthalmology.  It also has the all-important "sub-internship."  This is an opportunity for the fourth year student to take on the role of an intern on a team, usually in whatever specialty they plan to go into.  I obviously did my "sub-I" in internal medicine.  It was incredibly valuable- more on this later.  The fourth year also has a decent amount of time dedicated to applying to and interviewing at residency programs (time-consuming and expensive) and studying for the second step of the licensing boards.

Proponents of compressing medical school seem to have three main motivations.  Here are each of them, with my response.

1.  There is a projected physician shortage.  Compressing medical school will produce more physicians.

Shortening medical school will produce more physicians for exactly one year- the initial year of implementation.  As long as class size remains the same, after that first year the same number will graduate every year.  In addition, there are a set number of residency spots in the USA.  The number of spots is tightly controlled by Medicare, which funds the graduate medical education program.  Without more funding for residency programs, there is NO WAY to increase the amount of doctors.  There will just be more MDs without residency training who therefore can not be licensed.

As if this wasn't enough- we need to train the right kind of physicians.  We need more primary care docs, not more specialists.  Very few would disagree with this.  Producing more doctors is worthless unless they are more primary care docs.

2.  Medical school is expensive.  Most students graduate more than $150,000 in debt.

So, something is too expensive, and the solution is to get rid of it?  How about...revising the cost of medical school?  Creating better loan programs?  Creating loan repayment incentives?  I can think of plenty of ways to reduce cost, short of discarding a year.  That's throwing the baby out with the bathwater.

3.  The fourth year is useless, filled with low-key relaxing electives.  The lead author of the proposal even says:
“We can’t dissociate medical education from societal and student needs,” said Dr. Steven B. Abramson, lead author of the perspective piece in favor of three-year programs and vice dean for medical education, faculty and academic affairs at N.Y.U. “We can’t just sit back in an ivory tower and support a mandatory year of prolonged adolescence and finding oneself, when society needs doctors to get out into the community sooner.”

This line of reasoning annoys me even more than the others.  For me, the fourth year was incredibly valuable.  My medicine sub-I was amazing.  My team, the patients and the nurses treated me like a physician.  It was my first opportunity to truly take responsibility of my patients and my actions, but yet still have someone looking over my shoulder.  "Prolonged adolescence?"  I think not.  After my sub-I, I did rotations in ophthalmology, dermatology, urology, reproductive medicine, and physical medicine and rehabilitation.  All of those taught me things that I use to this day.  I did a study abroad rotation in Edinburgh.  It was great to experience health care in another country.  I honestly think I would have missed out on a lot had I not had a fourth year.

Let's also not discount what life experience and age add to creating a physician.  When I did my rotation in Scotland, I worked with medical students there.  In Scotland, students do a six year undergrad/medical program rather than the 8 years that we do here.  On the whole, I noticed a difference in the maturity level between the med students there and the ones in my class back in Rochester.

Compressed programs have been tried in the past- six and seven year combined BS/MD programs and 3 year MD programs. Pretty much all have failed after a few years.  Students we exhausted by the pace.

Are we trying to produce robots or physicians that are also people?

Medical school should not be compressed.  At the rate that medical science is advancing, I think a more cogent argument could even be made for lengthening it.

It's not the medical education system that needs fixing.

What needs fixing is the entire US healthcare system.

Saturday, October 12, 2013


Once again, sorry for the long blogging absence.  I've been a bit down.

It all started at the end of August.  I woke up in the middle of the night with intense back pain.  Terrible, terrible pain on the right side of my low back, heading down into my hip.  I tossed and turned for the rest of the night, gulping ibuprofen and arranging my pillows in creative arrays to allay the pain. No luck.  When the sun rose, I was still in pain.

Never one to do things the easy way, I went to work.  It was painful, but doable.  I told myself that things would be better the next day.  They weren't.  Friday morning rolled around and the pain was even worse.  Nothing if not stubborn, I again went to work.  It was agony.  At this point, sanity started to prevail and I cancelled the rest of my patients.  (To everyone that had an appointment on August 30th, I apologize!!!)  I made an appointment for a massage.  It was painful, but after it I could at least stand up a bit straighter.  For about a minute.

By this time, I had pretty much figured out what was going on.  The iliopsoas is a huge muscle that runs from the lower thoracic spine to the inner hip.  It is one of the major hip flexor muscles.

It's a deep muscle, and pretty hard to treat.  How I injured it is beyond me, but I suspect it has something to do with the nagging low back pain that I've been studiously ignoring and running through for the past 2 years.

At any rate, I spent Labor Day Weekend in a recliner.  I ate, rested, and slept in it, as it was the only place I was comfortable.  Come Tuesday, I was back at work, but still in pain.

It's now 6 weeks later.  I'm doing better, in that I can walk without limping.  However, I still have pain.  And it's really, really aggravating.  I'll be starting physical therapy soon, so hopefully this will help.  I plan to start swimming again this weekend, and I hope to begin slowly running again soon.  I will try to take the advice that I give to patients after an injury- start slow and listen to your body.

We'll see.

Monday, August 26, 2013

It's All Right to Cry

I'm a crier.  I always have been.

