Dueling Medical Studies - Who to Believe?

People who primarily get their health information from the evening news, the local newspaper, or non-medical Internet sites are in big trouble. The amount of conflicting information about the risks or benefits of just about anything is staggering. I guess I am particularly troubled by television news. I use coffee as an example:

"New Study Shows that Coffee Consumption Linked to Breast Cancer"

This was a story that I heard over 30 years ago (before the Internet!). It was so shocking at the time, that women stopped drinking coffee all over the country. In one, highly-publicized study, coffee was blamed for fibrocystic breast disease and tentatively linked to breast cancer. This alarming coffee/breast cancer link was later disproven, but that news never seemed to make it to the media. This is really like having your neighbor hauled off by police as a possible child molester. The evening news shows him being put into a police car. The police quickly realize that they got the wrong man, apologize, and release him. All your neighbors really remember is that there is a child molester that lives in that house. The news that this was a mistaken identity doesn't really filter down. The accusation of being a child molester, even after being vindicated, is reason enough to move away. Capturing a child molester is a big story. The man not being a child molester is boring news.

A doctor in a nearby community was accused of fondling his patient's breasts. He was arrested in his office and put in jail. It made the evening news top story and the front page of the newspaper for weeks. After spending tens of thousands of dollars to defend his medical license and good name, he was finally exonerated after the victim admitted to lying. She had made up the entire story. What was once front-page news, complete with pictures, was now a tiny write-up on page seven. Most of his patients never saw that he had been exonerated. His practice and reputation was ruined by the news media jumping to sensationalism. People are supposed to be considered innocent until proven guilty, but the media can prematurely imply guilt.

Coffee has been vindicated, too. As a matter of fact, coffee has completely recovered from that story that it causes breast cancer. Coffee is now considered medically beneficial, assuming of course, that those recent studies were not funded by Maxwell House or Starbucks. People spend billions of dollars every year on this valuable commodity, so having a safe reputation is essential. According to WebMD there have been 19,000 studies that have examined coffee's impact on health. It appears that the benefits of coffee greatly outweigh any hazards.

Coffee contains a significant amount of caffeine, about 85 mg. - a potent stimulant. It can zip you up when you are tired, boost your concentration, but it can also raise your pulse and blood pressure, and make you a bit jittery, at least until it wears off. If you are not used to drinking strong coffee, those effects can be frightening.

When my daughter was in high school, she worked part-time at a neighborhood coffee shop. I worked for a university at the time, with a remote campus about ninety miles away. At the time, I was not a coffee drinker. I was a coffee virgin. Since I had to leave very early, I thought that I would try drinking coffee to keep me awake on the long, boring drive, so I ordered mocha. I assumed this was primarily chocolate. The guy behind the counter asked me if I wanted a "single or double". I figured this referred to the size of the cup. It was a long drive, so I said "double". I had absolutely no idea that he was referring to two shots of espresso. In about twenty minutes, the palpitations of my heart were so severe that I had to pull off of the highway. Now, my entire coffee consumption is just one cup in the morning - no double shots of anything. When driving non-stop back from Mexico, I did drink one of those new "energy drinks" heavy in caffeine. I definitely felt those effects and remained alert while driving the last six hours of an 18 hour journey.

As parents, we typically don't let children drink coffee, perhaps because we feel that kids are zippy enough without it. Believe it or not, no studies have shown that coffee is harmful to kids. Even if it is safe, I am not going to ever suggest that parents give their kids a cup of joe before heading off to school. With teenagers dozing off in math and social studies on a regular basis, perhaps coffee would not be a bad idea for them. Of course, we all worry about "complimentary behaviors" in coffee drinkers. I just can't picture a five-year sipping on a cup of coffee in one hand, a cigarette in the other, and looking for the newspaper. Okay, I know this is a bad stereotype, but you get the idea. Maybe coffee is a gateway drug? Perhaps we need a study.

Studies have now concluded the coffee is good for us; or most of us, at least. Coffee drinkers are less likely to develop Parkinsonism, decreased the risk of colon cancer, less chance of gallstones, and even less dental cavities. There is even evidence that asthmatics who are also coffee drinkers, have less asthma attacks. Coffee appears to be a good diuretic, too. There are just some of the positive health benefits that have been linked to coffee, if we are to believe those studies.

People are more likely to believe the last thing that they read in the newspaper, magazine, or on television news. We tend to quickly forget that a conflicting story may have been highlighted a few weeks prior, or even a rebuttal or disclaimer announced later. Once we glom on to a story, it becomes part of our belief system - one that we will freely share with others.

Every day in my clinic, I am defending vaccinations and dispelling junk-science about their presumed hazards. Once a parent is convinced that vaccinations may be harmful to their child, perhaps causing autism, it is very difficult for a medical provider to convince them otherwise. For some, holding on to those beliefs are like a religion - they are deep and personal.

I watched an anti-smoking documentary the other day that effectively used the Scared Straight technique. The anti-smoking lecture was given by a surgically-deformed cancer survivor who had most of his face removed. Those kids were listening. I think it would be a good idea to get a group of survivors of vaccine-preventable diseases, like polio, meningitis, or mumps, to have a talk with some of these parents.

Until I hear otherwise, from a well-designed, scientifically-controlled medical study, I am going to continue to promote vaccines, and of course, drink my one cup of coffee in the morning. Let the fools continue to smoke, avoid seat belts, drink booze, drive crazy, take drugs, have unsafe sex, and believe that vaccines are a government plot to control and harm us. Nature has some unique ways of dealing with them.

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Masks and Dark Glasses

As a seasoned medical provider, I can't tell you the importance of actually "seeing" the patient. I have always had issues when people come in wearing dark glasses. Since the eyes are the window to the soul, I find it very difficult to have an effective medical encounter with someone wearing dark glasses. When you address a particular medical question, you instinctually look at the eyes for response. Is the person making direct eye contact? If your patient is a teenager, are they "rolling their eyes" at you? Are they gazing downward? Before I start any medical encounter, I ask the person to please remove their dark glasses so I can see them, and not my own reflection.

Morgan / CC BY 2.0

H1N1 flu pandemic has hit our area big time. We set up a "flu station" in the lobby where people can use hand-sanitizers and pick up a surgical mask to wear. When I enter the examining room now, it is not uncommon for everyone to be wearing masks - except me.

Just like the eyes, I also like to see a person's entire face. I want to see if they are smiling, grimacing in pain, or frowning at me. If a person had both a mask and dark glasses, I would just assume they had a big paper bag on their heads. Just like the dark glasses, I ask them to remove their masks once they are in the examination room. I don't know how Westerners can practice medicine in the Middle East. If I saw a person wearing an Islamic burqa, I am not sure how I would react. But at least, could see her eyes.

The Lone Ranger wore a mask, like no one would really recognize a well-spoken man in clean white clothes, riding a white horse along with this companion, an Indian that speaks like Tarzan. Bank robbers and train bandits wear a scarf or bandana over their mouth and nose. Spiderman wears a full face mask apparently so you won't recognize him as Peter Parker. Superman doesn't wear a mask, but uses a pair of dark-rimmed glasses when he changes into Clark Kent - another clever disguise designed to fool idiots. A guy in a ski mask coming to my front door would definitely get a rise out of me.

Josh Westbrook / CC BY-ND 2.0

If someone walked into a bank today, wearing a surgical mask and dark glasses, they would definitely get the attention of the security guards. Halloween is just around the corner, so our pediatric practice allows the staff to dress up, without masks, of course. Masks typically scare kids, even surgical masks. We don't get the Trick or Treat crowd in our rural neighborhood anymore. I sort of miss them.

The first time that I saw people in public wearing surgical masks was in Japan many years ago. Japan is a crowded, but highly-organized and respectful society. When I inquired about the masks, I assumed that people were protecting themselves from the germs of others. To my surprise, it was the people in the masks who were trying to keep their germs to themselves. They had colds or influenza and did not want to infect others. This is a very respectful hygienic practice that we rarely see in the U.S. People on the subways in the U.S. will just about sneeze in your face; or sneeze in their hands just before the grab the hand rails.

I have been exposed to so many cases of H1N1, that I expect that I have some residual immunity. I have been endured numerous sneezes and coughing in my direction. I have held contaminated hands. I have wiped noses of children. If and when the H1N1 vaccine arrives, I am not really sure I need it. I will take it for my patients, of course, but I suspect that I am either immune from prior infections, or darn lucky.

