Open Mic Night


I wanted to try something new, and got the idea from Ace of Spades. We’ll see how it goes.

Tonight and tomorrow, I’m leaving an open mic for comments. Anyone can comment on anything that they want to get off their chest. I’ll throw my two cents in the comments section when I get some free time on Monday.

Only requirement for the open mic is that the comments have to be medically-related. I don’t want to get into political arguments on this site.

Please keep things civil. Remember that if you disagree with a comment, attack the idea, don’t attack the poster – no ad hominems.

Let ‘er rip.


  1. What is it with patients who are completely passive in their care? I mean the ones that won’t even take off their own covers when they ask for an assist to the bathroom. I actually had one patient who would not even scratch her own nose! She asked her family member to do it! Honestly — I just don’t get it. I fully understand using anger and hysteria as coping mechanisms, but I just can’t comprehend passivity. What do they do when no one is there to help them?

    • I was going to link to an article on learned helplessness, but the situations you are describing are beyond that. Dang.
      Hide the call bells.

  2. Mama On A Budget on

    Why do I need to make an appointment to see a doctor in order to just get the prescription to get lab work done… the results of which I won’t get unless I make ANOTHER appointment to see the doctor?

    I just want to scream, “NEWSFLASH! I’m a thyroid 33 year old thyroid patient. Uninsured thyroid patient. I get that I’m going to more than likely be on meds the rest of my life since I’ve been on them the last 5 years. I get that I have to come in once a year for a physical/girly exam, etc – I’m okay with that. I’m NOT okay with having to spend $150-250 to get a frickin’ piece of paper. Why can’t I just go to a lab and say, ‘I want my TSH tested, please… T3/T4 if I can afford it, too. Thanks!'” I’m not asking for a PET scan or a CT or a full work-up – I’m not even asking for the results to be passed under the table to me without a doctor. I’m asking for the same test I’ve had run multiple times a year for most of my life – I’ll go to the professional for the results and prescription info.

    And while I’m griping (thanks for the opportunity), when are we going to get the “menu” of charges before committing to services/tests? I *want* to be responsible and proactive with my health care – but I also want to be able to afford to feed my kids. So when I find myself with some weird symptom or some very obvious change in my physical health, how I can know that going to the doctor is only going to be $200 for 15 minutes – not that the 15 minutes will get coded for some odd classification that ends up costing my 3 times as much. I’m totally fine with being told mid-appointment, “If we keep discussing XYZ, this appointment will move up a level of care classification and will end up costing more.” But I can’t even prepare in advance to pay cash at the window if I can’t know in advance that the visit costs X, the pap costs Y, the test will cost Z, etc.

    • Your doctor can write a standing order for labs that need to be checked repeatedly. There’s no reason that you have to pay to get the order and pay again to get the results, although I understand that the doctor should be compensated for the time and expertise needed to evaluate the lab results. In my case, my doctor wrote “copy to patient” on my standing order, and the lab sends me my results. Bloodwork every 6 weeks, check-up every 3 months – with the understanding that if the labs come back screwy I’ll have to go in to have that addressed. You should have a heart-to-heart with your MD to see if there isn’t a similar solution that’s better for your financial situation.

      • I have to side with Mama, despite being a doc. All medications that are as safe in use and overdose as the current over the counter ones should be available in low doses without a prescription.

        If the patient has an established diagnosis, she should be able to order routine, harmless blood work without a prescription, if willing to pay cash for it.

        She should be able to have a visit by email (with no set time). She can pay $5 a minute for the doctor’s time. If he takes 2 minutes to reply, she owes him $10. Doctors who type too slowly should charge less. All insurance should have $10,000 deductible, and cash should come from a medical savings account. Under such an arrangement, the patient is doing her own pre-authorizations, “Doctor, please, explain how this MRI will change your decision making. If you are afraid of being sued, I agree to not suing you for not doing this MRI.”

      • @SC – sure, it would be great if she could order her own labwork; since she can’t, wishing for change doesn’t solve her problem right now. Given that writing her own lab orders isn’t allowed, how can she do what needs to be done in a more affordable manner? Wouldn’t it work to explain the problem to her doctor and ask if there’s a more economical option?

      • I can’t think of any way, under current circumstances. I have accused lawyers of rent seeking. The licensing requirements of medicine may dwarf the rent seeking of lawyers.