I well up during television commercials.  Many a book has been returned to the library somewhat waterlogged by my teardrops.

I cry when I'm sad, when I'm happy, and when I'm angry.  I cry when I laugh.

And I cry in front of patients.

I used to be embarrassed by this.  I'd hide my tears with a tissue and a muttered excuse of "allergies."  Or I'd turn my back to wash my hands at the sink, furtively giving my eyes a swipe.

But sometime in the past few years, I stopped being ashamed of my tears.  My patients come to me and share both their happiest and their most terrible moments.  I've been honored to tell many patients that they're pregnant.  Why shouldn't I cry with happiness at the beginning of a new life?

I've also had to tell too many patients that they are dying.  I've sat with them and their families during their final hours.  And if they've allowed me into such a sacred time in their life, why should I hide my tears from them?

I care about my patients, deeply.  Some say that it's wrong for doctors to show emotion, and that caring so much can lead to burnout.  I say that's a load of bunk.

For me, the day I stop caring enough to cry with a patient is the day I hang up my white coat and find another profession.

Thursday, August 22, 2013

Busy Work

I'm sure everyone hates busy work.  By definition, all it does is take up time while providing no actual intrinsic value.  I don't need stuff to take up time needlessly.  I'm short enough on time as is.  That's why I hate getting stuff like this:

This was sent by a private visiting nurse service regarding one of my patients.  She has been receiving home services from them for years.  Years.  Nothing has changed.  However, they've now changed accreditation companies, and the new company wants me to state my orders in a different fashion.  Note that this adds NOTHING to the care of my patients.  My old orders work just fine.  They just want me to say if differently.

Not to worry, though.  They sent this helpful sample letter.

So, it's basically like Medical MadLibs.  Fill in the blank.  Just without the humorous results.

So I dictated a letter with her name and meds filled into the blanks.

Why was this necessary?  Why do I need to waste my time on such drivel?

Here's another great example of busy work.  As an employee of a large corporation, I am required to do all sorts of "compliance training."  I have to do it on my own time, of course.  Just to make sure it's done, I'm constantly getting helpful email reminders.

One of my favorites was the required course on preventing physician burnout.  It was a four hour course.  To be completed on my own time.  A course on preventing burnout, to be done at home, when I should have been spending time with my family.

Do they not see the irony in this situation?

I added up all the training that I've had to do for work in my "free time," and it came out to 12 hours. That's a full day and a half of work.

No wonder they need to spend four hours telling us not to get burned out.

Tuesday, August 20, 2013

Equipment Review- Waterfi Waterproof iPod Shuffle

In my last post, I expounded on my dislike for swimming.  I'm just not very good at it and I don't like doing it.  I find it boring.  Now, every year when I give my little motivational talk to the new members of my running group, I review some common excuses that people use for not running.  One of them is "It's boring."  My response to this is, "Activities aren't boring.  It's up to the person doing the activity to find the pleasure in running."

Well, I'll say it right here.  Swimming is boring.  Going back and forth in a pool, staring at a black line on the bottom...zzzzzzzz.  It's like being on a treadmill.  And yes, treadmills are boring.  But I have also vowed that I WILL swim more, so that I don't end up being one of the last finishers again in my next race.

When the weather is bad and I'm relegated to the treadmill, I listen to music or audiobooks.  It's the only thing that makes the treadmill bearable.  I figured there's got to be a way to do the same while swimming, so I started researching waterproof headphones.  It turns out there are options!  I was initially attracted to the Finis SwiMP3.  Instead of earbuds, it has these paddles that clip to your googles and lie against your temple and cheekbone.  The soundwaves transmit through the skull, and it's supposed to work really well.  However, the MP3 format doesn't support the Audible.com audiobooks that I listen to, so I nixed that option.

I eventually decided on the Waterfi Waterproof iPod Shuffle.  Since I love all things Apple, this was a good fit with me.  It would allow me to sync my already existing iTunes library without any difficulty, and I could also listen to my audiobooks.

The device itself is pretty cool.  The people at Waterfi actually take regular Shuffles and completely waterproof them.  The resulting product looks like any other Shuffle, but it's waterproof up to 210 feet. The kit comes with waterproof headphones.

It also comes with velcro to attach to shuffle to the goggles strap, but I found it just as easy to just clip on the Shuffle.  The headphone wires are needlessly long, which was kind of annoying.  I followed the directions and looped them around the velcro to make them shorter.

Then put on a swim cap, googles on, and good to go!

I have to admit, upon getting into the pool there was a moment of panic. I mean- I was willingly entering the water with an electronic device strapped to my head.  This went against nature in a very fundamental way.  Well, I had come that far, and I wasn't about to do that boring swim without listening to my book.  I took a deep breath and plunged in.  To my relief, my head did not catch on fire.  Even better...it actually worked.  I was listening to my book and swimming!

It made the swimming much more pleasurable.  Before I knew it, a half hour had gone by.  I did have to stop a few times to adjust the earbuds until I figured out the best way to position them for both good sound and no water in my ears.  Once I had that down pat, it was smooth sailing.