One provider was complaining this week that he had to wear to complete biohazard suit, complete with a battery-powered air filtration system and full spaceman helmet when he was examining a baby in the ICU. The baby was in protective isolation. He said it was impossible to listen to heart or lung sounds using a stethoscope while wearing a space helmet and noisy respirator.

Until this pandemic is over, we must all learn to tolerate people in surgical masks - even when they are surgeons. It could be worse. We could all be wearing those space suits.

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Dog Tired

Our clinic has been unbelievably busy, thanks in part to the H1N1 scare. We have set up a fully-staffed flu clinic just to keep on the demand for the seasonal flu vaccine. The new H1N1 vaccine is supposed to be here in about 2-3 weeks, assuming we get our allotment. At first, we heard that two H1N1 vaccines will be required, but now the word is "just one". Our multiple-provider clinic can see about 400 patients in any given day, and we expect the demand to be high.

In practice devoted to pediatrics and adolescents, the high-season is usually Thanksgiving to the end of February, but this year is different. Our schedules are completely booked and everyone is working to capacity. If and when the H1N1 hits big-time, I hope that we will be able to accelerate this already-busy pace. All of us are dog-tired. Of course, I have even more of a reason to be dog tired. At the moment, with the new puppies, I have eight dogs; about five too many.

Photo: Rod Moser

Our dogs have the newborn baby schedule. They stay up late; wake in the middle of the night ready to eat, poop, and play, and then get up early in the morning to repeat the process. It was nice when they were able to be contained in a plastic swimming pool "whelping box", but now they have taken over the house. Since I work 12-hour shifts, it is starting to wear on this old man. I worked to 9 PM last night. I stayed late to suture a 21-month-old who split her lip and to deal with a shocked teenager who I discovered was pregnant. She came in for something else, of course. This was just the icing on the medical cake. When they have sex and don't use birth control, I am constantly at awe that they are surprised when I tell them they are pregnant. How long did they think they could play sperm roulette?

My grandson is in a year-round school, so he is off this week, staying with us. I tried to take him to see a movie this afternoon, but I fell asleep in the theater. Since we were the only two people in the theater, it wasn't an issue. Apparently, I did not snore, or at least my grandson didn't hear it over all of the shooting and explosions in GI Joe. GI Joe was the only movie in our theater that was not rated R. He liked it. I will reserve a vote until it comes out in DVD and I can see it again for the first time.

My wife and I bought a huge, metal gazebo when we were in Mexico a year ago. We had it dismantled, tied it to the top of the truck, and drove it home about a thousand miles. When my turn came at the border crossing, the customs agent asked me if I bought anything in Mexico that I was bringing home. I had this huge, jumble of metal tied to the truck, sticking out in all directions, perhaps standing four feet taller than the roof. I looked at him and said, "No, why do you ask?" He smiled and wondered why I didn't get it painted first. In retrospect, he was right. We had our oldest son finally weld it back together this weekend. It's going to take another two weekends to paint it.

It rained a bit in Northern California last week, just enough to cause a few hundred lightning fires; no big ones, fortunately. A few weeks ago, about 80 homes and businesses were lost when a wild fire raged through our foothill community. We were able to tour the devastation. Lifetimes of memories went up in minutes. Some families only got out with the clothes on their backs.

In a weakened moment, I agreed to take a medical student in my practice for the next month or so. Usually, students will slow you down, but this one is a bit more experienced, so I am hoping he will be able to help with the deluge.

I took off five days in mid-September to speak at our annual conference in Palm Springs. My topic this year should be fun. I am speaking about bizarre patient encounters. Maybe it's me, but I seem to have some sort of magnet that draws the strange and unusual to my door - the foreign bodies in the nose and ears; the people with a confusing array of symptoms, the hypochondriacs, the drug-seekers, etc. They come to my practice and they stay because I am nice to them. Over the years, I have collected quite a number of them. With the utmost respect to odd human behaviors, I will be talking about them this year. No names, of course. I will be offering suggestions on how to deal with these most-challenging patients.

Someone once said that one out of five people are absolutely crazy. I thought of my four closest friends; and they seemed "okay", so it must be me. Or I am just dog-tired.

A puppy just bit me on the toe. I will probably get rabies.

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Work Notes, School Notes, PE Notes - Aaaargh!

When did we become a society that requires doctor's notes for everything? I spend a great deal of my precious day writing note after note to coaches, teachers, day-care providers, and bosses. Is this really necessary?

I have always felt that people are basically honest until proven otherwise. When a responsible employee is required to submit a note to his/her boss just to confirm an illness, I find this very problematic. If I have seen the patient for a particular illness, I will write the note, although I think it is ridiculous that adults have to do this. In generations past, if you were too sick to go to work, but not sick enough to pay for a medical visit, then you just stayed home. Now, people have to pay for a medical visit just to get a work note sometimes.

Yesterday, I had one of the "no show" appointments. Someone made an appointment, but didn't have the courtesy to call and cancel it. When I reviewed the records, I discovered that this person has no showed for eleven visits! I am surprised that the PCP (primary care provider) has not discharged them from our practice, since they are costing us a considerable amount of money. When someone no shows, they prevent someone else from using that appointment slot. I find this rude and inexcusable. Sure, we all forget and miss an occasional appointment. We are human. But, eleven appointments... this person has a problem. I suspect this is the same person that will call me in a few days asking for a note for her employer because she was "sick"... apparently too sick to come in, and too sick to pick up the phone and cancel her appointment.

Someone with chronic work absenteeism, someone that tends to be sick only on Mondays or Fridays, or someone who becomes too ill to work the day before a long holiday weekend, would certainly raise my eyebrows as a boss. For these yahoos, I would require a note, too, or better yet, provide them with a note - an official DCM (Don't Come Monday, you're fired).

State and federal employees always ask for notes. Teenagers who work for fast-food places ask for notes. People who are on probation for chronic absenteeism ask for notes.

This is football season for the high schools. Coaches are scrambling to get their players ready for competition, so many have practices twice per day now. If a player misses a practice, the coaches require a note to prove they were ill. A note from the parents is apparently not good enough. They want a "doctor's note". I get so tired of doing these that I have become passive-aggressive, often writing "Jim was sick today" and sign my name. I don't feel that the coach has any business knowing the nature of the illness if it does not affect the player's performance or put others at risk for a contagious illness. There are days that I would like to write, "Jim has gonorrhea and cannot play today."

Schools are probably the biggest abusers of notes. It took me a while to realize that these notes are worth big bucks to the school, since an excused absence due to illness still qualifies them for federal matching funds. For instance, a school may get $35 per student per day from the government. If just ten kids fail to show up, the school will lose $350 - perhaps the salary of one teacher (including benefits). When a hundred kids stay home during a flu epidemic; that can add up to a lot of money... and, a lot of notes for me to write.

For some reasons, teens try to get out of PE. I know, our kids were always asking us for notes. Our oldest son, Josh, wanted a note to get out of PE because of "back pain". Apparently not realizing what we do for a living, we examined him and determined that he was a malingerer - nothing wrong with his back. We gave him a note for "remedial PE" that did not include running, so he was fine. He was fine, until the PE teacher decided that if he couldn't run or play basketball, then he would be reassigned to the special needs class. For two days, our son was in a class with kids in wheelchairs, leg braces, crutches, or with mobility issues because of cerebral palsy. He quickly discovered that his bogus back pain wasn't really that significant. On day three, his disabling back pain miraculously resolved and he returned to his regular PE class. Some time later, we discovered that he had PE during first period, and it messed up his carefully styled hair!

Kids with the True Flu (medically-diagnosed Type A Influenza) MUST stay home. As a matter of fact, if they are doing okay, I would prefer that they not come in to our office, either. A doctor's office, no matter how we try to keep things clean and sanitized, is a great place to spread illness, and a great place to come in with one illness, and leave with another. Here is the Catch 22. If they need a doctor's note, I have to see them. If I have to see them, I have to have an open appointment or work them in. I often have a dozen more requests for appointments per day than I have open slots. If they can't get an appointment (to get the note), they go to urgent care or the ER, over-crowding the waiting rooms and over-exposing everyone they meet. I suspect the quest for notes costs our economy billions of dollars per year.