        Try to find a very busy doctor. Busy means others think she is good. Busy means she will schedule for medical necessity, not for the need to generate more fees. Busy means she will be amenable to efficiencies such as those from email. I respect my own doctor’s time and skill. I may mail them a form to fill out and to sign. But I slip a $20 bill in the envelope. It just recognizes the value of their service. It is mail, not a visit. The visit would cost me more, plus the value of the time to travel there, wait, be seen, and travel back to work. So the $20 is a bargain.

    • I have a congenital disorder that requires me to see a specialist at least once a year. When I was a kid, my doctor’s office would send us the lab order a few weeks prior to the visit so I could get the labs drawn beforehand. He’d then have the results ready to discuss at my appointment. The doctor I see now does the lab order at my visit and then emails me after with the results and any medication changes. If there’s anything particularly screwy he might suggest I come back to discuss it, although that hasn’t happened yet. Maybe your doctor would be willing to try one of those two methods.

    • There is a place in my town called “Any Lab Test Now” perhaps they have a franchise? STD’s, drug screenings and paternity testing seem to be their bread and butter but “any” does imply flexibility.

  3. okay, here’s my open mic comment.

    as of 8/1 i am reducing my clinical time by 33%. this is the first of what will hopefully be a multi-step process to pull out of clinical practice completely. this is for a multitude of reasons but the final straw was something i still cannot really discuss in detail- let’s just say the outcome is very likely to be favorable for me but i will be twisting in the wind for a long while before getting any kind of closure, and just leave it at that.

    there is so much nonsense in my line of work that i would have been willing to take a paycut to be relieved from some of the hassles. as it turns out, my new job will pay me more both for my clinical and nonclinical time. whod’ve figured? it takes my career in a direction i had not anticipated, and i’m not sure i’ll continue on this particular path but it will definitely give me experience that is applicable to a wide range of nonclinical work going forward and will open a lot of doors for me.

    several of my colleagues are also pursuing other careers. of course, one can argue that there is still no convincing evidence that emergency physicians are leaving clinical practice and access is worsening for patients- that these are all just anecdotal, isolated examples. you are welcome to believe that. i have nothing to gain by convincing the unconvinceable. all i know is that in a few weeks, i will have a little more peace of mind.

    i intend to keep my licensure and board certification current. i am hoping to some day work entirely nonclinically, and spend some time out of the year doing charity emergency care abroad in an underserved area- just getting back to helping people without the government, insurance companies, administrators, and trial lawyers getting in the way. i’ll sit back and wait for the actually needed reform to happen in this country in the hope that some day i can return and give americans the help they need. i won’t be holding my breath.

  4. There is a drug called Relistor that treats opioid-induced constipation. It’s expensive, and it’s only injectable, but it’s awesome for when no other laxative works.

    It’s a mu-opioid receptor antagonist that just works in the gut, so it has no effect on pain relief.

    Somewhat OT for an emergency medicine blog, but I wish that more doctors would take bowel management seriously with their patients who are taking a ton of opiates. Although, Relistor could come in handy in an emergency context, I guess. Do people ever come in with really, really bad constipation?

    • I gave this once- on a patient with a large and small bowel obstruction. It was ordered by a doctor who swore to me he just looked at the flat plate and there was no obstruction. It wasn’t good.

    • Reminds me of an old recipe I used to use for constipation in cancer patients on opiates.

      2 cups finely chopped raisins
      1 cup finely chopped dates
      1 cup finely chopped prunes
      1 box senna leaves (finely chopped)

      Mix all ingredients together. Add small amounts water until mixture can be flattened out into small pan.
      Cut into small bars.
      Cover each bar in graham cracker crumbs.
      Freeze on cookie sheet then put frozen bars in bag in freezer.
      Eat them with a large glass of water.

      • My husband’s constipation would not have been impressed. It was pretty special, though.

        I just wish all docs would have a policy of recommending a bowel regimen whenever they prescribe opiates, and asking about bowel health at any follow-ups. Especially for patients taking high doses.

  5. Aaron in Florida on

    *ahem* Vancocin capsules. STOP FUCKING PRESCRIBING THEM.

    Vials of vancomycin + sterile water + cherry syrup = C. Diff treatment for 1/10th the cost.

    • I’m with you.
      On my old blog I compared the cost of a week’s worth of vancomycin pills (28 pills) at $1800 versus a weeks worth of vancomycin IV solution to drink ($60) for treatment of c. diff in a family member.

  6. I want to know why pharmacy (Rite Aid) sells freaking homepatheic meds. Seriously? The diluted stuff..please… Now there are some interesting “alternative” herbal crap out there…at least that could do something…

    And antibotics in farm animals. Why haven’t the FDA pressure the USDA to stop making superbugs (oh yeah…$$$$)

    And why is my body falling apart at age 37?

