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Tag: Lucy Hornstein

The White Coat

I have not worn a white coat since I opened my own practice more than twenty years ago.

Not that I had anything against white coats in principle. I wore my short white one in med school with pride, and the longer one in residency too; their pockets filled to bursting with the 4 x 6 inch six-ring binder emblazoned with my name in gold, courtesy of Burroughs-Wellcome, the long-defunct pharma giant, which had presented one to each medical student in the US for many years, as well as assorted pens, note cards, alcohol wipes, hemoccult cards, and so forth. I even had a tiny teddy bear pinned to my lapel, my own way of personalizing the impersonal.

When I went out on my own, though, I made the conscious decision not to wear one. I confess that all these years later, I don’t completely recall my thought processes on the subject. It seemed pretentious, especially since I was the only doctor in the office and therefore not easily confused with other staffers. Little kids were scared of them, held the common wisdom. I decided that I wanted to project a warmer, less formal tone now that I was out on my own and could do whatever I wanted. Don’t get me wrong: I took pains to remain quite professional. I wore skirts, hose, and heels (sensible low ones, of course) at all times.

Patients noticed, and often commented. My explanations were accepted. It was my style, and I’ve always been comfortable with it. Even when a broken foot 10 years agoled me to begin wearing slacks instead of skirts, I never even considered wearing a white coat.

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Guidelines are in the Eye of the Beholder

Cancer. Just the word is scary. Actually, that’s the problem. Once you say that word, the average American will do anything — ANYTHING! — to just get it out of my body!!! Whether or not they have it, whatever the actual numerical chances of their ever developing it, no chance for detecting or treating it should ever be neglected. EVER! Ask any Med-mal lawyer. Better, ask any twelve average people off the street (ie, the ones who are going to wind up on a jury). “The doctor didn’t do every possible test/procedure, and now the patient has CANCER? String him up!”

Hence we have the new guidelines for PSA testing. (Given that many patients with prostate cancer have normal PSAs and lots of patients with high PSAs don’t have prostate cancer, it doesn’t seem semantically correct to call it “prostate cancer screening”.) Surprise! Turns out that not only does PSA testing not save lives, but that urologists don’t really care. Certainly not enough to stop recommending PSAs to just about everyone they can get their hands on.

Nor do breast surgeons have any intention of modifying their recommendations, not only in light of new understandings of the limitations of mammography, but even as their own treatment recommendations contract, becoming ever more targeted and less invasive. I recently heard a local surgeon speak about the progression from radical mastectomies to partial mastectomies to lumpectomies; from axillary node dissections to sentinel node sampling; from whole-breast radiation to intra-cavitary seeds. Listening to him, breast cancer therapy is becoming downright minimalist.

Yet at the end of the talk, when asked about the new recommendations for biennial mammography, his response was, “Every woman should have an annual mammogram starting at age 40. I mean, there are no downsides to mammography.” Never mind the psychological stress of extra views, ultrasounds, and false positives, not to mention the bruising and even skin tearing that I see far more often than I’d like. “No downsides”? Not for him, that’s for sure. When will they realize that mammography catches slower-growing cancers that would be treated just as easily if they were found a year later? Women die of aggressive tumors that pop up between annual mammograms, which by definition would not be detected by standard screening.

The gynecologists are no better. They all still insist on annual visits for paps to find cancers that take 10 years to grow (and then only in the presence of HPV) and pelvic exams that detect, well, nothing. Whether driven by legal concerns or patient insistence, scientifically unnecessary medical care is running rampant in this country, playing a pivotal role in bankrupting us in the Orwellian name of “the best medical care in the world”.

What to do, though?

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Meaningful Use Requires Meaningless Data

Race is a medically meaningless concept.

Spare me the few tired cliches about prostate cancer, diabetes, and sarcoidosis being more common in blacks than whites, or even the slightly increased risk of ACEI cough in patients of Asian descent. We screen Jews of Ashkenazi descent for Tay Sachs without any racial labeling. All that information is readily accessible under the Family History section of the medical history. It is no more than custom which dictates the standard introductory format including age, race, and gender. It turns out I’ve blogged about this before at some length (pretty good post, actually). What is new is the advent of electronic medical records.

Much hullabaloo has been made about federal stimulus funds allocated to doctors as payments for adopting EMRs; “up to $44,000!” Here’s the problem with that figure, though, including how it breaks down (source here):

[M]aintaining [an EMR] costs multiple thousands of dollars a year. Bear in mind that they’re not talking about a lump sum payment of $44,000. It’s $18,000 the first year, $12,000 the second year, $8000 the next, $4000 the next, and then $2000, for a total of $44,000 spread over five years. FOR A SYSTEM EXPECTED TO COST AN AVERAGE OF $10,000 PER DOCTOR PER YEAR, not counting the start up costs, which run in the vicinity of $50,000. $44,000 over five years for something that will cost us $90,000 over the same period? And that’s even if they actually get around to giving out the money in the first place! According to this, in order to qualify for “meaningful use,” EMRs must be used for ePrescribing, for communicating with other EMRs like labs and hospitals, and for transmitting information on performance measures (the paternalistic proxy for “quality”) to the government.

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The Year of Going Paperless

Seven months into 2011, things look very different than they did this time last year at my office. Not only have I been using an electronic medical record for nine months now, but I’ve also been submitting claims electronically (through a free clearinghouse) using an online practice management system. I’ve also begun scanning patients’ insurance cards into the computer, as well as converting all the paper insurance Explanation of Benefits (EOBs) into digital form. I’ve even scanned all my office bills and business paperwork and tossed all the actual paper into one big box. As of the first of the year I even stopped generating “daysheets” at the end of work each day. After all, with my new system I can always call up the information I want whenever I need it.

How did such a committed papyrophile get to this point? It is the culmination of a process that actually began last summer with the purchase of an adorable refurbished little desktop scanner from Woot ($79.99, retails for $199, such a deal!) The organizational software is useless for my purposes, but it does generate OCR PDFs, which makes copying and pasting ID numbers from insurance cards into wherever else they need to be a piece of proverbial cake. The first step was to start scanning the office’s administrative paperwork (phone bills, electric, etc), since that didn’t affect the staff’s workflow. Suddenly, instead of having to sort the increasingly teetering piles of paper bills into file folders in an upstairs desk drawer, I had a single file on my computer where I could access any document I needed with a click or two.

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