So, a big thumbs up/ 5 stars for the Waterfi iPod Shuffle.  Happy swimming days are ahead.

Thursday, August 15, 2013

Race Report

Sorry for the long blogging absence.  We were on vacation, then crazy catch-up at work, and of course, training for the triathlon!

And....I did it!  It wasn't fast, it wasn't pretty, but it was completed.  So, here's my race report of the first annual Kingston Triathlon.

First of all, kudos to the race planners and volunteers.  The race was well planned, well-run, and overall a pleasure to participate in.

I arrived at the race at 6:30 AM.  Now, I'm used to road races.  You pretty much show up with your running shoes and go.  No so with a triathlon.  You need a lot of...stuff.  A lot.

Obviously, you need your bike.  And your helmet.  Sunglasses.  Sneakers. Biking shoes.  A towel or two.  Water.   Snacks.  Socks.  Goggles (which I forgot and was lucky enough to borrow a pair).  You get the picture.  Then you have to arrange everything just so, for quick and easy transitions in between segments of the race.

Many triathaloners wear wetsuits for the swim.  I didn't wear one, thinking, "It's August and the water is 72 degrees.  What do I need a wetsuit for?"  I was stupid.  I forgot that wetsuits give you nice buoyancy in the water.  So, basically, I had already handicapped myself for what was already going to be my weakest segment.  No matter.  I was excited and ready to go!

For the swim portion of the race, there were three start times.  The first wave was men, the second was women, and the third was novices/slowpokes.  Guess which wave I started in.

I was pretty relaxed until I actually walked out onto that dock.  That's when it started to sink in that I was actually going to have to swim in this lake, and that if I got tired I couldn't just grab onto the side of the pool.  My training leading up to the race mostly consisted of biking and running.  I'm embarrassed to say that swimming took a back seat, partially due to the overall crummy weather, but mostly because I just really don't enjoy swimming that much.  I was about to get a lesson in the consequences of poor preparation.  After all of us in the slowpoke wave had walked out onto the dock, we had to jump in and tread water.  That sucked.  I had hoped that we could dive in and start swimming, because I could use all the momentum I could get.  No dice.  We had to tread water for about a minute and then the gun went off, and we were off.

Slowly.  I was quickly left in the metaphorical dust.  All around me, people were gliding forward with a graceful freestyle.  I settled into a tortoise-like pace with my trusty breast-stroke.  After a minute or so, I looked behind me.  I didn't see anyone.  There were a few swimmers even with me, but I was one of the slowest.  This pissed me off, I won't lie.  When it comes down to it, I'm a competitive person.  I don't think I'd be where I am today if I wasn't.  And being last was pissing me off.

Now, I may be competitive, but I'm not stupid.  I was tempted to pick up the pace to try to catch up to everyone else, but the rational part of my mind said to keep to my current pace, since drowning would really suck.  I'd just try to make up time in the other parts of the race.  I'm glad I listened to the rational part of my mind, because by the end of the swim I was tired.  Really tired.  And I cringe to think about what would have happened if I had tried to overextend myself.

As I dragged myself out of the lake and ran up the hill to the transition area, my legs felt like lead and my only thought was, "Crap. I'm only 1/3 of the way through."  The donut and coffee I'd had for breakfast were threatening to make an unwelcome reappearance.

Well, I had come this far. I wasn't about to quit.

The bike ride was actually the easiest part of the race.  It was hilly, but I had already done a practice run on the course and I knew what to expect.  It went fast, and the competitive part of me was happy to pass a bunch of people.

Then it was another transition, and on to the run!

Now, it said on the website that it was a 5K trail run.  I was expecting a run through the woods.  I wasn't expecting to have to scale boulders, climb over downed tree trunks, and splash through mud pits.  Needless to say, it was not my best 5K time.  Not even close.  I actually fell three times. Luckily, the ground was soft.  I stopped being embarrassed after the first fall.

And that's it!  I was headed to the finish line.

So, that's my race report.  Will I do another triathlon? You bet!  But next time, I'm actually going to practice the swim (and wear a wetsuit!).

Sunday, June 30, 2013

Another "Wonder Drug" is on its way.

I've written before about how much I hate "me-too" drugs.

I think I've just found the worst offender of them all...and it hasn't even been released yet.

Two days ago, the FDA approved the "first" non-hormonal drug to treat hot flashes in menopausal women.  First- a bit of background.  Hot flashes are an extremely common symptom of menopause- it's estimated that up to 80% of women will experience them.  Hot flashes are caused by fluctuations in hormone levels causing blood vessels to dilate.  At best, hot flashes are a minor annoyance.  At worst, they are truly debilitating, happening several times an hour and interfering with work and sleep.

For decades, the mainstay of therapy for symptoms of menopause was hormone replacement therapy.  This consists of giving women small dosages of estrogen and progesterone, the two main "female" hormones that decrease during menopause.  Then, in 2002, the preliminary results of the Women's Health Initiative Study were released.  This showed a significant increase in the incidence of breast cancer in women who were on hormone replacement therapy versus women who were not.  Mass panic ensued.  Over the next few years, doctors wrote 70% fewer prescriptions for HRT.  As the years have passed, more information has be released and more data obtained, suggesting that the increased risk of breast cancer is not all that clear-cut.

