I haven’t counted how many times this happens every month, but I find it annoying. I send a prescription for a drug (sometimes not even expensive) to the pharmacy and soon after, I get a fax asking me (or my medical assistant) to go online and print a prior authorization form to complete and fax to the insurer, or answer numerous qualifying questions on the screen, or (worst of all) 
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Last week I had a patient with mild kidney disease and a high potassium. I thought that it would be easy to take care of. We called around to all the pharmacies from Bangor to Ellsworth to Belfast, and nobody had Kayexalate, the time-tested antidote, in stock. It happened to be on a Tuesday night with my Suboxone group starting at 5 o’clock. The patient had been there since 4; his ...

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Driving north in a snowstorm Tuesday of Thanksgiving week I certainly took my time. I left after our Suboxone clinic wrap-up conference, around 7:30 p.m., and arrived at my unplowed driveway in Caribou about 1 a.m. On the way up, I saw two ambulances, one from Caribou and one from Presque Isle, on their way back home from Bangor. I’ve got a large SUV with all-wheel drive and studded Finnish snow ...

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I’ve huddled since before we used the word for it: You want to be prepared for the patients coming in that day. “Followup MRI” – did they have it and what did it show? “Ankle pain” – do we have X-ray today? “Eye pain” – be sure to check her acuity and put her in a windowless room, and did the new fluorescein strips come in? All fast-paced, to the ...

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I have known him for over thirty years. He has been legally blind for the past five. He tends to be a practical, no-nonsense man. The other day, he seemed restless and very concerned as he lowered his voice and said: “I don’t want you to come to the conclusion that I’m crazy, but I’m seeing things,” he began. “I’m seeing children with elfin faces …” His large, thin hands were in ...

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I am beginning to think that we should not see chronic care patients between Thanksgiving and New Year’s Day. It just makes us look bad. Our quality metrics make the last blood pressure and the previous diabetic lab test of the year for each of our patients our final report card. We should quit while we’re ahead, in mid-November. So here we are: The office has Christmas decorations up. There are trays ...

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“Red” McDougall had terrible leg pains soon after going to bed. He did have a bad back, and some mild spinal stenosis, but I hadn’t heard much about that in the past few years. He was dealing with the ache in his legs when he was on his feet too long. A few months ago he saw his vascular surgeon for a routine followup. He’d had a femoral-popliteal bypass to restore ...

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I guess I should take it as a compliment when patients come to see me after visiting a specialist and ask me a bunch of difficult specialty-related questions. “Did you ask the specialist that?” I typically ask, and the answer will be a plain “no.” I’ve seen it in action. Some doctors speak quickly, say a lot, and exude so much authority that it’s hard to stop and question them. There is ...

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“Admission diagnosis: causa socialis” In my training in Sweden, it was not unusual to admit patients to the hospital for social reasons: an elderly person who could no longer manage at home, a person whose social network fell apart, and so on. “Social reasons,” causa socialis, was a legitimate diagnosis (Swedes used more Latin than Americans, at least back then). And it was used with only mild grumbling. There was a clear ...

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Health care is on a different trajectory from most other businesses today. It’s a little hard to understand why. In business, mass market products and services have always competed on price or perceived quality. Think Walmart or Mercedes-Benz, even the Model T Ford. But the real money and the real excitement in business is moving away from price and measurable cookie-cutter quality to the intangibles of authority, influence, and trust. This, ...

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