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with Rod Moser, PA, PhD

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Thursday, February 4, 2010

Wasted Medical Visits

A medical provider only has so many hours they can devote to appointments. I typically work 12-hour shifts (my choice) with a patient scheduled every 15 minutes, taking only one break (lunch) during my busy day. I reserve the hours of 5:30 PM to 8:30 PM for urgent care visits – about ten appointments. Our advice/triage nurses are supposed to screen the patients for these limited evening appointment, allowing only acutely ill patients; those who cannot wait until the next day, and those not so ill that they need the services of an emergency room. I never intended for these evening appointments to be “convenience care” – utilized by people who will not make an appointment during our normal office hours. People are so grateful that I have extended hours, three days per week. Some people do abuse this service, I have to say.

We do not have a lab or x-ray services after-hours, so any encounter that may need imaging or lab, like a suspected appendicitis or orthopedic cases, I send them to the ER. I get a great number of kids with otitis media, people with Strep throat, mysterious rashes, vomiting/diarrhea cases, and of course, fever of unknown causes.

I will see most lacerations that need suturing. Lacerations should be repaired within a few hours, no more than eight, so waiting until morning is not an option. I am one of the few providers in our group practice that will see kids with lacerations. I don’t believe in sedating them, and I rarely restrain them on papoose board (probably not a politically-correct term). The vast majority of children (even two year olds), given an adequate explanation of what you are going to do to them (they are mostly concerned about pain, as you might imagine), will sit still and allow me to sew up their little faces without squirming. If I had to take a guess, I tend to have more issues with the parents, than the kids. At least once a month, a parent will faint or vomit while I am suturing their child. As I am suturing, I have to keep a close eye on the parents (mostly fathers) who are sweating and looking pale. On a few occasions, I had to suture both the child and a father that hit the floor.

Now that I have set the stage about what types of patients I like to see in the evening clinic, I would like to talk about “wasted visits”. I guess I shouldn’t complain too much, since even people who come in for unusually-minor problems; are still charged the same fee. What really tics me off are those who fabricate the reason for their visit in order to snare one of these precious appointments, those that have illnesses or conditions so minor that I can see them heal spontaneously in front of my eyes, and those that just need notes for work, school, or PE. If I could charge more for these wasted visits, I would.

  • Jonas was a two-year old who was bitten by some sort of crawly creature (flea, ant, mosquito, or spider) two days ago. He had an appointment last night for two, tiny mosquito bites on this right foot. He didn’t seem to notice them, but mother was particularly worried because he had a history of getting an infection in the past. Mother wanted to have him started on antibiotics right away, so that those bites would not become infected. Needless to say, she left disappointed and a few dollars poorer. In the vast majority of cases, antibiotics should not be used to prevent infections. The only thing that Jonas needed was a bath, nail-clipping, and some hydrocortisone cream. If you have ever made a doctor’s appointment for plain ‘ol mosquito bites; shame on you.
  • Cory was 13 years old and was supposed to have a laceration of his scalp. My nurse put him in the treatment room and prepared him for sutures. After spending a few minutes looking for the spot that was supposedly-bleeding, I finally found a tiny, tiny, tiny scratch at the back of his scalp. He said that it suddenly bled during social studies class. He did not fall asleep and hit his head, nor was he shot by a random bullet or arrow. The hole was not big enough for brains to fall out, although I considered the possibility. After a period of denial, he finally admitted to scratching off a scab from previous injury sustained during wrestling. He left with a dab of antibacterial ointment on the wound – another wasted visit.
  • Madison was ten days old and was bleeding from her ear. This got an immediate appointment. The new mother was in such a panic, she scraped the entire side of their new car pulling out of the garage. Upon examination, a tiny scratch was noticed on the outer ear, mostly likely self-inflicted by sharp, little newborn fingernails. Her nails were like razors, but the mother was reluctant to trim them. There were no other sources of bleeding found. The baby was perfectly healthy, mother was embarrassed, and Dad seemed pissed about the car. This was wasted visit number three.
  • The last of the inappropriate visits involved a rash that had completely resolved. The parent was hoping that I would be able to determine what it was. Based on history alone, I determined that it was probably hives, but now that it is gone, there is really not much that I can do, other than suggest Benadryl next time. I had to inform the parent that there are no blood tests that can conclusively determine what caused the hives. They needed a note for missing school today.

The other six were appropriate visits, however, one even needed hospitalized for RSV (respiratory syncytial virus). This child, having considerable breathing difficulties, is one should have been triaged directly to the emergency room.

When I was a child, there is no way that my mother would have coughed up $3.00 for a medical visit for mosquito bites, a scratched ear, or a bleeding head. Granted, my mother was not the best triage person either. I once came home after completely impaling my right foot (I still have the scar) with a rusty pick; ruining a good pair of tennis shoes. The pick went all the way through my foot between the metatarsal bones. She filled the holes (both ends) with Vaseline and wrapped with a clean rag. I can’t recall a tetanus shot or even a subsequent antibiotic. After washing my shoes, I continued to wear them, holes and all. My right shoe tended to leak in the rain.

I excuse new parents for not having the experience or knowledge to make reasonable health decisions. Everything freaks out new parents – rashes, fevers, one bout of vomiting, moles, funny-colored poop, yellow mucous, fevers, yucky tongues, flat feet, ear-pulling, penis-pulling, fevers (I know I mentioned fever three times, but this is a big one!), constipation, diarrhea, and fussiness. The same folks that study pregnancy like an obstetrician, attend childbirth classes, and read books on childcare, tend to loose it when Junior gets a runny nose. Since most childhood afflictions are self-limiting, when there is nothing to treat, I use these wasted visits as educational visits. Education tends to last longer and have less side-effects than medication.

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Posted by: Rod Moser, PA, PhD at 6:24 pm

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