Happy Thanksgiving to all, from Bob the Llamaturkey!
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Just a glimpse into the ICD-10 shows how to code the all-too-common problem of when people are injured on railway vehicles (which are not streetcars, mind you). I think it is fitting, when talking about ICD codes, to start with the area of train-wrecks...
At the beginning of 2013 I stared into the great unknown of this new practice. I had no idea which plans would succeed and which were foolish dreams. The road was much more difficult than I expected, but also much more satisfying. I spent much of my time learning what doesn't work, but in the end learned that most good ideas grow out of the remains of a hundred bad ones that didn't survive.
I have a split medical personality. On one hand, I am a pediatrician; I light up around babies and love to mess around with little kids. On the other hand, I am an Internist; I love complex problems and love talking to the elderly. But the one part of internal medicine which gives me perhaps the most joy is the opportunity to solve medical puzzles. Yes, pediatrics has puzzles in it too, but they are far more common in adults.
The term used for a medical puzzle-solver is diagnostician. It is always a great compliment to a physician to be called a great diagnostician. It means you are a good thinker, have a good store of facts, know how to organize your thoughts properly, and can see patterns in things you otherwise would never have found. It is the Sherlock Holmes, Lord Peter Whimsey, or Harry Dresden side of medicine. The diagnostician searches for clues, but especially searches where they are most often missed: right out in the open.
I am not sure anyone has called me a good diagnostician, but there are few things that give as much satisfaction in my job. It calls on my creativity, my memory, my mental organization, my ability to ask questions, my power of observation, and my ability to put all the disparate pieces together to form a cohesive whole. It's not just coming up with an answer; it's coming up with a plan.
This is also one of the sides of medicine that makes it mentally taxing. The simplest sounding problem may be something much more in disguise. "My baby has a fever" may mean nothing, or it may be Kawasaki's disease or meningitis. "I have a cough" may be bronchitis (wink-wink), it may be lung cancer, or it may be the blood pressure pill someone was given a month ago. The important thing in approaching all of these patients is to do so with a process that is as consistent as possible. I try to go through every complaint, no matter how minor, using the same process. It's always tempting to jump ahead and speed things along, but that is where the worst mistakes are made.
Here is the process I use when approaching a patient with a problem they want solved:
- Listen - I have to listen to what the patient says. How long has it gone on? What does it feel like? How long does it last? I have to pay attention to the details. Sometimes they will give the answer without knowing it, like when people say they've been tired for the past six months and then say that the neurologist started them on a medication, or that their mother died six months ago.
- Direct the dialog - it's not just about asking the right questions, it is keeping the patient on track. Often they come in saying "I have a sinus infection," or "It's an asthma flare-up again." I don't let the patients pull me to conclusions for which I don't have enough evidence. I re-direct them, asking them to only tell me facts about what they experienced. I want to hear the story as best as they remember it, asking questions to get out the things I think are most important.
- Believe the patient - Nothing makes doctors look worse than when we ignore what the patient says. I don't accept the patient's self-diagnosis, but not because I think they are lying to me; I just want to hear the story and see if I come to that conclusion as well. Patients are often very self-conscious about the story because it "sounds crazy", "doesn't make sense," or because they don't really remember things and think they will get it wrong. I do realize that people will get things wrong when they describe them, but that's where my questions come in. I ask enough questions, clarifying where they are not quite sure and repeating things to make sure I heard it right. It's OK that pain is hard to describe - it often is. I have no better source than the patient for the facts about what they experienced.
- Examine - The physical exam is just part of the data gathering put into the context of the story the patient tells. It is sometimes the tipping point, but it is the whole story in which the answer lies. A heart murmur means different things in a child, a pregnant woman, a man with acute chest pain, and an elderly woman with shortness of breath. The exam should be thorough, but also should be directed by the story. I examine people to get more puzzle pieces.
- Get more data - Family members are often helpful to give another perspective on things. Sometimes the patient has to come back several times before they remember a critical fact, or I ask the right question. I have to remember that sometimes at the first part of a movie or book, things seem confusing and contradictory, only to clarify as time passes and more facts are uncovered.
- Make a list - this is actually something I do through the whole process, and is one of the big factors separating good clinicians from bad ones. The list, known as the differential, has two parts: 1) What are the things that I must rule out? What is the worst thing this could be? and 2) What are all of the other possible things this could be? The differential takes imagination and relies on the diagnostician's knowledge base of medicine the most. I usually don't make a physical list, but I always make the mental list when listening to patients. Sometimes I can rule out serious problems just by hearing the story, but sometimes they require more testing.