Daycare providers often think they are medical providers. If I had a nickel for every rash that was supposed to be measles or chicken pox, only to be hives or mosquito bites, I could have retired years ago. My wife and I used to teach a class called "Pediatrics for Child Care Providers" that was required for licensing in our county. We taught thousands of eager child care providers how to properly recognize certain infectious diseases, and how to establish reasonable exclusionary polices. When child care providers exclude your child for suspected pink eye or the plague, the parent has to leave work to pick them up, make a timely appointment for my office (usually the next day, so they miss TWO days of work), and require a doctor's note before the child can return, then I have to write TWO notes - one for the child care provider since they don't trust the parent, and one for the boss, also because they don't trust the parent.

One study showed that over 80% of all missed days for working women are for the illnesses of their children. It doesn't take very long for a responsible working parent to quickly run out of sick days just to take their kids to the doctor. If the employed parent becomes ill, they have to go to work sick, where they will expose their fellow workers, who will become sick, inadvertently infecting the kids going to day-care, thus starting an epidemic. They will then show up at my office asking for notes.

If I were the dishonest, entrepreneurial type, I would have a note vending machine in my waiting room. People could insert a five-dollar bill, type in the days they missed work or school, and out pops a signed note. That is a good idea. The Doctor Note-O-Matic! This would be a noteworthy and lucrative venture. Sorry about that...

I do have a confession to make. In my teen years, I became quite skilled at forging notes so we could go to the library instead of French class, or a teacher's signature as proof that we had completed a chemistry experiment. One of my proudest days as a forger occurred when a teacher turned down his actual signature since it did not look like the other (forged) signatures that I had done!

Actually, I attempted to write my own note in first grade when Gregory and I decided to play hooky and hide in the woods all day. In my youthful naivety, I did not know I would need a note to get back to school the next day. When mean old Miss Rider told me that I had to have a note from my mother for missing school yesterday, I truly became sick. After dozens of attempts to replicate my mother's handwriting, I knew it was not very good. Fessing up and hoping for a one-time only reprieve, my mother was not sympathetic. She actually wrote "hooky" on my note! This would not do.

I went across the street to my kindly Aunt Norine (now, 95 years old), to see if I could con a note out of her.

"Why didn't your mother write this note?" she inquired.

"She didn't know how to spell "sick", I replied.

My aunt wrote the note and I was ever so grateful. She also made me go to church the next Sunday hoping that I would confess my sins before it was too late. I found that you could pray for forgiveness. Unlike Miss Rider, God didn't require a note.

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Interesting Tidbits from the Medical Literature

More on Losing Health Insurance
It is worse than I thought. Up to 14,000 Americans per day may be losing their health benefits during this economic downturn (a nice term for "crisis") according to a report by the Center for American Progress and Health Care for America Now.

"Approximately 2.4 million workers and their families have lost the health insurance their jobs provided since the current recession started in December of 2007, according to an analysis by Nayla Kazzi at the Center for American Progress. "

"More than 51 million Americans under age 65 do not have health insurance as of January 2009, and millions more drift in and out of coverage as their employment and financial situation changes. According to a March 2009 study from Families USA, approximately 87 million Americans under 65 - nearly one in three - went without health insurance for some period in 2007 or 2008."

(See "When You Have No Health Insurance or Money" blog post). More and more people are being qualified for the government's Medicaid program - millions of people are already enrolled and the number is growing. If families try to purchase private insurance, they need to expect rising costs there as well (assuming they are healthy enough to qualify and do not have any pre-existing health problems).

And More on COBRA... It Strikes Employers, Too
The economic stimulus package will subsidize 65% of the COBRA health insurance costs for up to 18 months. Some companies feel that this will be an additional (and costly) burden to companies who have to pay the administrative costs to manage this program for laid-off workers. Personally, I think the minor administrative costs are the least a company can do for these disadvantaged workers. In a way, it was nice for our government to help out.

Get Ready for the Upcoming Epidemics
Most young families have never seen measles or Hib-related diseases, but that may change soon. There have been pockets of Hib and measles cases popping up across the country. There were about 400 cases in the U.S. last year. Unimmunized families may see them first-hand, unfortunately. As more and more families opt not to vaccinate their children due to unfounded fears that they cause autism and other developmental disorders, those diseases will surely return - perhaps with a vengeance. Measles has never left and continues to be among the leading causes of death in children worldwide. I suspect that families without health insurance will also be skipping these important vaccines.

According to the CDC, there were 131 cases of measles in 2008, the most since 1996. Most experts feel that this resurgence of measles is due to the highly vocal anti-vaccine movement.

Swine flu may be less serious than we expected, but expect an unprecedented vaccine campaign in the fall. Not only should a swine flu vaccine be available, but we will still have our usual and customary annual strains that take about 35,000 lives each year. Anticipating the circulating strains is becoming more and more difficult as these ancient viruses mutate and change. The World Health Organization fears that up to two BILLION people could be infected by swine flu if the current outbreak turns into a true, global pandemic

Speaking of Vaccines
The pneumococcal conjugate vaccine, Prevnar, which has been protecting infants and children against seven of the more common streptococcal strains is now going to be even better. A newer, improved vaccine called Prevnar 13 will be adding protection against six additional strains, offering even more protection against pneumonia, meningitis, and yes, even the dreaded middle ear infection.

In the last decade, the insertion of tympanostomy tubes for recurrent ear infections has increased 35%; a whopping 85% increase since 1996. Although there has been an active campaign to reduce the astronomical amounts of antibiotics used in the management of pediatric ear infections, the overall usage has not drastically improved. Many parents feel that tubes are a less-risky alternative to frequent antibiotic use.

Cell Phones May be Contributing to Hospital-Acquired Infections
First they blamed dirty hands, then stethoscopes (rightfully, so). A few years ago, a study proved that our neckties (I stopped wearing them and I have a great collection of medical ones) may be spreading dangerous pathogens. Now, cell phones are being blamed for the spread of MRSA (Methicillin-Resistant Staphyloccoccus auerus) - the superbug in a study of Turkish hospitals. It doesn't surprise me at all. Since I do not carry a cell phone with me during clinic hours, this does not pertain to me. Computer keyboards and other hospital equipment may also be contaminated. Personally, I consider EVERYTHING in the hospital potentially contaminated. I hate touching elevator buttons ("Can you push three from me, please?) and I never touch stairway banisters.

Electronic Medical Records (EMR) "Depersonalize" Medicine
I read a New York Times story about how EMRs are going to transform medicine into a highly-efficient machine, saving billions in healthcare costs. This is not without a big price, however, in the social arena. Not only do medical providers have to spend additional time documenting their medical records (not all medical providers are good typists!), but computers have created yet another depersonalized barrier in the medical relationship.

We have used EMRs for several years in our office, but I rarely use the computers in the exam room during the encounter unless I am just briefly checking lab results, etc. I just do not want a flat screen between me and making eye contact with the patient, I am sorry. I find it terribly disruptive to have a medical provider typing away as a patient is talking. I experienced this as a patient with my own medical provider. As in the past, I still jot down my notes, only to type the later, in the comfort and quiet of my own office.

We get less than 15 minutes allotted for each patient visit. I am not going to waste 12 minutes of that precious time by typing notes.

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Living Without Pharmaceutical Pens

I am down to my last few hundred pharmaceutical pens. Some of the pens are older now, perhaps advertising drugs that are no longer available, pulled from the market due to side effects. Some are for medications that I have never used, or will never use. I don't really pay attention to what is written on those giveaway pens. I am more concerned that they write smoothly, have a retractable tip, and fit in my pocket.

We do live in a world of subliminal cues - the purpose of advertising pens anyway. I noticed that I used a Singulair pen to jot down a few ideas this morning. It did not make me want to write a prescription for it though. I think I do pretty well about ignoring pop-up Internet ads, billboards, magazine advertisements, radio/television ads (that I fast-forward through), but perhaps I am still subtly influenced.

About a year ago, our group decided to severely limit the pharmaceutical representatives. They can no longer waltz into our office, asking us to sign for samples, or having them plop down in the middle of a busy day, telling us some new information about an old drug, or about a new drug with old information.

I always try to be respectful to the reps. Many times, they do offer an educational service, providing me with information about a certain drug that I didn't know. They have been trained not to bug us, but on a busy Monday morning with every exam room full, they can't help but bug us.

My stash of pharmaceutical pens must have been discovered by the medical providers who use my office on my day off. I now have to hide my favorite pens. I lose about three pens a day, leaving them in patient rooms where my medical assistant snatches them, or on the counter in the lab where they can be inadvertently contaminated by urine or something. I consider those pens to be lost.