    • I just remembered that homepatheic pills are sweet. They’re glorified sugar pills! I think if they work at all it’s the placebo effect.

  7. After being the accouting and budget manager working in a sliding scale clinic… I think the public can benefit from this model incorporated with some HSA and high deductible ins plans. In this model, self pay individuals (those without insurance) pay for their medical care based on their income. Our clients actually had significant bills (example: $250 for a visit at 175% of the poverty line) and were thankful for the opportunnity to see a doc. Just a thought

  8. I have health insurance with a high deductible so that the monthly premiums are kept to a level I can afford. Meanwhile I’m the one who is actually paying for my office visits. So I think I should qualify for a discount for paying cash…is this possible?

    And why is dental care considered separate from medical care? I have no dental insurance and have to pay cash, but my dentist doesn’t give discounts for cash payments even though it simplifies their bookkeeping. Any suggestions about how to influence my dentist to give cash discounts??????

    • When I lost dental insurance, my dentist recommended getting my cleanings done at the local training college for dental assistants. $30 instead of $150 was a great deal, and instructors check the students’ work when they’re done.

    • Absolutely possible. Call around to doctor’s offices and ask what the fee is for paying in cash at the time of visit.
      Make sure that you tell them you plan to pay at the time of visit and don’t expect to be “billed” – most offices won’t accept the “see me now pay me later” approach.
      Shop around for dentists, too. You’d be surprised how many will discount services for cash up front.

  9. There should be a “penalty box” in the ER where demanding patients and family members with Entitlement Disorder (TM) have to sit for misbehaving. Each penalty is an additional 20 minutes of waiting before the MD will see them.

    • i’m gonna guess there are a lot of places/docs that operate with unofficial penalty boxes. also i believe the correct diagnostic entity is “entitlementiasis.”

      • Everyone suffers from that, even (maybe even especially) physicians.

        But from the patient side of it, why shouldn’t they suffer from it? When you don’t pay the true cost of something, particularly a professional’s time, you’re much less likely to value it.

      • Mama On A Budget on

        Matt – that’s exactly the problem that I’m talking about. HOW do we find out ahead of time what the physician (or other professional) believes their time’s value is? I have ZERO problem paying someone what they’re worth. But, as the patient in this scenario, I can’t go into my doctor’s office and get a menu of what the types of appointments are going to cost. Heck, even those “minute clinic” places only give lists of how much the average visit will be “after insurance.”

        No insurance! What’s the *actual price* without the slight of hand? I can’t afford $500/mo for just me to be insured and get the privilege of paying a $1000 deductible on top of that. If my child wakes up with a sore throat and white pockets on the tonsils, is it more affordable for me to go to the Family Practice med center up the road or drive to the next town for the minute clinic? Or the urgent care? This isn’t an ER issue. But what if it was? Broken arm… ER here or ER there? Wouldn’t that be great to know ahead of time, or to be able to check on the way to the hospital (assuming someone else is driving)? Every other profession has to let you know what kind of expenses you’re getting into. Not doctors or hospitals. I live in fear of waiting too long to go to a doctor because I’m afraid of going too soon and bankrupting my family for lack of pricing knowledge.

      • Most urgent care places should be able to tell you their prices. I went into an urgent care center about 6 months ago, and when I told them I didn’t have health insurance, they told me how much the visit would be. When I saw the doctor, he recognized that I was self-pay, and asked me before performing each test if I wanted it done and how much it was going to cost (example: “Recent studies have shown that women who come in complaining of urinary tract infections can be diagnosed and treated based solely on their symptoms. A urinalysis will cost $20 [this could be wrong, I don’t remember the exact cost], do you want to do it anyway?”). That information is available, you just might have to be a little more proactive about obtaining it.

  10. “Matt – that’s exactly the problem that I’m talking about. HOW do we find out ahead of time what the physician (or other professional) believes their time’s value is”

    For most other professions, you just ask. As a professional, I may offer you different billing options (flat fee, percentage of gross in certain types of cases, or hourly), but I can give you plenty of choices and we’ll find one that works for you. I recently hired an architect – same thing.

    Physicians can’t do that. I read somewhere that the way the govt. got physicians to support Medicare was the fact that physicians realized they would get compensated for may things they’d previously done for free. Any professional who bills by the hour and bills directly to the client knows exactly why they saw that as appealing. But the physician profession apparently never realized the downside. And it’s taken 40 years to come about.

    But it’s here now.

