Super Doctor.

I was talking to a fellow physician and he inquired “how many patients do you see in a day” I said “maybe around 20”.  He smirked and replied “20 ONLY! I can see around 40 in a day and still have time to hit some balls”. Hmmmmm....... there is something fishy here at Smallville.

Few years ago I used to work for this company; I had no option but to see a huge number of patients. Sometimes my census would be around 40 or so. I remember one day that I got 26 new admissions. I took care of them all along with the patients who were already on my list. By the end of the day I was a tad confused. When nurses would call it would take me a moment to recall a patient. I would have to think twice so that I don’t confuse a chest painer with a GI bleeder.

You can see a lot of patients but I think it is not fair to the patient. As I always say it is just not about billing. You can not provide adequate care when you are breezing through your list. The goal is not just to see them but to make the right decisions. One way to see them would be to call 20 thousand consults and let other doctors make decisions for you or you can try to see them like you should and spend your whole day ……. and night seeing them all.

Devil is in the details…. If you are detail oriented and if you have a good system in place, then you decrease your chance of error. Believe me it is going to happen… you will make an error (Murphy’s Law) but the difference is the gravity of error.

So what is the magic number, various factors play a role when you consider the right number of patients to see. If you have midlevel support or you have residents, than you can probably see more but that is not the case for most of us. I think 15-20 patients per day is a fair number in a 12 hours shift in a hospital setting. I read  this article sometime ago at Today’s Hospitalist, it nicely breaks down various situations vs census of patient accordingly.

I call these doctors Super Doctors. It is like "look! It's a bird. . . . It's a plane. . . . No....It is a SUPERDOCTOR!” No patient can really identify what breezed through them. But just remember it takes only one kryptonite to bring down the mighty. 


About the pic: Not Krytonite, it is a Topaz at Smithsonian Museum at DC.

Birthday Party and "I Have A Sick One"

Birthday is supposed to be your day, you enjoy, relax and have fun with your friends and family. Statistically and according to my personal observation, people who have the most birthdays usually live the most.

Few days ago I had mine, somehow it doesn't look kosher if you try to take a day off. My birthday started a little early with a page from ER around 2 in the morning. They gave me routine greetings and put me on hold for some major announcement. Soon I was talking to a fellow physician who said those dreaded 5 words "I have a sick one". When you hear something like this you know you better get up and get ready. Someone is heading to ICU. 

I drove to the ER, dodging few deers (Yes real deer!) and reached there around 3 in the morning. This lady was really sick, she literally decided to throw the book at me. She saved all known critical medical problems for me specially for this day. That took few hours to stabilize. At the same time I was informed that a turkey gulper is waiting for me. Around thanksgiving I usually see one or two who decide to gulp a turkey without utilizing the mastication process which results in a turkey stuck in limbo in the esophagus.  Anyways patients kept on pouring in for the rest of the day without showing any sensitivity that it was my birthday. 

Later I went to the wound care center where my office manager Debbie was kind enough to bring this cake, 

due to lack of resources I had to use a scalpel to cut this cake. The rest of the day passed by pretty fast. I came home around 6 pm, pretty fatigued for the day but it was lovely to see my family and have a great dinner.

PS: No wounds were harmed while utilizing this particular scalpel.

Flu Shot, Did You Get One?

According to CDC (Center for disease control), flu 2010-2011 season started in October and it will peak in January. Current recommendations are that everyone above 6  months of age should get the vaccine. This year you don't have to get a separate vaccine, this year vaccine includes protection against 2009 H1N1, H3N2 and influenza  B  virus.

I got my Flu shot early last month at the hospital cafeteria, I was ambushed as I was on my way to get some food. Unfortunately my wife and our two daughters were not so lucky. So as we got out of the plane at Washington Dulles Airport, we saw a kiosk right near the baggage claim, personals over there were offering free Flu vaccine. My wife got a shot and the little ones got nasal sprays. Children were overjoyed when they figured out that they will get a "mist" rather than a shot.

Anyway I like this campaign, it is very effective and convenient. Don't forget to get your shot.

21% Medicare Cuts and Air Tran.

Some of my blogs get published at other online websites like here at KevinMD.com; I saw a number of comments at one of my recent post which I originally published it here. Some of these comments were thoughtful, some very critical and some very amusing. I would like to mention few here.

