“What diagnosis do you want to use for those ear drops you sent on Mr. Johnson,” Jenn texted me. “ICD-L21.8 for seborrheic dermatitis?” Sigh. Welcome to prior-authorization hell. These are generic ear drops I ordered for presumed fungal infection of the external ear. The cash price for the drops is $15 for a 10-milliliter bottle (I checked before prescribing them). “No,” I responded, “it would be ICD-B36.9 for otomycosis.” (translation: ear fungus) Jenn ...

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It was about ten years ago. I was already running about an hour behind, and the next patient on my schedule was a familiar one. But not for good reasons. This was a very complicated patient with huge emotional needs, whose visits would routinely go 30 to 45 minutes, well beyond the 15 minutes allotted. My heart sank. I would either have to hurry a visit with a genuinely needy person, ...

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I was struck by the difference between my care and that of the rest of the system as I cared for a patient recently. She was complaining of a strange pulsating noise in her ear that had started a few weeks before. We chatted for a while, as I asked about any sinus symptoms: If she’d ever had anything else going on like this, what other significant symptoms she was ...

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That statement from a recent patient was a summary to me of what is bad in our health care “system.”  It’s a terrible summary of what is seen all over this country with people who must make the choice between financial solvency and health. Here’s what happened:  It was a new patient I saw, who is a veteran who owns two businesses.  He went out on his own when he “kept ...

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I have good days and bad.  Some days I am content, connected, focused, and motivated.  On those days I enjoy my job, I enjoy the people I’m with, I am willing to be inconvenienced by interruptions. On other days, not so much.  I wake up as grumpy Rob and (despite multiple cups of coffee) the old codger doesn't leave me alone.  I keep score of all the ways in which life ...

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I really like Van Morrison.  If I need to be lifted up on a Friday afternoon I'll play a greatest hits album and will quickly be smiling.  One of my favorite songs is Days Like This. You would expect when someone says "there will be days like this," they are complaining about days when everything goes wrong and you just have to endure to the end, hoping that "the sun comes up ...

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I recently went hiking in a beautiful national park outside of Columbia, SC. This park was in a swampy area and contained all sorts of wildlife (called “critters” down here) and plant life (called “trees and those other things” down here). When I was young, my dad would take us kids on hikes through the Adirondack Park in New York, and so being on hikes in nature hits my soul ...

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Hi, I’m Rob.  I’m a recovering doctor. Yeah, I know I used that line once before, but it’s a special day for me today.  Humor me.  Five years ago today I earned my last money from an insurance company.  Yep, today is my five-year sobriety date. Five years. That was before the Affordable Care Act, before the Cubs won the World Series.  Before anyone knelt for the national anthem, and ...

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The consultant note read:

Weight 250 lbs. BMI 40.3.  Patient is morbidly obese.  Counseled on the dangers of excess weight.  Counseled to increase exercise and decrease calories.
I walked into her room.  She smiled at me as I walked in, a lovely smile that reached her eyes.  I scanned her record.  She was in my office for an ankle injury.  Blood pressure normal.  Weight 248 lbs., BMI 40. When I looked back at ...

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"Wait. When did you say you started that medication?" "Two weeks ago." "And when did you say you started having those symptoms?" "Uh ... about ... let me think ... it was — two weeks ago." This kind of circumstance is my holy grail. It is the ultimate moment where I connect the dots. It has happened several times recently where patients have had chronic symptoms and have related to me that they have ...

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I was really anxious.  My father's legs were getting weaker and his pain was worsening.  He had been having pain for quite a while, and that pain was often disabling in its severity, but the weakness was alarming. Dad went to the neurosurgeon, who was also alarmed at the weakness, but didn't feel that the problem was surgical in nature.  When I heard this I broke one of my most tightly-held ...

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Taxes. Doing taxes feels like a financial rectal exam.  I hate doing taxes.  Yeah, I don't like getting rectal exams either. It's not that I resent paying the government for the fine services they render and the high quality of elected officials we have. It's not the existence of taxes I hate; it's just doing taxes make me feel extremely insecure.  Sharing my personal and business finances with my accountant and the ...

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I was talking with a few friends not long ago.  Our conversation somehow got to the issue of authority, and what exactly respect for authority looks like.  One of them, trying to make a point, turned to me and asked: "So you surely deal with people who don't listen to what you have to say.  What do you do when your patients don't take the medications you prescribe?" I think he ...

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My last post discussed the wide gulf between health care and the rest of the world in the area of customer service.  To sum up what took over 1,000 words to express: Customer service in health care totally sucks because the system promotes that suckiness and does nothing to penalize docs who make people wait, ignore what they say, rush through visits, and over-charge for their care.  We ...

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No, customer service in the U.S. is terrible when it comes to health care.  No, the customer service in the U.S. health care system is horrendous.  No, health care has the worst customer service of any industry in the U.S. There.  That seems about right. What makes me utter such a bold statement?  Experience.  I regularly hear the following from people when they come to my practice:

Three (and a half) years ago, when I left my old practice, I was near burnout.  I was exhausted, not because of the amount of time I was spending -- it was actually about the same, if not less than I had worked before -- but because of an ever-increasing gulf between me and my patients.  I have always tried to give care that focused on the person with me ...

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I had a patient last week who was a real pain in the ass.  Wait.  No.  He was actually a really nice guy.  He wasn't a pain in the ass; he had a real pain in the ass.  Literally. I was initially concerned about a pilonidal cyst, given the unfortunate fact that he was previously afflicted with this condition (which I consider to be incontrovertible proof of Satan).  But, fortunately to ...

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2015 was a hard year for my father.  He's a remarkably healthy 89 year old, with no diabetes, no hypertension, and (most importantly) he's got a sharper mind than I do on most days.  Perhaps that's a low bar to cross, but it's pretty good for him.  I think this is from all the crossword puzzles he's done over the years. Dad's troubles started around the middle of the year when ...

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October 1, 2015 is a huge day to the medical community.  It is a day that will live in infamy.  It is the object of dread, of diaphoresis, of doom.  October 1 is ICD-10 day.  This view was further bolstered when I went to the CMS (Government Medicare) website; there was actually a doomsday countdown timer at the top of the page. For those still unaware, ICD-10 is the 10th iteration of ...

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I recently attended (and spoke at) the Concierge Medicine Assembly in Atlanta.  My role was to give the perspective of a "successful" direct primary care (DPC) practice.  This being the second such conference in three weeks, I've learned that my panel of 600+ patients and survival for two and a half years puts me in the higher ranks of solo DPC practices.  The Atlanta conference was actually a combination conference, catering to ...

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