    • okay, leaving aside the validity of those numbers (both of which can vary widely based on how you define medicare fraud and defensive medicine, which in both cases will give you a huge range of numbers in potential money saved depending on what your agenda is), i would argue that $60B a year and $54B a decade are both large sums of money that we should try to save. why just choose one? wouldn’t you agree?

      • If we can come up with a way to reduce “defensive medicine”, I’m all for it. The remedies we’ve been trying for the last 40 years haven’t worked.

    • I agree with you.
      What can we do to convince the government to curb its payment model?
      Now the feds are organizing legalized hit men to shake down medical providers via “RAC audits.”
      Pay out on billions of dollars of fraudulent claims while shaking down practitioners for questionable claims and driving them from the business.
      Doesn’t make sense to me.

  11. Random FYI: Way before Crass-Pollination, I used to write for Ace of Spades HQ (like when it was still on blogspot), and I’ve met some of Ace’s friends (but never Ace, he was kind of elusive). True story.

  12. Does anyone have any advice on how to find a good doctor who is still accepting new patients? I have a friend who has moved to a new state and has a child with serious medical problems. I’d like to be able to do some background research for her on the doctors in the area and give her some leads to follow up in person. However, the patient doctor rating sites seem to be more a measure of bedside manner than clinical competence. Often it seems to come down to looking at the list of in-network providers and picking the one with the friendliest name. There has got to be a better way! Help?

    • First, contact the state and/or local medical associations. See if the doctor has been disciplined.
      Check for local doctor web sites.
      Go to the medical staff office at the hospital in the area. Ask about the doctor. If you’re nice and explain your situation, you might even get them to tell you what doctor they’d go to if they had a problem.
      Look through newspaper archives to see if a doctor has written articles.
      See if the doctor is on staff at any nearby medical schools or residency programs. Teaching is always a good sign. Call the programs and see if you can get an appointment with a staff doc.
      Contact the national organizations (the American Academy of Pediatrics in your friend’s case). See if they have any specialists in your area that treat your friend’s child’s medical problems.

      Unfortunately, the way that things are headed in this system, if your friend’s child has Medicaid, it is going to be difficult for them to find a provider outside of a county hospital system or residency program.

      • The Medicaid thing is a state-by-state deal. Around here, nearly everyone accepts Medicaid.

        Twice I’ve selected MDs based on teaching hospital-type stuff. Who is “known” at the university, etc. However, it seemed there is no time for me and my appointment. They’re lecturing, rounding at the hospital, tied up in some meeting, or else they’re around and I get checked by a med student and then the doctor appears an hour later. Fair warning.

        Every time I used the “friend recommendation” method, the MD was not accepting new patients…probably a good sign.

        I’d personally make an appointment with a pediatrician affiliated with a children’s hospital and get their recommendations. I’d select this pediatrician by calling the clinic, asking to speak to a nurse, and telling the nurse about the child’s medical problems and asking them to recommend a provider there who has an interest in that particular thing.

      • Being checked by a medical student is actually not a bad thing. They have lots of supervision and have the most time of any care provider to spend listening to you, understanding your concerns and chasing down your test results. As a medical student I have been told by many patients that the time I spent answering questions and listening made their hospital stay much improved over previous visits.
        Additionally, medical students can advocate on your behalf to other providers. For example, I had a patient recently with terminal cancer with spinal mets and new leg pain. His spinal canal stenosis was unchanged and he had already had radiation. I looked at his scans and thought the tumor extended outside the vertebral column. I went back to radiology and requested the scan be reread looking for extra-vertebral mass. I took that to radiation oncology and verified he had not received the max dose of radiation to that area. He is now receiving palliative radiation that will significantly reduce his pain in his remaining months of life.
        As medical students we carry a lower patient load than other physicians so we have more time to spend with you and advocating on your behalf. Isn’t more time something that everyone wants from their doctor?

  13. Design…I actually had a really lifestyle-killing medical problem cured by a medical student (apparently by himself) after 1.5 bajillion visits to a specialist and internists. He’s all have you tried [insert name of cheap, effective drug here] in addition to your current drug? So I tried said drug, and after 9 months of suffering, my symptoms were 100% resolved. New set of eyes. Student health, baby. Feel the power.

    But for my chronic medical problem that I’ve had since I was a child that requires prescription refills and monitoring labs, it’s really annoying to wait three hours at the (non student-health, but university affiliated) clinic to be seen when another doc can do the same thing in 25 minutes. If this lady’s kid needs frequent visits, she’d probably want to shoot herself between the eyes if she was being squeezed in between rounding, lectures and all that though. Really just depends on how the thing is set up.

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