“I had a plumber come to my house to snake out a blocked sewer line. Two guys showed, and it took them an hour to do the job. The bill? $100.00 plus the cost of a new wax seal for the toilet bowl. You can’t say hello to a doctor for that kind of money. 

“Which is why they make about 500% more than plumbers on average. And they make that regardless of whether the job they do is phenomenal or not.”

“I don’t know about finances but patients are much more likely to say thank you after I teach them to SCUBA dive than after I save their kid’s life. They are also much more likely to pay their fees to the scuba shop for certification than they are to my office for vaccination of their infant.”

Well I can answer some of their concerns but I will leave it for everyone else to make their own inference.  

I recently traveled through Air Tran, I took a picture of this pretzel packet, I found the text very amusing and very practical on the other hand.

It is a possibility that with recent fear of 21% cuts to Medicare payments, we may just not have problems with finding treatment for our elderly, just like it takes forever for Medicaid patients to get an appointment. But we may also find little brochures in hospitals and doctors offices with similar language.

You Think You Got It Bad.

Usually I do not post these videos, but sometimes you see certain thing which make you wonder how. If you think that you got it bad you got to see this video.

Last Chapter.

My friend who inspired me start this blog died last week. I wrote about him here and here.

I was out of town when this happened. My motivation was really low to write anything. Around the same time I had couple of injuries, I tore a muscle and most recently a hand injury while running. So all of these events compounded to this recent hiatus.

I came back last night and I saw his family today. The problem is what can you really say? not much. Even if you say anything it does not change anything. 

He recently received Patriot Award, this award goes to employers who support their employees beyond basic requirements by law.  He was that kind of a guy.

A friend of mine says that the last chapter of life is the most difficult to write. His last days were full of bravado, courage and inspiration. I think his last chapter was too short, however it was most admirable. RIP.

About the Picture: Busch Gardens.

Computerized Progress Notes and CPOE.

Yesterday I gave a talk about computerized progress notes to some of our staff physicians. As we are now doing 100% CPOE orders, our next phase is to be paperless at some time in the near future.

I am very proud to say that our group of hospitalist are now 100% paperless. This includes computerized physician order entries, admission and discharge medication reconciliation and now progress notes.

I started doing electronic progress notes almost a year back. It was a challenge for the first few days but now I don’t think I can go to paper again. So these are some of the advantages I see in doing electronic notes.

• All the data you need can be pulled into your progress notes including labs, microbiology, radiology, vital signs, pathology and is updated automatically everyday.
• You don’t have to look for charts which are never there when you need them
• This makes it a one stop process, rather than first writing your note, place orders somewhere else and review data under 10 different tabs.
• You can see all your patients and than sit at one place and complete your charts.
• When you sign off, your partners can copy your notes and edit them and create a new note without inventing the wheel all over again.
• You can improve your coding as your note has more components.
• It is a much faster process.
• You can create your personalized templates and use them as needed.

Next stop history and physicals, if they become user friendly.

I Have A Question.

I was talking to a friend of mine, Dr Nawaz who has Internal Medicine and dermatology practice in Wesley Chapel, Florida. He raised a very good point the other day. He said a good doctor is skeptical; he raises questions, even for common problems. And that…..defines a good practitioner.  

He gave a very good example, he saw a patient who has been complaining of ear pain for some time. He was seen by various doctors and eventually was diagnosed with an ear infection. He was treated with antibiotics and what not. Patient finally came to him and he saw this patient in the clinic. His examination was not consistent with an ear infection. He ordered CT brain and found out that patient had a brain mass.

His point was that you have to ask questions even for your everyday problems. Every GI bleed is not due to an ulcer, every sore throat is not pharangitis and every chest pain is not because of a heart attack. I am not trying to say that you should order a brain CT for every earache, however, when we see a recurrent problem without any relief, you need to start asking questions fast.

As they say in medicine common things are common. You should not be looking for Zebra all the time, but you should know when you need to take your binoculars out. There is an unsaid rule in the ER, if you have recently discharged a patient from the ER without admission and if he comes back soon with the same problem, you got to admit him. Even if conventional wisdom says otherwise. We as hospitalist usually try not give them any grief when they call us for those admissions.

So the bottom line is that you should be ready to think outside the box, and more importantly you should know when too.