Ode To Mr. Fingerprint

We can’t figure it out, exactly.  There isn’t one thing that we can point to and say, “Yeah!  That’s were everything became too much.”

But somewhere along the way, this little adventure piled up and reduced both of us to tears.  How the Army manages to organize itself enough to go around the world killing people – unless through excessive paperwork – still mystifies me.  But I can say that if they just stuck to the paperwork – threatened to attack the terrorists with administrative paperwork – world peace would be ho-hum news. 

“We give up!  We recant!  Never mind all that Allah stuff!  We’re Americans now.  Look, look, we’re buying Hummers and we all have flat-screen T.V. in our camel-skin tents with only CNN and Disney channels on them.”

I will say this:  With exception of the laudable fingerprint dude, I have never been to an Army office and gotten done what I came there to do on my first attempt.  Never.  And, for the guy to do my fingerprints that day, he had to overlook 2 reasons to send me away. 

If I’d had a trophy, I would have given it to him.  I DID sing his praises; describing his feat in a halting, emotional, too-grateful voice.

“I….I….I just want to let you know that.  *AHEM!*  Sorry, something in my throat.  Some sort of lump.  Anyway….”

Corpulent man in too-short square tie knit by kids in Taiwan R.O.C. funded by Wal-Mart stares dully, shifting slightly in his creaking office chair.

“You’re the first, EVER, to give me what I came to get on my very first attempt!  It’s a record.  Over the past 6 months, in dozens – maybe hundreds – of office visits my wife and I have needed to make just so I can do a job, you’re the first to not send me away on my first request.”

“Huh.  That’s good.  Fill out an I.C.E. card, alright?”

“What’s that?”

“A card.  You know, a card.  Tell ’em how I’m doin’.  Let ’em know I set you up.”

Right.  I.C.E. card.  I took that thing home, spent 45 minutes filling it up with love and gratitude toward the first man EVER to spare me making 2+ trips just to get a simple administrative task done.

Then I realized it would take another trip to that office to put the card in the guy’s box.

And I shredded the thing.

Doctor Sells Insurance For His Own Procedures

**The following is another installment in an SW101 exclusive series entitled Medicine In America (MIA), covered by our crack journalist team scattered around the globe.**

TULSA, OK – “Just in case I screw something up,”  Dr. Jason Hines says, smiling, as he helps an elderly man sign a form and pay for his “procedure insurance.”

Dr. Hines, owner of New Day Family Medicine, a small group practice here, is one of a growing number of primary care doctors who are getting creative as they struggle to increase falling reimbursements.

“I got the idea from my very own Family Medicine Academy,”  Hines says excitedly, holding up a postcard with bold, red letters emblazoned across the top reading LAST CHANCE!  “They’ve been trying to get me to buy their life insurance policies for about 2 years.  This is the 14th ‘last chance’ notification I’ve gotten.

“Then it struck me!  Even the AAFP is getting in on insurance, why can’t I?  I mean, we can’t all be lawyers and dentists, right?  Gotta make the bucks somehow. ”

Dr. Hines’ fledgling business-within-a-business had a rough start.  “Nobody saw a need for it,”  he said.

Debbie Lawrence, one of the first patients to sign on, described her initial doubts.  “It seemed a little strange, you know?  I’ve already got insurance for my car, my house, for medical bills.  I even usually get that extra insurance for rented DVD’s.  But then, as the doctor described the procedure of removing a mole on my back, I saw this slight tremor…and then he read me the consent form!  Boy, it just seemed like the safest thing to do.”

“I had to figure out some way to promote things.”  Hines explained.  “The postcard idea was already taken by the AAFP, so I wanted to do something more creative.”

His solution was to enroll in an acting class at the local community college.

“Watch this!”  He said excitedly.  “I’ll just reach for this piece of paper, aaaaannd NOW, I’ll have this nearly-imperceptible tremor just before I pick it up.  See that?  We really worked on the subtle-but-obvious thing in class.”

Then he modified his legally-mandated consent form process.  “So, they make you blah, blah, blah about the risks and benefits of every procedure, right?  Well, I just figured I should capitalize on that.”

His consent form reads:

My signature is proof that I consent to the forthcoming procedure.  Procedures are dangerous.  Most are not proven to actually improve anyone’s health.  I understand that I risk serious pain, including but not limited to severe disfigurement such that my children and spouse might recognize me only by mannerisms.

Often, procedures of this kind result in lasting nerve damage, potentially to the genital area.  I understand and fully consent to an ambivalent and uninspired sex life from this point forward.

Bleeding is usually something that can be stopped.  If not, I am willing and happy to slowly dwindle into a shivering unconscious blackness from which I may never emerge.

I also agree to not underestimate the risk of infection.  I realize that flesh-eating bacteria exist everywhere, at all times, and are constantly attempting to gain access to my body.  I understand that should infection occur, I may wake up with parts of my body unexpectedly reduced to nothing more than exposed skeleton held together by rotting fascia.

“That’s the mellow one,”  Hines’ states matter-of-factly.  “I use it for wart removal and immunizations.”

After the slow start, business now is booming.  Dr. Hines calculated his acting class cost – “110 bucks a unit for a 3 unit class” – at $330, which he claimed on his income taxes as a business expense.  He sells insurance for any procedure in his office, usually at a cost of $25 to $350 per procedure.  “I’m thinking of adding waiting room insurance – you know, in case the roof collapses – but we haven’t worked that angle yet.”

What has been developed is the “Cabo” insurance package, which includes a special waiting room with palm fronds, seltzer water, a chaise lounge and soft music.  Aside from guaranteeing the procedure to be safe and “up to standards”, the patient also receives a massage at the conclusion.  “Sometimes, we’ll give their dog a massage also.” He said charitably.  “After signing my consent form, people are pretty keyed up.  I usually just throw the dog in for a reduced fee.”