However, the damage was done, and women have been suffering from hot flashes, afraid to try HRT.  This of course sparked an interest in finding non-hormonal treatments for menopausal symptoms.  Doctors have been using types of anti-depressants, SSRIs and SNRIs for years.  They work, a bit.  None of the studies have honestly been that impressive.  Some show a slight benefit, others are barely better than placebo.

I guess that a certain pharmaceutical company has decided that the combination of hot flashes and fear of HRT is a cash cow.  As I said above, on Friday the FDA approved the "first" non-hormonal medication to treat hot flashes.    The new drug is called Brisdelle.  Its generic name is paroxetine.  That's right.  Paroxetine.  Otherwise known as Paxil.  Paxil was FDA approved for treatment of depression in 1992 and has been generic since 2003.  It is available in 10 mg, 20 mg, and 40 mg tablets.

Brisdelle is a "novel" drug because it is available in a 7.5 mg dosage.  That's right, a whopping 2.5 lower milligrams that generic Paxil.  Is there ANY difference between taking 10 mg of Paxil and 7.5 mg of Brisdelle?  I sincerely doubt it.  I'd stake my medical license on it.

Even the drug company's own research was pretty pathetic.  Per the Times article, women on Brisdelle had an average of 6 fewer hot flashes, while women on placebo had an average of 5 fewer flashes.

Noven Pharmaceuticals has not yet released how much this new wonder drug will cost.  Well, here's a news flash for them.  If it is any higher than $2 a month, they're charging too much.  You can get generic paroxetine 20 mg pills for $4 a month at Walmart.  Break them in half and you've got 10 mg of paroxetine, which is basically what Brisdelle is.

I can't think of any scenario in which I would prescribe this drug.  To me, it appears to be expensive and ineffective.

Thursday, June 27, 2013

Big Brother is watching.

I'm willing to bet that most people think that what happens in the exam room is just between them and their doctor.

How wrong they are.

The Health Insurance Portability and Accountability Act (HIPAA), which came into effect in 2003, states:  "A covered entity (that's your doctor) may disclose PHI (Protected Health Information) to facilitate treatment, payment, or health care operations without a patient's express written authorization."

That means that all of your private health information can and is shared with your insurance company, pharmacy, and pharmacy benefits management company (like Caremark and ExpressScripts).  Don't think they're interested in what you're doing?  Wrong again.  I am constantly getting "helpful" communications from them regarding what you're doing.  Here's an example:

Not taking your medication?  Don't think I'm not going to find out!  Your pharmacy keeps track of how often you refill your pills.  They pass on this information to your insurance company.  They pass it on to me so I can...scold you?  Rap your knuckles?  Send you to bed without dessert?

I don't find these communications helpful.  I find them insulting to my intelligence.  I know people don't take their medications all the time.  No one does.  There's lots of research to back this up.  Because I know this, I monitor their chronic issues.  I bring them in for blood pressure checks.  I do lab work.  I do physical exams.  If something is not as it should be, I address it and work with my patients to make changes they can live with.  If everything is A-OK, we leave it alone.  I don't need to parent my patients.  That's insulting to them.  I'm an internist- I take care of adults.  If I wanted to treat people like children, I would have been a pediatrician.

So, I'll keep on adding on my own little check box that states "I find this communication to be useless." 

Even if Big Brother wants me to scold and nag.  

Thursday, June 20, 2013

Public Service Announcement: Your dog and pot. Just say no.

This is my dog.

The is the vet bill for my dog on drugs.

Any questions?

Yeah.  I'll bet you have lots of questions- the main one being, "Marni, what the HELL are you talking about?"

So, here's my story.  Wednesday was a beautiful day.  I decided to go for a run when I got home- just a quick 3 miles.  As usual, I took Indy with me.  He loves a good run...usually.  However, I noticed that he was a bit slower than usual.  I didn't think too much of it, since he's been getting lots of exercise lately.  By the beginning of mile 2, he was really dragging.  By the time we got home, I was getting really worried.  I tried to give him water, but he just kind of slumped down into the water dish.  At this point I was well and truly panicked, as was Patrick.  He decided to take Indy to the emergency vet while I stayed with the kids.

After about an hour, he called me.  They were doing lots of tests but still weren't sure what was wrong.  Indy had a low-grade fever, was agitated, and was drooling.  He also couldn't seem to control his bladder.  At that point, the vet recommended having him stay there for overnight care, fluids, and further testing.

Patrick came home and I spoke to the vet about an hour after that.  She reviewed his lab work, which all looked pretty normal.  She then said to me, "This is a bit awkward to ask, but is there any possibility that Indy could have gotten into some marijuana?"

My initial response was a sound that was somewhere in between a snort, a choke, and a laugh of disbelief.  Here's the thing.  Those of you that are my patients, I'm sure, hope that I am a totally drug-free person.  Well, you can rest assured.  Those of you who know me on a personal basis can attest to the fact that I am one of the most straight-laced, boring people out there.  I've never smoked pot, or even a cigarette.  My good friends will tell you that the idea itself is laughable.