Gone are the days when pharmaceutical reps would bring us t-shirts, hats, paperweights (who in the world uses paperweights anymore?), back-to-school notes, blank note pads, and such clever giveaways as a scorpion embedded in a block of Lucite (who thought of that one - and why?). When the kids were still home, they happily took advertising pens to school. I distinctly remember my son going off to Junior High wearing a Flagyl Vaginal Cream t-shirt, or an Ortho-Novum Contraceptive baseball hat. They didn't care what they wore most days. We even intercepted one of the kids wearing my wife's pants that mistakenly ended up in his drawer! You would think that the side zipper would have given him a clue.

All stops are removed when you go to medical conferences. Pharmaceutical companies pay big bucks for booth space at the bigger conventions. Pharmaceutical giveaways are in high demand, especially by the students. They walk around with HUGE shopping bags filled with every worthless trinket they can get their hands on. There are Frisbees, anatomical models of genitalia, posters, decks of cards, candy, more bags to put inside your bag, and of course, the pens. I must admit that I will use a pharmaceutical pen at their booth to sign their book, evidence to their bosses that they spoke to us. If the pen is a good one, I take it. It they are real good, I take a lot of them. A few hours in the exhibit area can get me enough pens for the entire year. I will be speaking again at the state medical conference in September. I only accept the gratuity of free conference tuition, but my real mission is to get more pens.

I have bought pens in bulk at Costco. I must admit that they are better, but they are also stolen more often and harder to trace. I am always accusing people of taking my pens. Sometimes, they sheepishly produce it, and claim they did not know it was mine. Sometimes my thorough interrogation and body searches are fruitless. My pens simply disappear into thin air. Some people will deny that the pen in their pocket is mine. Frequently, I will have to show them the ink marks on my front pocket to prove that the ink is a perfect match. I have little sympathy for pen thieves. They should be prosecuted to the fullest extent of the law.

I lost the key to my desk, so I can't lock up the remaining pens. A quick inventory yesterday produced some serious doubts that I will make September without going to Costco. I have even considered stealing other people's pens under the guise that I am just retrieving the ones stolen from me.

We are supposed to be a paperless office. If this is true, then why do I even need pens? I use up most of the ink writing notes for school or work. School notes are worth about $35 each - the federal funds given per day of instruction. If a child has an excused absence, the school still gets the money. Ten kids without notes can be a teacher's salary for the day, so I write those notes...all day long. Parents, too, need work notes saying that they took off to take their kids to the clinic. What kind of society have we created that requires "doctor notes" for just about everything?

The value of legitimate-looking doctor notes cannot be underestimated. When I used to work in family practice, I would always have some guy request a note for a day or two he missed last week when he claimed he was sick, but did not want to come in and "bother me". Most people are honest about these things, but some guys just went fishing. I would quiz them a bit, and usually the fisherman would fess up under my highly-honed interrogation style. Depending on my mood, I may still give them the note for being honest. In return, I would get a lot of fish. One guy even brought me a fifty pound tuna - much better than ink pens.

Side Note: This is my 300th Blog Post!

Related Topics:

• Drugs & Medications A-Z
• Ear, Nose & Throat Message Board with Rod Moser, PA, PhD
• Living Better Newsletter - Wellness news to keep you healthy and strong!

The Fine Art of Incompetence

Everyone makes mistakes. To err is human. Making a mistake is not incompetence. Repeating mistakes, over and over, and not learning from those mistakes is incompetence. Some people have just taken incompetence to a much higher and more refined level than others.

Today is my day off so I was in line at a large box home improvement store. I brought in a painted, broken piece of baseboard, complete with bent nails sticking out of it, so that I could buy the same type. While I was checking out, the cashier was very troubled by the fact that this piece of wood that I brought from home did not have a price tag.

"Did you bring this from home?" She asked.

"Well, yeah. It old, broken, and has nails sticking in it. Do you sell them like this?"

On Sunday, I had to call the satellite TV tech support because my DVR was not recording the shows that I pre-programmed. My wife went ballistic because Dancing with the Stars did not record. She insinuated the problem was my incompetence - that I had not set it correctly. I dislike calling the tech line, especially on Sundays. I assume (usually correctly) that the newest and least-competent people have to work the lines on Sunday. My heart raced as I navigated the phone tree. Will I be talking to a heavily-accented foreigner who claims his name is Jeff? As a fatalist, I know the person will not be competent, or perhaps I set my goals too high.

"My name is Jeff. How can I help you?" (Damn, I knew it!)

"My DVR is not recording shows that are programmed."

"Is it plugged in?"

"You are really good, Jeff. Thank you." (I called back on Monday)

We have a very large medical office; many providers, many medical assistants, and many support staff. Some days, it looks (and sounds) like Grand Central Station. We are just ending a very long "cold and flu" season, just in time to start our spring allergy season. Instead of feverish, coughing kids and kids with ear infections, we now have the wheezers and sneezers. Spring break is upon us and nervous parents are bringing in the ill and suspected-ill children to make sure they will be well before going to Disneyland. The busier the office, the more likely mistakes will be made.

Let's start with the front desk and receptionist. Within ten minutes of my arrival, a contrite receptionist will be standing in my doorway requesting a "big favor". Some unknown person apparently made a mistake. Instead of booking the appointment for tomorrow, they booked it for next year (just one number off).

"The patient is here now; you are completely booked. Can you see them?"

"Yes, of course." They always ask me because I rarely, if ever, will turn them away. No matter how busy I am, I can see just "one more patient". This wasn't the patient's fault; it was a bit of incompetence on our part.

An hour later, another receptionist is hanging out by my office, waiting for me to come out of an examination room.

"It is 9:30 and your 8:45 patient just arrived and wants to be seen. They claim that the automatic, appointment-reminder call system told them the wrong time (that really doesn't happen since calls are directly linked to the appointment time)."

If people would just tell the truth, or at least come up with a more creative and entertaining lie, I would be more willing to forgive them. I actually enjoy hearing bogus excuses, though. Over the years, I have heard lots of them. In most cases, failing to make appointments on-time is really incompetence - poor planning.

Now, the medical assistants: Many names sound the same. Yesterday, I saw Caden (age 5) for a physical exam. Caden had gained 30 pounds since his last visit a month ago; grew eleven inches taller. My medical assistant did not seem to notice. Caden was also not Caden; but really Aiden (age 9). Blame it on being rushed, or the noise, or a simple mistake. Or, call it like it is: incompetence. In the scope of things, this is a little mistake in a medical office. There can be big ones, too. We ALL have to check and double-check: comparing names with birth dates and confirming that we do, indeed, have the right person and the right chart.

Before my wife went in for abdominal surgery, I physically wrote her name and the type of surgery she was going to receive ON HER STOMACH. Her surgeon was amused, but at least she didn't get the wrong surgery.

The pharmacist: We use electronic or e-prescriptions (and e-faxes) in our office to limit mistakes. It is now more difficult to give a medication to a person who was allergic to it. People no longer lose their prescriptions on the way to the pharmacy, and of course, druggies can no longer change the amount, say from 10 to 100 pills. We can however fax the prescription to the wrong pharmacy in the wrong state. Every state in America seems to have a town named Roseville and a Walgreens. A slip of the finger could send your amoxicillin to Minnesota.

The patient was sitting there when I sent her prescription electronically. There was confirmation that it was successfully sent. She showed up in the pharmacy about an hour later and was told that no prescription was sent. She called me. I confirmed (again) that I had sent it. Cyber-crap does happen, so I just sent it again. She went back to the pharmacy and was told they never received it. Now, I am mad, so I called the pharmacist personally. It took about 15 minutes for him to get to the phone. I nearly had a nervous breakdown listening to bad music on hold. I told him of the two prior failed prescriptions, and he told me what was happening.

When the pharmacy technicians get busy, they simply remove the paper from the fax machine and allow the fax to be stored in the buffer. That way, when the patient arrives at the pharmacy, they can honestly tell them "they did not get it". As soon as they catch up, or when the next shift is getting ready to come on, they simply put the paper back in the fax and magically, a few dozen prescriptions (including both of mine) come out. I orally gave the prescription to the pharmacist this time.

Twenty minutes later, the patient is on the phone again. This time she is standing in the pharmacy where she is being told A THIRD TIME that they do not have her prescription! No one bothered to even ask the pharmacist in the back if he had it. This is incompetence.

As a medical consumer, it is imperative that you take an active, participatory role in your care. Make sure the prescription at the pharmacy is the same as what your medical provider told you that you were getting. Of course, there is the "generic versus brand name" issue.