The AAFP did not return calls for comment, but did release this statement,

The AAFP does not condone the practice of selling non-medical products within the environment of medicine.  We believe in assisting our doctors as they provide the best care possible for the entire family.  Just look at the success of primary care medicine in America over the past 30 years for evidence of our presence in Washington.

Although the insurance business does offer unbelievable profit margins and investment returns of nearly 50%, we strongly believe that individual doctors do not have the expertise to get into the business.  Individual family doctors should leave the big business and real financial gains to organizations that are qualified to actually make money.

Finally, although we typically keep information about doctors confidential, it should be mentioned that Dr. Hines appears appears to have let his board certification lapse.  He is soon to be rejected from our community as a “fellow” if he doesn’t pay his dues by cash, check or debit/credit.

“They can say whatever they want.”  Replies Hines.  “I got the idea from them.  The AAFP opened my eyes to the fact that there’s lots of ways to make money on the medical field, as long as you don’t waste much time actually practicing medicine.  I can’t believe it took me so long to figure it out.  I’m just glad I got in on the gig now, when the para-medical business is still in it’s Golden Age.”

You Be the Doc: Shortness of Breath

Dear Doctor-reader of SW101,

In your case today, you are seeing a 58 year old woman with respiratory distress.  When you enter the exam room, she is lying on the table, sweatshirt over her head, coughing into a full sized towel.

Upon your entry, she emerges looking disheveled.  You can see that she’s sweating a bit and she is breathing a bit faster than normal (about 18 breaths per minute).  You could hear almost continual God-awful hacking well before you entered the room.

The woman is pleasant and communicative – although she constantly interrupts herself to cough so hard you think she will gag each time.  It takes her nearly 10 seconds to recover after each paroxysm of coughing.

Your patient says she has had the cough “forever”, but is has been really bad over the past 2 months.  She has taken all kinds of over the counter stuff, none working well or for long.  She uses an albuterol inhaler.  Someone somewhere said she had “asthma” once, but she doesn’t really know what that means or if it’s real.

She has a normal blood pressure.  Her pulse is around 100 (normal is 80) and respirations are already mentioned.  The O2 saturation is 97% on room air (normal is 98% or so).

What should you do, doc?

Family Medicine On The Move

Last night I spoke with the president-elect of the AAFP, Ted Epperly.  This is the guy who will shortly be running the show (as much as one person runs any national organization) at a time of dramatic change in American Medicine.

Epperly probably expends more energy in a day than I do in a week, so he’s perfect for his new job.  He mentioned that he is currently traveling close to 260 days a year.  Just the thought of being on the road that much makes me develop a nervous tic.  I often wish I could travel more…but not that much more.  I’d forget my own address.

Most of what I discussed with Epperly was with regard to running for an elected position at the AAFP.  There are numerous spots that need to be filled by family medicine residents and students every year; many of the elected spots go to attendees at the National Conference, where I’ve been for the past 5 days.  Epperly suggested that if anyone wants to lend a hand at the AAFP – student or resident – there will be a place for them.  The spot I was considering – as a delegate to the AAFP – would have required quite a bit of national travel and I needed my program director to support all the time away.  Turns out I didn’t apply for the spot and there appears to have been a good group of applicants this year to choose from anyway.  So, nothing lost by me not applying.

That said, according to Epperly anyway, I’m certainly not off the hook.  Nobody involved in family medicine is, irrespective of their involvement in the AAFP.  His premise is that American Health Care is poised for enormous changes over the next few years.  Both Obama and McCain will confront a care system that, for various complicated reason, is in shambles.  Idealogues both conservative and liberal (they like the term “progressive”) clearly see that reform of our system is imminent.  Exactly how that change occurrs, and who gets the lionshare of the “spoils” is going to be determined by how well each interested party lobbies the decision makers.  Thus, every believer in family medicine needs to be a part of the communication process.  Involvement in the AAFP is one way.  Letters to lawmakers is another.  Lobbying the AMA, letters to editors and blogging are big too (think, Kevin, M.D. etc.)

Without hesitation I say that family medicine doctors should be a major part of a health care system restructuring.  I think that family medicine – broadly-trained, general physicians – are without doubt the most effective and efficient agents in delivering health care.  I think they should have more power at the health care bargaining table than business, pharma, legal, governmental, insurance, para-professional groups, and allied health organizations that promote doctor-nurses, nurse practitioners, physician assistants, etc.

I’ve lived overseas and utilized a national health care system (Israel).  Additionally, I’ve read about the nationalized systems in New Zeland, Australia, UK, Canada, France, Germany and Japan.  While they all have their problems, one thing they have in common is an emphasis on primary care, and usually that care is provided by generalist doctors who have been trained in medical school and residency.  A recent article in the New York Times about eye-widening success in reforming health care in Siberia also describes how money was allocated almost exclusively toward primary care in individual villages.

Epperly was inspiring even because he is so confident that family medicine will prevail in this tussle for health care money.  His belief appears to be grounded in the idea that ultimately, family medicine is the best medicine not only for individuals, but also for health care systems.  Really, the only thing that appears to concern him is whether or not that message will be articulated effectively.  Epperly and some surrogates will be attending the Democratic National Convention this fall, and some other AAFP heavies will be similarly attending the Republican Convention.  The guy is on the road nearly every day in an effort to get the message out.  All who believe as he does, and as I do – that family medicine is the superior method of health care delivery – need to follow Epperly’s lead.  We may not travel the country 260 days a year, but we need to tell our stories that often.  If the world knows, healthcare wins.