I turned to Patrick and asked him, "Hey, do you think any of the neighbors are growing pot?"  His response was similar to mine.  I asked the vet why she was asking this.  She informed me that Indy's presentation was really classic for marijuana ingestion.

I thought about it some more.  Here's the thing.  Indy spends a lot of time outside in the summer.  We live at the end of a nice, quiet cul-de-sac, and we do let him run around off leash.  He also gets to go to the beach and run around off leash there.  Like all labs, he has an unfortunate habit of eating anything that doesn't eat him first.  He once ate a 10 lb. bag of kibble.  He also ate some of my underwear.  So, in truth, it's entirely possible that my dog could have gotten into someone's stash, or at least ate a discarded joint.

Luckily, marijuana ingestion is rarely fatal for dogs, but it can make then quite sick.  I'm happy to report that Indy recovered well with IV fluids and some sedatives, and he's now back to his normal self.

I'm still smarting over the fact that my stoned dog cost me over $1000.

Just say no.

Monday, June 17, 2013

Ten things you might not know about me (or any of your doctors)

Here are ten things you might not know about me:

1.  I don't care if you shaved your legs before coming to see me.  We're not on a date.  However, I do appreciate it if you've bathed.

2.  There is nothing you can say that will shock or embarrass me. Nothing at all. I spent 4 years working in Greenwich Village in NYC.

3.  The chair with the wheels on it is mine.  I get antsy when someone else sits in it.  Get off of my chair- there are two others in the room for you!

4.  I like to hear what's going on in your life outside of your health.  It tells me a lot about you.  It helps set you apart from my other 4,000 patients.

5.  I know you don't always take your meds.  No one takes them all the time.  I'll also know if you're not taking them at all.

6.  I don't mind if you look stuff up on the internet.  However, I appreciate it if you listen to my point of view, too.  Even though my name is not Dr. Oz, I do occasionally know what I'm talking about.

7.  Sometimes, when I'm giving someone bad news or hearing about someone's troubles, it's all I can do to not cry.

8.  I'm not shifting around and looking jumpy because I'm impatient.  I just have to go to the bathroom.

9.  If you're a jerk to my office staff, I don't care about how nice you are to me.  You've already lost my respect.

10.  I have saved every "thank you" card that a patient has ever sent me.  Every single one.  If I'm having a bad day, I take them out, look at them and remember that it's all worth it.

Thursday, June 13, 2013


A good friend of mine has convinced me to do a triathlon with her.  As is obvious from this blog, I'm a runner.  Not a particularly fast or talented one, but a dedicated one, nonetheless.  And, like many runners, I'm a one-trick pony.  Runners are notorious for loving running and having the firm opinion that all other forms of exercise are inferior.  

So I run.  Pretty much exclusively.  I'll occasionally throw in a yoga class out of some sense of obligation.  However, as I approach my 40's, I'll admit that all this running leads to more aches and pains than it used to.  I've had this nagging tendonitis in my foot that's been bothering me on and off for the past couple of years.  I get back pain now.  And so on.

So, I was already playing with the idea of adding in some cross training when Sarah brought up the idea of doing the triathlon.  My first response was, "No way, no how."  I run.  I know how to swim, I mean I won't drown or anything, but I'm not what anyone would call a good swimmer.  I know how to ride a bike. I even get on it at least once a year.  But doing a 15 mile ride, after a swim and following that up with a 5K run?  

I don't think so.

But the idea stayed with me.  So, last week, I got into the pool (brrrrr!) and swam the quarter mile.  44 boring laps in my pool.  And it was pathetic.  Took me 19 minutes, I'm embarrassed to say, although at least 3 minutes of that was spent clinging to the side of the pool, huffing and puffing.    The next day, I got on my bike.  I got to the end of the driveway and realized that air in the tires would probably be helpful.  After I put air in the tires, I went for a 6 mile ride.  And it was hard.  And I felt like I would die at the end.   But I didn't.

The next day I was sore.  But it was a good kind of sore- they kind you get from a good workout.  And I realized, I haven't been sore like that in a while.  And while I was sore, my nagging tendonitis and back pain hadn't been aggravated the way they are after a run.  

So, I've decided to go for it.  And I've put it out here so that there is no chance that I'll chicken out.  For anyone that cares to join me- it's the Kingston Triathlon on August 11th.  

Monday, June 10, 2013

Physicals, Billing and Insurance: Coding 101

The "annual physical exam" is somewhat sacrosanct. It's also a bit contentious. Often doctors and patients swear by its importance, while lots of research shows that the annual physical does not really show any evidence of contributing to better health.

I'm not going to talk about the values of the annual physical today- that would be a post for another day. What I am going to talk about is how we charge for an annual physical and how an insurance company pays for it.

First off- it is imperative to understand a bit about how we charge for medical visits.  We do this by a process called coding.  Every diagnosis under the sun is assigned a "code."  There are literally tens of thousands of codes.  The code for an annual physical is V70.0.  Every time I see someone in the office, I have to write down the codes for all of the diagnoses that I am dealing with at that visit.   Then, based on the complexity of the visit, I assign an "evaluation and management code" to the visit.  This basically grades the complexity of the visit on a scale of 1 to 5, with 5 being the most complex.  How I reach that number is totally complicated and nuts, but again, that's a post for another day.