"I am going to fax over a prescription for Omnicef."

Of course, when you arrive at the pharmacy, the bottle will say "cefdinir". Unless specified, the pharmacist is obligated to give the generic because it is less-expensive. A quick consultation with the pharmacist will confirm that you did, indeed, get the right prescription. Just like Caden and Aiden, there are many drug names that sound the same, too.

I was re-editing this blog post today before publication and the phone rang. It was my tax-preparer. She said that I apparently gave her a wrong social security number for my wife and the electronically-filed taxes were rejected and that I would need to file by mail.

"You have my wife's social security number. The same one you used last year, and the same one that is on the W2 form. You were the one that transposed one number differently on the 1040 form, not me." Silence followed.

"Yes. I see that is what happened. Thanks." Click. No apology for the mistake. No apology for her lame attempt to shift the blame. I am sure glad that I complained about their increased fee this year to do the exact same job. I guess the more you pay, the less we get.

If one out of four people are incompetent, then think of three other people. If they seem okay, then maybe it is you. Just kidding. Again, everyone makes mistakes. It is quite easy to blame others. It takes an honest person to admit your errors.

Don't just assume because your medical provider has a lot of letters after his/her name, that it automatically means they are always competent. I have been in the medical biz for over three decades and I have seen a lot of mistake; even made a few (little ones) myself. I thank God every day that I have never harmed anyone with a medical mistake -- a record I intend to keep.

It has been said that medical providers hide their incompetencies and bury their mistakes. My personal philosophy was inspired by a book years ago called Kill as Few Patients as Possible by Oscar London, MD, WBD. (Incidentally, the WBD means "World's Best Doctor" - a tongue-in-cheek degree.) There are no such animal as the "best doctor", only the best person.

I will end with Dr. London's (a pseudonym) final words in the book: "Keep out of jails...and hospitals."

Related Topics:

• WebMD Video: How Doctors Can Learn from Medical Mistakes
• What You Can Do to Prevent Medical Errors
• Help for Medical Billing Errors
• Ear, Nose & Throat Message Board with Rod Moser, PA, PhD
• Living Better Newsletter - Wellness news to keep you healthy and strong!

Dogs in the Examining Room

"Maggie" Credit: Rod Moser

If you have been reading my Blog, you know how much I love dogs. I have two Shelties now and would love to have one more. With this brief preface, I would like to share an incident in my office last night.

By choice, I work 12-13 hour shifts, three days per week. I know that people do not just get sick from 8 to 5, and that working people and those in school during the day need options. I, on the other hand, like to have some days off during the week; hence, this is my schedule.

I walked into the examining room to see a 15 year old girl with ear pain. She was accompanied by an entourage of three siblings (all girls), a mother, and a puppy. The puppy was actively peeing on my floor; on two of my examining gowns placed on the floor to be exact. As I stood their in awe as the yellow stain leeched onto the floor below, the mother proudly announced that this puppy paper-trained himself. She picked up the dog urine-soaked gowns and attempted to put them on the top of the waste receptacle under the sink. That is, before I stopped her.

"You allowed your dog to pee on my floor, on my examination gowns?" She paused with that comment.

"Babies crawl on that floor. People often walk in their bare feet on that floor. While I admit that examining room floors are not the cleanest places for those activities, dog urine is really not wanted. I would respectfully ask you NEVER to do that again. I will have my nurse provide you with some supplies so you can properly clean up that mess."

I am usually easy-going and tolerate a great deal of (human) body fluids in those rooms. It is not unusual to see a geyser of urine stream from a little boy arching through the air toward a startled (new) parent. Those things are expected to happen. I find those amusing and we all help clean it up…properly, followed by some sanitation procedures that go on after the patient vacates the room. Had I not walked in on an actively peeing dog (!), I am sure that nothing would have been said. Microbiologically, I suspect dog urine (like most human urine) is pathogen-free, but it still has a significant "yuck" quality.

We have patients with service dogs all of the time. These canine companions are well-trained, usually better than the toddlers I see. The law permits service dogs in virtually any area, as it should be. This puppy was cute (all puppies are cute), but this was not a service dog. The dog made it past our front desk receptionist contained in a pet carrier. If it were 105 degrees outside, I would not have had an issue (other than the fact that a responsible dog owner should not even take a dog out in the car under those conditions), but it was raining and it was cool, and there were plenty of kids that could have watched that dog…in the carrier…in an isolated corner of the waiting room away from children that may have a dog dander allergy. If our office starts allowing or not actively prohibiting animals in the exam rooms, it will definitely get out of hand, I can assure you.

I stopped referring patients to a local podiatrist when more than one person told me that he had a free-range cat in the waiting room. Most patients (apparently) did not mind - perhaps cat-lovers and owners themselves, but I had a problem. Cats can carry all types of germs on their feet as they walk around in their litter boxes. Some of the worst infections I have treated involved cats in some way. Some cats also carry ringworm – a fungus that is actively treated by podiatrists when it is on the feet and between the toes. I guess this would be convenient.

"Lexi" Credit: Rod Moser

My first Sheltie was highly-socialized, even before she joined our family. The breeder would take the adult dogs (and puppies) to nursing homes to be petted and handled. It was good for the residents and definitely good for the dogs. I suspect that the breeder has a pee-policy. Nursing home residents are mostly adults and the facilities are a bit different than a medical waiting room used by persnickety new parents.

Puppies also poop. Dog poop, unlike urine, is teaming with microorganisms and even worms. Granted, one of my kids (sorry, Alex) happily ate a dog turd when he was little. He did not get sick and is now an engineer. I step on a lot of dog poop in my yard, but I am not going to start stepping on it at work.

If you really love your dogs, please don't force them into places they do not belong. I don't want to see them sitting in shopping carts when I am at the grocery store, or poking their heads out of bags/purses at the mall. I definitely do not want to see them panting in hot cars with a window cracked one-half an inch. I don't want to see big dogs in the back of a pick-up truck barking at startled people walking by, or even tied to the back of a pick-up truck flying down the freeway. I don't like my neighbor's unrestrained dogs chasing my car; and I don't want other dogs using my self-manicured lawn as public toilet. My little dogs are okay but not the neighbor's behemoth and his impressive mega-piles. And, I don' really want dogs in my waiting room peeing on the floor. I don't really want "extra", uncontrollable kids in the examination room, but I don't want parents leaving kids in the car with the windows cracked either.

"Herman" Credit: Rod Moser

I have told my wife that if I were dying in a hospital bed, I would want my dog, Herman, lying next to me. Unfortunately, that role was tragically reversed. Two years ago, I had to lie next to Herman when he was dying. Friends do that for each other.

Related Topics:

• WebMD Video: Maggie the Hospice Dog
• Pet Symptoms: 6 Signs of Illness in Your Dog or Cat

"I Do Not Have Health Insurance"

Several times per week, I have a posting on the Ear, Nose, and Throat message board that mentions that the person posting does not have insurance, or does not have the financial resources to pay for a medical visit. With the economic crisis we are all facing at this time in history, I suspect we will see more and more uninsured Americans. One physician in our office stated just today that three of his patients lost their jobs, along with their insurance, and would not be returning for on-going care. This is just the tip of the financial iceberg.

For the most part, medical care in the United States is embarrassingly expensive. Since I am on the inside, I am often in a position to justify many of those charges to my patients. Insurance is equally as expensive and not all people have insurance benefits with their jobs. In most states, automobile insurance is required - it is the law. Health insurance is optional. I find that inconsistent with common sense since a liver transplant is considerably more expensive than fixing your bent bumper. Unless you have unlimited resources, going without health insurance will devastate your family in the event of a medical crisis. The government will end up paying the costs for the uninsured only after your resources have been depleted. The U.S. does not have universal health insurance, so those people without insurance must pay for their medical care.

When I was a child back in the 1950's, we had one general practitioner in our town. I don't believe my parents had any insurance. An office visit was $3.00 (this included medications in most cases), and a house call was $5.00. Even at those prices, adjusted for the 1950's, this was still a pretty good deal. We were a lower income family; so fortunately, I did not have to utilize medical care very often. At age 18, I had appendicitis, but my mother must have had health insurance by that time, otherwise she would have told me how much it cost.

The cost of a routine office visit in my practice is $141.00, or at least this is what is billed to the insurance companies. Insurance companies typically negotiate these fees and will reimburse considerably less. A cash-paying patient will pay about $98. There are some quick-clinics at the local pharmacy that charges about $65. An urgent care clinic will charge about $75. People who have insurance will typically pay a co-payment of $10 - $30 for their entire out-of-pocket expenses.