- Address the fear - It's very important for clinicians to remember that patients are often afraid. If they come to the office with headache, they are often wondering if they have a brain tumor or aneurysm. If they have chest pain, they wonder if it's their heart. It's not just good medicine to ask the question, "what are they afraid of?", as the patient may be correct, it's the key to the patient's satisfaction with the care they get. It's often that fear that caused them to come to the office in the first place. A person with arm pain may actually wonder if they are having a heart attack, as arm pain goes along with angina sometimes. It's also important to know when the patient doesn't have fear; they just need an excuse for work or school.
- Order the right tests - More is not better in this case. I don't like confusing the issue by ordering unnecessary tests. A person with a bright red throat, a sandpaper-like rash, and a fever of 104 does not need a strep test. Getting one will either show what I already know, or I will ignore it because it contradicts all of the other facts. This is where the differential list comes in: I only order tests that will rule-out important bad diagnoses or strengthen the case for others. But tests are not meant to change what I know, they are meant to change what I do. I don't order an MRI on everyone with sciatic nerve pain. That test is used for deciding if someone needs surgery or not. The best test for sciatica is to treat the presumed diagnosis with steroid and perhaps physical therapy. Those people who don't respond to these treatments are the ones who might need an MRI.
- Look for patterns - It's often the pattern that makes the diagnosis, not the symptom. Headaches that are episodic - that come on for a period of time and go away completely - are likely to be migraines. Symptoms like shortness of breath, chest pain, or arm/neck pain which happen when the person exerts themselves and goes away only with rest are suggestive of heart disease. Chest pain that lasts for a few seconds and then goes away, however, is almost never a serious heart problem. This is where the experience of the clinician is the most important, as well as their ability to get a good story from the patient.
- When all else fails, do nothing - As I said before, the diagnosis sometimes has to unfold over time. Doing nothing and watching to see what happens is very often the best thing (as long as serious problems are adequately ruled-out). If the mystery symptoms go away, then who cares what it was? Patients are usually OK with doing nothing if their fears are addressed, they feel that they've been listened to, they get a good enough explanation of the plan, and they have adequate follow-up. In other words, patients actually cooperate with doctors who communicate.
Gosh, this turned out to be longer than I expected. I really do love the detective portion of my job. I get to use my creativity and communication skills, and I get to comfort the anxious, answer questions, and sometimes uncover problems before they get serious.
Let me end with a bit of advice for patients:
- Tell your story first. If you have theories, tell them only after you've told the story, otherwise you may cause the doc to jump to conclusions.
- Don't be ashamed if it sounds silly. You feel what you feel, and sometimes the strangest symptoms are the key to the diagnosis.
- Say why you came to be seen. What is the worst symptom and what do you fear the most?
- Don't insist on tests or medications. More is often less. The best doctors, in my opinion, order less tests and give less medication than the worst ones.
- Get a plan. Understand what the plan of action is, and when you should call or come back in.
- Don't ever assume. If you don't get results, never ever ever ever assume "no news is good news." Never. You got that? Never.
- Try not to be an interesting patient. It's bad when you are a puzzle to your doctor. Words like, "man, that's interesting," or, "I've never seen anything like this before," are usually bad signs. It's even worse when you are presented in front of a group of doctors or are published in a journal. Don't seek fame in this way. Stay boring.
P.S. That last one is tong-in-cheek.
Puzzle 1: Get your own Llama Puzzle Here
Puzzle 2: Yes, that is a puzzle of Michael Jackson with a llama. There are actually several of them shown here. No, I don't understand.
The GLA is an award given to people who deserve it. There is only a single criterion (that's right Latin, isn't it) needed to get a GLA: my whim. If you do something that I think is particularly GLA worthy I will publicly endow you with the award so you can display it clearly wherever you want. I would give you one warning: Oprah has been gunning for one of these for years, so try to keep it where she won't see it. This whole OWN thing was a ploy to soften me up, and I am sick of the phone calls from her and her crony, Dr. Phil.
So what do you have to do to get a GLA? Well, you actually need to head over to my other blog, Llamaricks to find out. Yes, this is a ploy to get actual submissions to that blog (as everyone so far has been a dead-beat and not sent me anything). Go on over there and see what's up in GLA land! Come on; you can do it! Believe in the power within you. Visualize your inner creative powers and expand their borders. You just have to believe.
Oh no. I think I just channeled Oprah.