Physicals are billed using a V code.  V codes signify that medical care is taking place that does not involve an E&M level.  Preventative care, such as the annual physical, falls into this category.

What does all of this blather mean?  It means that an annual physical is purely a "wellness" visit.  Coding guidelines specifically state that there are "no complaints" for an annual physical, meaning that the patient is healthy and only preventative care is being discussed.

Why is this important?  Most insurance companies, and Medicare, pay for an annual wellness physical with no copay and no out-of-pocket expenses.  There is no deductible for most plans.  However, the only thing covered is the wellness exam.  Technically, if you have an acute complaint the day of a physical, one of two things should happen.  Option one- the appointment is no longer a physical and should be charged as a regular office visit and assigned an E&M level.  Option two- the appointment is still a physical and is charged as a physical with what is called a modifier code.  A modifier code allows both a physical and an acute office visit to be charged at the same time.  With either option one or two, you are going to have your regular copay and deductible apply, because it is no longer just a routine physical.

I don't usually take option two.  If someones acute complaints are severe enough for me to consider either of these options, I take option one.  The visit becomes a regular office visit, and we re-schedule the annual physical to another day.

Here's an example.  Let's say someone schedules an annual physical with me.  While reviewing their general health, I find out that they've had uncontrolled thirst and urination for a month.  I check their blood sugar and it's 300.  They have new-onset diabetes.  At this point, this is no longer a routine wellness visit.  I need to get lab work, start medications, and educate the patient regarding diabetes.  This needs the patient's full attention, and mine, and it deserves a visit all of its own.

Here's another example.  A patient comes in for an annual physical.  She is visibly anxious.  She just found a breast lump and is very concerned because her mother died of breast cancer.  Again, this is no longer a routine annual physical.  It is now an acute visit for a breast lump.  The patient needs some tests, possibly a referral to a surgeon, and counseling.

Get it? Here's the crux of the matter.  Just because you want a physical doesn't mean you're going to get one.  Just because you booked a physical doesn't mean you're going to get one.  What you are going to get is appropriate medical care.  The rest is just semantics.  However, if you get appropriate medical care that is NOT a routine physical, chances are your insurance company is going to want you to pay your copay and deductible.

And that's not my fault.  I don't make these Byzantine rules, but I do need to follow them.  My job is to provide the correct medical care.  My contract with your insurance company requires me to bill them appropriately.  So, DO NOT ask me to bill an acute visit as a routine physical so that your insurance will cover it.  That's called fraud.  And I won't do it.  Period.  End of discussion.  Even if you're my favoritest patient in the whole wide world.  No matter how much I love you, I won't commit fraud and risk prison time for you.  Sorry.

Wednesday, May 15, 2013

What I want my children to see.

Have you heard about the sanctimommy?  It is a lovely species that inhabits the internet, mainly frequenting Facebook, various mommy blogs and parenting forums.  A sanctimommy is a mother who is doing it all better than everyone else.  Never fear, no matter what you're doing, she's doing it better.  More than anything else, sanctimommies are sad.  Why? Because their hearts are breaking for all the children who don't have it as good as theirs.  Tears well up in their eyes when they see a mom on her phone instead of hanging on her child's every action.  When they see a toddler tantruming in the grocery store, their arms ache to hold that neglected child.  When they see an infant being fed formula, they want to shove their own breast into the baby's mouth, rather then see it take in toxic "imitation breast milk." They shame women who work outside the home by saying that their children are being raised by other people.

You get the picture.

A post I read today was a fine example.  The title is "What Our Children Want Us to See," from the Hands Free Mama Blog.  In it, the author recalls, in rather hyperbolic terms, how when she was a teacher a child once told her that he wished she was his mom.  The reasons aren't that clear- apparently he said that he just wanted his mom "to see me."  Well, that's a rather deep and existential statement from a child.  Of course, her eyes fill with tears and she has to swallow past that lump in her throat as she tries with all her might to give that child everything that she assumes is lacking from his own mother.  She then goes into a litany of things that we should "see" about our wonderful, special children.

After reading the post, I could no longer see, because my eyes had rolled too far back in my head.   I'm blown away by the idea that anyone who actually has kids can take a statement like, "I wish you were my mommy" seriously.  Kids say stuff like that and it means nothing.  Not long ago, my son told me that he wanted to live with his friend's family from now on.  Why?  Was it because I don't "see" him?  No.  It's because his friend has a trampoline.  Kids say stupid stuff.  All. The. Time.  Get over yourself, Hands Free Mama.

So, here is what I want my children to see.

I want them to see that the world is a big place, filled with billions of individuals.  Most of those people will approach life differently from them.  Learn from them- don't judge them.

I want them to see that they've been born into a privileged life in a privileged country.  This does not give them the right to project their values onto others.

I want them to see that while they are the most important thing in my life, they are not the center of the universe.

I want my boys to see, and learn, that a woman's worth is determined by more than motherhood.