Like medical care itself, insurance premiums are astronomical. I have many infants and children in my practice, some who were born with special needs. A parent of a 2-year-old child last week told me that her medical bills are over three million dollars (so far). It only takes a few of those for insurance companies to raise their rates on healthy people to make up for it. In Ancient China, doctors were paid a fee to keep people well. If you became sick, the doctor had to pay you!

I have always been very sensitive about charges, but in my current practice, I have no control over fees that are charged by the medical foundation. I am on salary. If I were in private practice, I would have been bankrupt from giving away free or discounted care. The cost of routine medical care has skyrocketed to the point of embarrassment. The cost of using liquid nitrogen to freeze off ONE common wart is about a $150, and one treatment may not do the job.

When I see a patient or perform a procedure, I put down a billing code that represents what I have done, the complexity of the visit, and the time spent. This code is translated into a bill, either sent to the patient or the insurance carrier. I am basically out of the loop.

Medical providers can "down-code". In other words, they can put down a lesser billing code than what was done. Providers can also not charge for certain "simple and quick" procedures, like removing ear wax. The cost of removing earwax in my office is well over a hundred dollars for the procedure alone. If it only takes me a minute or so to clear out that ear canal so that I can properly see the eardrum, then I do not charge extra. However, if I spend a half hour digging out an impacted amount of earwax from some obsessive Q-tip user, I am going to charge extra - about the cost of 30 boxes of Q-tips.

When I know that a patient is private-pay (paying with cash or credit card), I tend to down-code or cut them a break if I can. If I have samples, I tend to give it to them. There is nothing like paying for an expensive office visit, only to be dinged again at the pharmacy. Medication costs have skyrocketed, too.

When the antibiotic Augmentin first came out, it was expensive compared to plain 'ol amoxicillin. A full-course to treat a middle ear infection in a child could be $65 to $80 or more; amoxicillin was only about $10 or $15. My wife and I were traveling in New Zealand years ago, so I compared some of those prices with a Kiwi pharmacist (chemist). Augmentin in New Zealand only cost about $8.00 and was from the same pharmaceutical company. Why? According to the chemist, the entire country of New Zealand negotiated a lower price - and the cost is not increased to the consumer. In the U.S., we pay top dollar for the same medication. Of course, Augmentin is generic now, and the price has dropped (sort of).

The Veterans Administration and some large HMOs do negotiate for cheaper medications for their patients. When I worked for the VA years ago, it would drive me crazy. I would get someone controlled on one blood pressure medication, only to discover that it was now not available. I would have to change it to another one. Six months later, I would be told that that medication is not available, and I would have to go back to the original one that is now suddenly available again, now at a cheaper cost the government, of course.

The cost of medications has driven many Americans across the border to Canada or Mexico looking for deals. This practice is highly discouraged by our government, and is really illegal in some respects. People on fixed incomes who are paying more than half of their monthly income for medications for cholesterol, blood pressure, or diabetes are desperately looking for ways to reduce their costs. Smuggling medications across the border happens every day. I have personally witnessed people being hassled over a bottle of blood pressure medications they bought in Mexico, while tons of cocaine and marijuana seem to make it across okay.

Our government sites safety as their primary concern. Fake medications made in China are showing up everywhere, even in the U.S. Look-alike medications are being sold by the ton in Mexico to tourists. When someone shells out some cold hard cash for a bottle of Viagra before the cruise ship leaves, there is little recourse when those little blue pills fail to work. Maybe you get the real Viagra, but maybe your little blue pill is just that - a little blue placebo from China. Personally, I would not have any problem buying medication in Canada, but I would be a bit leery of some of those Mexican pharmacies along the border.

When it comes to buying food or buying gasoline, someone without health insurance tends to set priorities. Food comes first, followed by rent or mortgage. Then comes automobile costs. The lowest on the list tends to be routine medical and preventative health care. Emergency medical care tends to get attention, even in the worst of economies. When you have an arrow sticking out of your head, you don't typically wait a few days to see if it goes away on its own. A guy in a neighboring community was shooting arrows into the air. Not understanding gravity, he inadvertently hit himself in the head with one of those falling arrows. He hesitated going to the ER because he did not have insurance. I am surprised that the arrow didn't go all the way through since there appeared to be nothing inside his skull.

If you don't have auto insurance, you are screwed if you wreck your car. If you blow your engine because you can't afford routine maintenance and oil changes, you are screwed because auto insurance does not pay for repairs. If you do not have health insurance, and choose to ignore your crushing chest pain, you may not need health insurance anymore - you so need life insurance for your family. If you do not go to the doctor because you have a cold, you will probably be fine. Colds are self-limiting and you don't really need a doctor to tell you that again and again. Of course, if your cold seems to be turning into pneumonia, you are going to have to make a big decision. Should I take the chance of dying, or use my credit card or hard-earned cash to get some medical care? Get the care. Borrow some money or worry about paying the credit card later.

My auto mechanic charges $90 per hour (even if he fixes my car in five minutes). He is a high school graduate and makes more than my own hourly rate in my clinic. Is it fair? Probably; he can fix my car - I cannot. Of course, when he cuts open his head when he slips on some grease, I am not going to reduce his cost by down-coding him. I am going to get even.

Related Topics:

• 45.7 Million in U.S. Lack Health Insurance
• Health Insurance Costs Climb Again

Relationships and Medical Practice - Making a Connection

Over three decades of practice in the same community, I have a share of "grand-patients" - children of children that I have cared for over the years. There are patients in my practice that I forget immediately after I leave the examination room, but over the years, there have been numerous special patients and families that you never forget. No, it is not their illnesses or their special medical needs that trigger this attachment, but rather who they are as people.

When I first started in clinical practice, my physician boss advised me never to get personally involved in the people that I treat. Be friendly; but don't be friends. Although it sounded odd, I followed his advice for many years, missing opportunity after opportunity to get to know the wonderful plethora of human beings on this planet. I absolutely love people, so when I changed jobs so that I could raise my children in a smaller and safer community, I totally rejected this advice. I wanted to be a part of the community.

If my patient owned a gas station, I bought gas from him. This came in very handy during the gas crisis in the late 1970's. People lined up their cars for hours just to get gas, but not me. My friend (and he is still my friend) made sure my tank was full. When his kids were sick in the middle of the night, I was there for him. This is the way America used to be and the way it should be now. Medical providers are not different species. We are humans and humans simply enjoy the company of other humans.

I look for connections with patients that we all have. Everyone on this planet has a connection of some sort. We have the same hobbies; lived in the same area in the past; drive the same cars, or kids going to the same school, or whatever. If you talk to a person long enough and are really interested in who they are, you will find that all-important connection. Sometimes, the connection is profound.

Learning about your patients is a powerful way to understand who they are as humans. You don't treat an "ear infection in room one," you treat a PERSON who just happens to have an ear infection in room one.

So, during my ongoing effort to get to know people, you find friends. Back in the late 1970's, I took care of a family called the Hammons that I really loved. They were the greatest kids and the nicest parents you could imagine. I didn't need a chart when I saw them. I knew their medical histories, and who they were in my heart. Jump thirty years later and a lot of water under the bridge of life. A mother is bringing a little child to see me. She is smiling. This little child was another "grand-patient".

"Do you remember me?" She asked. "My name is Kim Hammon."

"Kimmy! You have grown up.", I responded.

"Of course, I remember you. How's your brother? How's your Dad, Randy?" A fond connection was re-established across three decades of our separate lives.

Her Dad and mother divorced years ago. Her mom still lives in town. Her Dad remarried and is now "sort-of-retired", living in Loreto, Mexico. She gave me his e-mail and asked that I send him a note. I remember that family like I saw them yesterday. There are days when I can't remember where I parked the car, or what I came upstairs for, but I fondly remembered this family. We had a connection.

E-mails were exchanged. Plans were made. To make a long story shorter, my wife and I just returned from a 2800-mile road trip to Loreto -- the longest house call that I ever made. This is my "old patient" and friend, Randy, with his grandson, Aturi.

Related Topics:

• Talking Religion With Your Doctor
• WebMD Video: Human Side of Being a Doctor

Technorati Tags: medical practice, doctor, health and wellness

Part 5: The Top Five Reasons Why Patients Are Dissatisfied

In a recent patient survey in our medical group, there were five areas of dissatisfaction that were identified. This is the last of the top five reasons.