I think people missed my point. Let me say again to those who misunderstood my last post: I am talking about the health care system being broken, not health care itself. Our system is broken, which means that the money put into it is being wasted in staggering amounts. Yes, we are getting some amazing results in regards to the care itself, but those happen despite the system, not because of it (most of the time, at least). My first item of broken-ness will make the point.
Our office is not getting paid this year. We used our credit line to fund my last paycheck.
Bad business? Not at all! We have worked very hard, seeing lots of patients in the usual surge that happens at this time of year. So, one would expect, more work means more pay, right? Not in our system. While we do collect some money from patients up front, most of our billing goes to a third-party (insurance or government), and in many cases a fourth party (supplemental insurance). The most important bill we send for our work goes to the "carriers," not to the patient. We have all accepted this as the norm, and it may be the only way to do health care in some circumstances. But this year there is a major glitch in the system.
I was actually not 100% truthful in my statement about who we bill. The truth is, we don't actually send our bills to insurance companies. Since there are a gazillion insurance companies, all with different contracts with different doctors, we actually send them to a clearinghouse. These companies (not to be confused with those who present giant checks at people's doorsteps) take electronic submissions from doctors' billing systems and re-routes them to the appropriate insurance vendor. This saves us the hassle of remembering where to send each bill, which would be nearly impossible. They do take a little bit of our money in the process, but the time it saves us is worth it.
Assuming the clearinghouse gets it right and sends the bill to the proper place, the insurance company then either pays on the claim, or denies it. The news of their decision then goes back through the clearinghouse and to us. If it is denied (which it often is), we figure out why that happened, and whose fault it was. Sometimes the insurance company made a "mistake" and denied it in error. Sometimes the clearinghouse sent it to the wrong branch of Blue Cross or got our identifiers wrong. Sometimes we submitted it using a bad diagnosis or other technical error. Sometimes the patient forgot to tell us their insurance changed or lapsed.
This is the day-to-day complexity of medical billing in our system.
But things aren't working this year. The problem is in the clearinghouse part of the equation. As of January 1 there was a new standard that clearinghouses had to comply with, called the "5010 of the x12 HIPAA transaction and code set standards." It puts me into a dazed stupor when I read the explanation of just what this is, but the HIPAA part has to do with patient privacy, so I suspect this is a patch to some privacy leaks in the billing system. This also has to do with the change to ICD-10 (another broken thing I'll hit on in future posts), which is the code we have to use to submit our bills to the clearinghouses and ultimately to the insurers. The problem is, many of these clearinghouses are not compliant with the 5010 rule. Since it was a government rule dealing with HIPAA and since these clearinghouses are not paid if they do not run through transactions, I assume it was a highly complex and confusion standard. In other words, they had a hard time doing all the things the government required.
But the upshot of this for us: nothing is going through. Nothing. And that means that we don't get paid.
Word on the street is that this is a nationwide problem, and we aren't the only practice not getting paid. The insurance companies have no problem with this, as they are hanging on to "their money" a little longer. The clearinghouses are frantically trying to fix this, but we're not sure when that will happen. When it does, the queue for submission will be enormous, and so the payments will undoubtedly be more delayed.
All of the complexities in our system add cost, and the billing/payment system is mind-boggling in its complexity. The bottom line is that there is always a long separation between the work I do and the payment I get. There are many steps requiring many people and giving room for many problems. These problems, of course, give more people work to do (all of whom get paid faster than I do) cleaning up the mess made by the confusingly complex system.
It reminds me of the game I played when I was a kid, where one person whispers "Llamas hygiene is next to godlessness" to the person next to them, and that person in turn whispers what they heard to the next person. When it gets to the end of the line of people, the last person tells what they heard, usually something like "the elevator spins in an ornate bathtub." This translation is often similar to what happens in our payment system, with payments not quite resembling the bill that was sent. It is, of course, our responsibility to find any errors in the payment, re-submitting them through the chain to get the payment we should get from the billing. It is our responsibility because everyone else got paid. We used to have multiple employees to do this, but now have a company that specializes in this to do the job (they get a cut of what they collect).
This gives a glimpse into a reason the cost of care is so high. I have to negotiate a higher bill than I need because of all of the other people earning money off of the transaction. I have to count in the cost of the complexity of the system. This happens everywhere a medical transaction is made, with a very large percentage of people working in health care only doing so because of the onerous complexity of the system. All of those people between those who work and those who pay them will get more work to do if that distance gets further.
It's just like that game, except: "I worked hard" translates to: "Error. Please resubmit with proper documentation and coding."
It's crazy folks.
It's broken. It's also #1 out of 53 so far.