I want my children to see that it really does take a village, and they need to be a part of their community.

That's it.  Let's just all do the best we can.

Tuesday, April 23, 2013

Odd Stock Photo Choices

I have informational brochures in my exam rooms.  They are about common medical conditions, and they are put out by this company.  Overall, I think they're pretty good.  The information in them is accurate and easy to understand.  My patients seem to find them helpful.  I do, however, find the cover art of the brochures to be amusing.  Take this one, for example.

That guy looks awfully happy for someone suffering from gout.  Here's a picture of acute gouty arthritis:

Now, does that look like something to smile about?  I didn't think so.

How about this one?

Again, that is not what a child with an allergic emergency looks like.  A child with an allergic emergency looks like this:

And what is up with the picture on the bottom of the brochure?  Here's a close up:

What is that? Is it a bunch of kids trying to hit a piñata?  What does that have to do with allergies?  My office manager and I were trying to figure it out.  His suggestion was that maybe they were swatting at a beehive instead of a piñata.  I thought that perhaps the piñata was filled with allergenic peanuts and shellfish.

Anyway, this is my favorite:

Yup.  The face of chronic constipation, right there.  Happy, joyful, not a care in the world!

Boy, it's a good thing I went into medicine and not marketing.  The photos I would have chosen for chronic constipation would look nothing like that.

Sunday, April 7, 2013

Oh, Joy.

I've written before about how I'm in the process of re-certifying my Internal Medicine Board Certification.  This exciting process has taken about 18 months, and it culminates next week when I take my exam.  The entire process has pretty much been a pain in the ass, and an expensive one at that, costing $1675.00.  That doesn't include review materials and the review course that I took.

One of the things that has kept me going through this process was the thought that it would be 10 long years before I had to do this again.

Until I checked my email this morning and read this email, with the subject line, "Coming in 2014: Important Changes to ABIM's MOC Program." My morning was instantly ruined.

Here are the important changes: basically, maintenance of certification is now going to have to be done on a yearly basis.  A certain amount of points will have to be earned every year.  The exam is still every 10 years.

Why are these changes being made?  Well, the Board claims it will help us "keep pace with the changes in the science of medicine."  Whatever.  I can firmly say, on the cusp of completing my most recent MOC, that it served no value to my knowledge base whatsoever.  I already have to do 50 hours of continuing medical education a year to keep my license, and in reality I do much more than that.  This is just busy work.  Oh, I get to pay $200 a year for the privilege of doing it.

Here's my opinion of the real reason.


There are roughly 250,000 ABIM diplomates.  Let's say that 10% a year do MOC under the current requirements (probably a good estimate, since you have to re-certify every 10 years).  At $1675 a pop, that's $41 million a year in MOC income.

Now let's charge all 250,000 ABIM diplomates $200/year for MOC.  That's an even $50 million.  Oh, look.  The ABIM just increased its bottom line by almost $10 million per year.  Just like that.  Over a 10 year cycle, they're up $100 million.

I wish I could make money by just changing the rules on people.

So, in summary, all I have to say to the ABIM is, "You suck.  Really.  Thanks for NOTHING."

Tuesday, April 2, 2013

AMA- Get out of my mailbox!

I'm not a member of the American Medical Association.  Never have been.  And I have no intention of joining.  Apparently I'm in good company- only about 25% of physicians belong to the organization.

I have multiple reasons for this.  The AMA, at its core, is really nothing more than a political lobbying group.  It exists to protect the interests of doctors.  That being said, their interests really don't align with mine.  The AMA is incredibly geared towards specialists.  They created the RUC, which works with the Center for Medicare Services to determine payment to physicians.  The majority of RUC members represent specialties, rather than primary care, and very few will argue that it is not responsible for the huge disparity in payment.  I'll take it a step further and say that we probably can thank the RUC and, by extension, the AMA, for contributing to the shortage of primary care physicians in the USA and the huge amount that we spend on healthcare.

Anyway, it is particularly galling to me that every month I get this in my mailbox:

Looks like a bill, right?  Even what's inside looks like a bill, at first.

Yeah, that's right.  These bozos want $420.00.  Sure.  I'll get right on it.  For good measure, they send me one at home, too.

It does such a good imitation of being a bill that my husband actually tried to pay it once...which is exactly what I think the good folks at the AMA are hoping will happen.  Luckily, I caught him before he mailed out the check.

If you look at what else is in the envelope, it becomes a little more clear.

OMG!  I can get a FREE subscription (valued at $250!!!) to JAMA if I join????  Oh, now I'm sold.  Except...this also came in the mail today.

Yeah, it's a copy of JAMA.  It comes every month, clogging up my mailbox.  I don't read it.  I get a great journal summary every month that I read instead.  I never subscribed to JAMA, yet they continue to send it to me.  Every. Week.  For the past 10 years.  That's over 500 magazines that I never asked for or wanted.  I've tried to get them to stop sending it.  No luck.

What's even more ironic is this leaflet attached to the cover of the magazine.

Renew today or they'll cut you off!!!!  Don't delay!!!  If only.  I never send the card back.  And yet, like clockwork, the cycle starts again the next month.