5. Waiting time in the reception area is too long (8.4%)

Reception area? I thought it was called the Waiting Room. Being a medical provider, and also having numerous opportunities of being a patient, this would be number one on my list. I absolutely hate waiting with a bunch of sick people.

When I go to the clinic, I enter through the employee entrance that just happens to go through the Lab Waiting Room (sorry, Reception area). Perhaps people are bored or anxious, but my entrance through the door creates some sort of diversion. Everyone, I repeat, everyone, stares and watches me as I walk through this area. I have always been taught that staring is impolite, but I have recently started staring back at them.

People are leafing through magazines or Watchtower flyers dropped off by Jehovah Witnesses, catalogs of classes offered at the community college, or yesterday's newspaper. A few are pounding away at laptops; teens have their iPods in their ears. Most are staring at me as their only form of entertainment. Perhaps I should dance? There is usually someone talking out loud on their cell phones.

"Yes, I still have that oozing rash. I am here at the lab to get some tests to see how contagious it is. What are you up to?"

In pediatrics, we have two waiting areas; one for the sick kids and one for the well ones. The receptionist and the parent usually decide which area is for them. We have another room that we use for "rashes," mostly to rule out varicella (chicken pox). There is usually someone in there with a non-contagious skin eruption, like eczema.

I always feel sorry for the people in the Sick Waiting Area. They could easily come in with one illness and leave with another. We do not charge extra for this service. Well adults are usually sitting with their sick kids wondering what they will catch. There are televisions with movies playing to make waiting more bearable, at least for the kids.

In the sick area, there are always plenty of "buffer" chairs separating the sick kids from the other sick kids and lots of hand sanitizer being used. Meanwhile, over on the well side, children are freely interacting. Since most viral illnesses are contagious a day BEFORE you know you are sick, our Well Waiting Area should probably be renamed, "Kids that are not sick... yet."

Any time spent in a waiting room or reception area is too long in my opinion. We have many celebrity patients, mostly highly-recognizable NBA basketball stars who often bring in their kids. So that the other well-meaning people will not hound them for autographs, we tend to bring them back quickly. I sure wish that I was seven feet tall sometimes, but when medical providers become patients, we are treated exactly the same as everyone else. We sit there and try to be a patient patient. When the receptionist looks up, we smile and glance at our watches, trying to portray that hurried look. It doesn't ever work.

I heard a comedian say that he claims to have chest pain when he goes to the ER so he can get prompt service. As soon as they get him to the back, he claims his chest pain is better now, but his finger (the real reason for the visit) is really sore. I don't recommend this approach, but people do change the reason(s) for their visit. This is one of the major reason medical provider tend to get behind. We call them "Oh, by the way..." issues.

Yesterday, I had a mother bring in a teenager for a headache. No sooner than I started to take the medical history regarding this headache, she brought up a good half-dozen other issues. Perhaps she felt this would better fill up the idle time I would have during this 15 minute visit. In addition to those headaches, there was back pain, a rash on her leg, a changing mole on her back, menstrual cramps, and ingrowing toenails.

Since I could not possibly devote the two hours needed to adequately cover these issues, we had to negotiate some to a future visit. To be nice, I spent twice as long on this visit as planned, arranging for her to return for the less "critical issues." Even after that, she pulled out some immunization records for me to review and a sport participation form she wanted completed. On the outside, I smile. Inside? Aaarrrghhhh!

There is nothing more pleasurable for me than seeing a patient promptly; on-time. As soon as my nurse finishes her part, I like to shoot right in before the door even closes, much to patient's amazement. Unfortunately, I can't always be as prompt, but I try my best.

"Wow, that was fast."

"I thought I would try and make up for all of those times you had to wait."

She takes out her list.

I smile.

Related Topics:

• WebMD Video: Special Report: Waiting Time for Docs
• WebMD Video: Wait-Free Doctors' Appointments

Technorati Tags: top 5, doctors, appointments, waiting room, wait time

Part 4: The Top Five Reasons Why Patients Are Dissatisfied

In a recent patient survey in our medical group, there were five areas of dissatisfaction that were identified. This is the 4th of the five reasons, but this is nearly identical to the second one: Provider's ability to return your calls in a timely manner (10.6%)

4. Office phone calls not answered promptly (10.1%)

On some days, we may see upwards of 450 patients in our pediatric practice. For each patient see, there may be twice as many phone calls directed at the dozen or so medical providers in the practice. These calls must be answered by our staff. During the morning rush, when the phone banks open, we have about eight people answer our lines until things quiet down. Our medical group carefully tracks how long people wait on hold so that we can create bench marks to do better.

I think we do pretty well in our particular office, but other practices within our medical group may not be doing as well for this to make the top five. Most of our patients are able to get through, speak to a competent human, and have their issue addressed. Although we do have to put people on hold from time to time, depending on their request, we try to limit the idle time.

No one, I repeat, no one likes to be on hold. I am probably the worst person to be put on hold. I answer postings on the WebMD ENT board; I work on Blogs; I play solitaire. I count the minutes. What I don't do is listen to that awful music, which always seems to be Spanish Eyes or another tune that I hate. Tunes that you hate always result in the worst case of ear worms -- tunes that repeat over and over in your brain; tunes you cannot shake the rest of the day. Of course, if you didn't have the music, you would think you were disconnected and call back, getting a busy signal because they have you on hold.

When you are ill, being on hold makes you sicker. This is just a personal theory. First, you are already not feeling well. You listen to Spanish Eyes a few hundred times and life is no longer worth living. Once your call is finally answered, it is all that you can do to not take it out on the overworked person who was unlucky enough to get your call. If the person who answers the phone is (a) courteous, (b) efficient, and (c) accommodating to your schedule, you are unbelievably gracious.

xOur brief message that the patient hears first informs them of our "busy phone times" and suggests that they call back later if they can. Most people hope the other people call back, so you will not have to wait. Basically, most people wait.

Almost all doctors' offices have that disclaimer: "If you have an emergency, hang up and call 911." We have that announcement, but fortunately very few people with true life threatening emergencies call us first. The message is for those rare people who decide to remain on hold with a severed limb or something.

One of my patients told me that she starts calling immediately at 8:00 AM on Monday mornings if her kids need to be seen. If she gets a busy signal, she hits redial over and over until she gets through. I bet she is not the only one that does that. She prides herself in getting through relatively fast by this method. One woman called on her cell phone, was placed on hold. She was still on hold when she walked into our office, so when they answered her call, she was already sitting in the waiting room. I loved that story.

I had an important flight canceled one time. As soon as the announcement was made, hundreds of people ran like cattle, dragging bags and kids by the arm, to try and get on the next flight at another remote gate. I was second in line when they canceled the flight, which placed me near the end of the mob rushing to the new gate to be booked on the next flight. Perhaps out of fear of being trampled, I dialed the 800 number for reservations and booked my seat before those sweaty losers even made it around the corner. I don't know why I told you this story, but I love this one, too.

We don't have complicated voice mail announcements in our office. I find these worst than being on hold with Spanish Eyes:

"If you would like an appointment, press 1. If you would like a refill of an existing medication, press 2. If you have a question for our advice nurse, press 3. If you are calling about the status of a referral in progress, press 4. If you would like to speak to the receptionist about an existing appointment, press 5. If you have a severed limb, please hang up and call 911. If you would like these messages repeated, press 10"... and so on.

Maybe it is my short attention span, but by the time I get to the end of those voice mail messages, I either forgot the number I should have pushed, or NONE of those choices are really what I want. Usually, I just hang up, put my severed limb in a bag of ice, and call back later.

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Part 3: The Top Five Reasons Why Patients Are Dissatisfied

In a recent patient survey in our medical group, there were five areas of dissatisfaction that were identified by patients. This is the third of the five reasons.

3. Patient's ability to contact providers after hours (10.4%)

People do not always get sick between the hours of nine to five, Monday through Friday. Since medical providers cannot be in their offices at 3 AM when someone has an allergic reaction or a sudden bout of abdominal pain, doctors take call. In other words, they carry their beepers and cell phones with them in case their patients have an immediate need for advice. Unfortunately, although some medical providers practice advanced forms of telephone medicine, advice is just about the only safe thing that can be provided via the phone.

Medical providers are supposed to be available to their patients 24 hours a day, seven days a week. In large medical groups, doctors will share call, since no human being should have those 24/7 responsibilities. In our group of a dozen or so providers, call is shared about three times per month, depending on vacations, etc. That doesn't sound too bad, but when you realize that one medical provider is covering call of tens of thousands of patients, they are most likely in for a busy night.