I think that $420 a year probably goes to postal charges.

Friday, March 29, 2013

Beacon Runners 2013

It's that time of year again.  The 9th season of the Beacon Runners is about to get started.

For the initiated- I started the Beacon Runners in 2005 as a way to encourage my patients to start exercising.  It's grown over the years...



Anyone is welcome to join- man, woman, child, dog.  All abilities are welcome- we've got an appropriate level for you, I promise.

The goal of the program is to complete a 5K race in May.

Group workouts are Saturdays at 9AM at the Red Hook Brewery and Tuesdays at 6PM at Jenness Beach.

See you there!

Wednesday, March 20, 2013

Watch an Insurance Company Try To Drive Me Insane- Algebra Edition

Wow.  Express Scripts/Medco must really HATE people who have herpes.  This is the second post in a row about trying to get proper treatment for this condition.  This time I wrote a prescription for acyclovir, a generic anti-viral.  The correct dose for suppression of herpes is 400mg twice a day.  That's what I wrote for.

Of course, they asked me to fill out a prior approval form for it.  Now, please note, acyclovir is CHEAP.  It's like, $30 a month cash.  It's the cheapest option for treatment.  But, again, like a good little soldier, I filled out their form.  And got back this:

Ok.  First of all, who the HELL figures out dosages like this?  80,000 mg of acyclovir every three months?  What????  So, I did a couple of quick calculations in my head.

400 mg x twice a day = 800 mg/day.  800 mg/day x 90 days = 72,000 mg.

So, this is what I sent back to them.

It'll be interesting to see what they say.  


80,000 mg per 90 days = 888 mg/day.  Acyclovir comes in 200, 400 and 800 mg tablets.  How do they expect anyone to take 888 mg/day?

Friday, March 8, 2013

Watch an Insurance Company Try to Drive Me Insane, Again

As you may or may not know, Express Scripts and Medco merged last year.  What are Express Scripts and Medco?  They are what's known as Pharmacy Benefits Management companies (PBMs).  Basically, they are a third party that processes prescription claims.  They are the ones who create the charming prior approval forms that I'm always complaining about.

Anyway, two of the largest companies, Express Scripts and Medco, merged. They made sure to reassure customers that they would continue to "receive the high-quality care you expect."  Well, my expectations were pretty damn low, and I'm happy to report that the newly merged company has more than met them.

Oh, I hope you enjoy my new Post-It notes that I've used to block out identifying information.  They eloquently express my feelings.

This saga started on January 8, when I received a PA form for valacyclovir, an anti-viral medication that is generic.

On January 10, I received a letter from Medco, stating that the PA was not even needed.  Please note, THE PATIENT HAD ALREADY PICKED UP THE MEDICATION ON JANUARY 8, THE SAME DAY I WAS MADE TO FILL OUT THE DAMN FORM IN THE FIRST PLACE.

Then the patient's pharmacy (CVS) called me asking, "Where the hell is the PA for this patient's medication?" despite the fact that they HAD ALREADY DISPENSED THE MEDICATION TO HER!

I faxed them the form form back saying that no PA was needed and faxed a copy of the letter to them.  They apparently didn't really care, because they sent me another request for a PA on February 5.

I faxed them a copy of the letter again.

Then, today, I received another PA from Express Scripts for the medication!  Two months into this saga.  Like a good little soldier, I filled it out again.

After I filled it out today (since I received it today), I got this fax, sent today but dated yesterday.

Apparently, they are unable to approve the medication that they have already approved.  Why not? Because apparently my evil twin withdrew the PA request.  So, Medco tells me it's not needed, Express scripts tells me it is, and hours of time are wasted.

Read what Express Scripts had to say in their press release about the merger:
"Our merger is exactly what the country needs now," said George Paz, chairman and chief executive officer, Express Scripts. "It represents the next chapter of our mission to lower costs, drive out waste in healthcare and improve patient health. We remain focused on formulary management, channel management and closing gaps in care, which will allow us to further improve the health of people with chronic and complex medical conditions.

Yup.  Tell me another one.

I can't wait to see what's waiting on the fax for me on Monday.

Tuesday, February 5, 2013

Watch an Insurance Company Try to Drive Me Insane

Lately I've been seeing a new trend for drug approvals.  Several companies have started requesting a narrative justifying why whatever was prescribed was needed.  This is annoying, because I have to dictate a whole note about it.

However, what is even more annoying in this particular case is the third paragraph.

Let's ignore, for a moment, the complete and utter randomness of the deadline of 3:24 AM.  Instead, please direct your attention to when the fax was received at my office:

That's right, folks.  The information that was due at 3:24 AM on February 4 was not even sent to me until 1:43 AM on February 5.

As if that wasn't bad enough, they felt the need to send me 14 copies of the same thing.  FOURTEEN COPIES!

Your insurance premiums at work, folks.

And yes, that is Silly Putty that you see at the top of the last photo.  I get out my frustrations by smushing and smashing it.


First thing this morning...hot off the press.

Yup.  You read that correctly.  It says that the drug is already covered and no approval is needed.  The request that they sent me FOURTEEN TIMES was not needed in the first place.