I am fortunate not to have call duties in our practice. When I worked in family practice, we all shared call and Saturday clinic. One night, I was awakened at 2 AM by a person complaining about ankle pain. Apparently, she had twisted it two days ago, and chose 2 AM to share it with me. I remained calm; told her to elevate it, apply some ice compresses, and take some Motrin. She was also told to call in the morning to make an appointment to examine the ankle. She did not call or show up the following day. Her inappropriate call woke up our baby, too. Nice.

I am a bit embarrassed to share that I was on call again two days later. Again, I was startled awake by a patient call around 3 AM. This time, it was a woman that may have been going into premature labor. She was sent promptly to the ER. As I wrote her name down in our call book, I noticed the ankle pain from a few days prior. As much as I tried to resist, I dialed her number. A sleepy voice answered.

"This is Rod Moser from the clinic. You didn't show up at the office, so I am calling to see how that ankle is doing."

After a brief, sleepy hesitation, she responded, "Fine."

"Excellent. Have a good night."

When I started working for our medical group, there were no after hour options other than telephone care. If the patient needed urgent medical services after 5 PM, they were simply sent to the local urgent care facility or emergency room. Prior to joining this group, I worked in one of those free-standing urgent care facilities. We worked three, 12-hour shifts per week. There was absolutely no reason why I could not do that for my new group. I figured that I was there; I was dressed; and putting in another four hours was not a big deal. When I was younger, working those extra hours wasn't a big deal. It is not as easy now as it used to be, but at least we have coverage for our patients until 8:30 PM.

Some after-hour calls are certainly appropriate, like the premature labor. Unfortunately, many are like the sprained ankle. There is really not much that medical providers can do other than provide some advice. We have many new parents in our practice. There is nothing that panics a new parent more than fever in a child. Although fever is inherently harmless, the higher the number, the tighter the parent's anal sphincter becomes. If there is one child, a parent can only tolerate about a 100 degrees; two children, about 102; and three children, about 103. If there are more than three children, fever doesn't frighten them anymore. Kids basically have to have smoke coming off of them. In a pediatric practice, fever tops the list of after-hour calls.

The word physician means "teacher." An integral part of our job is to teach people when it is appropriate to call after hours, and when it is appropriate to (a) wait until the next morning; or (b) utilize urgent care or ER facilities. Yes, medical providers deserve a life and they should not be bothered in the middle of the night by two-day old sprained ankles, but part of our responsibility is to help these more "challenged" people make those decisions. If patients call, we need to answer. This is the job we chose.

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Part 2: The Top Five Reasons Why Patients Are Dissatisfied

In a recent patient survey in our medical group, there were five areas of dissatisfaction that were identified. This is the second of the five reasons.

2. Provider's ability to return your calls in a timely manner (10.6%)

A large proportion of a medical practice involves voice communication. As our EMR (Electronic Medical Records) system evolves, we may soon be able to add secure e-mail to communicate with our patients, but right now we predominantly rely on Alexander Graham Bell's invention.

Most medical providers have appointment templates. In our office, we have both 15 minute and 30 minute time slots for patient visits. In some practices, providers are expected to see patients every 12 minutes. Sadly, one of our local HMOs has their providers on 10 minute appointments. Since Time is Money, the more patients that can be seen during the busy day, the better. Or, is it?

It is not unusual for a provider's schedule to be completely booked weeks in advance. In our practice, we have initiated an Advanced Access system: any patient who would like to be seen today, will be seen...today. While this is good news for patients, it can be a major headache for providers.

As soon as the phones open in the morning, the calls begin to flood in. Some are requesting appointments; some are requesting medications based on their symptoms and do not want to be seen; some are requesting refills; and some are simply asking for advice. Regardless of the reason, people need access to their medical provider and they would like to be called in a "reasonable" time frame.

From the moment the medical provider walks through the door, there are patients to be seen. Many have been processed already and are sitting in their little paper gowns, shivering and looking at their watches. In the "old days" (about two years ago), written phone messages attached to huge charts were stacked, often in order of urgency, on our desks, waiting for responses. Now, our computer message board starts to fill up, not unlike our home computers offering Viagra or hot stock tips. Patient messages are not SPAM; they are real people with real problems, and most are expecting an immediate response.

So, who comes first? Should we see the patients that have appointments first, or should we make them wait and immediately call back people who (a) did NOT make an appointment, or (b) may need an appointment but would like to get out of it. In a way, these phone calls are just people trying to jump first in line, so most of us will see the patients that are physically here first. If we do not see the patients close to their scheduled times, complaint will surely follow. If we do not promptly call our messages, complaints will occur as well.

The patients in the room are PAYING for their visit, either through insurance or out of their pocket. The patients on the phone are getting care for free. So far, the medical establishment does not charge for phone advice. Telephone medicine remains a free service.

I am usually provided with a least three different call back numbers: work, home, and cell. It is up to me to decide where the patient might be at a particular time. Usually, I am wrong. If I call work, they just left. I try the cell, I get voice mail. I call home and they have not arrived and the ten year old that answered the phone is not helpful. Three calls; nearly ten minutes. No luck. I try again later. At some point, I get them...

"My husband woke up this morning with pink eye. Can you call in prescription?"

"I am in-between insurance policies. I have been coughing for the last two weeks. I know I have bronchitis. All I need is a Z-pack."

Or, my favorite: "My child has this rash. What do you think it is?" Some of these are not unlike the postings that I get on the WebMD ENT Board. There are people out there who believe we can see through the phone, or through the Internet.

Medical providers must practice a certain amount of telephone medicine, but unfortunately, this is a very risky business. That pink eye could be herpes keratitis - a serious, sight-threatening condition. That cough could be pneumonia or congestive heart failure. And, that rash could be meningococcemia - a life-threatening disease process.

Most medical providers return phone calls between patients (if there is time), during lunch (I am sure you have heard the sounds of chewing, or even worse!), after work (while they are doing charts), on the way home using their cell phone, or from home when they should be spending time with their families. My PA wife works in family practice. Last Friday, she answered more phone calls than she saw patients. Revenue generated for the practice? Zero. Additional time away from home? Two hours. Additional compensation for a salaried employee? None.

After 12-13 hours of seeing non-stop patients, I will finally get to some of the less-critical phone calls.

"It's about time. I waited for you to call back all afternoon."

"How can I help you?"

"Oh, never mind. He seems to be doing better now."

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The Top Five Reasons Why Patients Are Dissatisfied, Part 1

Our medical group and administration spends a great deal of time trying to make things better for our patients. Medical care is now a buyer's market, so it is up to us to identify areas of improvement to make our patients happier. In a recent survey, there were five areas of dissatisfaction that were identified that I would like to share with you in the next five Blog posts.

1. Keeping patients informed if appointment time is delayed (14.8%)

As I have mentioned in past posts, medical providers never really know what is behind door number #2. Patients often make appointments for one problem, and then decided to tack on a few more once they have our attention.

Most appointments in our pediatric practice are in 15 minute slots; some are for 30 minutes (such as minor surgeries). On Monday, my first appointment was a 30 minute visit to remove an ingrown toenail. The patient arrived on time; it took about 10 minutes to register them and check the insurance status. It took another ten minutes or so for my medical assistant to take the vital signs, enter the information into the EMR (electronic medical record) and set up the surgical tray.

I was handed the chart five minutes later; twenty-five minutes after they arrived. My 9:00 AM physical had now arrived, and I have yet to do the surgical procedure. Let the patient juggle begin...

I explained the toenail removal procedure to the anxious ten year old girl; prepped the toe, and injected the local anesthesia. Since it takes a few minutes to take effect, I shot in to the kindergarten physical and took the appropriate history. I excused myself after ten minutes, ran back to the ingrown toenail and performed the now, painless procedure.

I gave the family the aftercare instructions, and shot back in to finish the physical. By now, I had two more patients (sick ones) "in the rack." I finished the physical and made it to the first sick one only 15 minutes behind schedule (not bad), only to be faced with a really sick baby that was going to take longer than 15 minutes for sure. To complicate matters, the mother brought another child, equally as sick. Welcome to my Mondays.

As much as we would like medical visits to be clear-cut, predictable, and straight-forward, they rarely are. This is what we deal with every day -- extra, add-on patients, patients that try to get five years worth of postponed medical care done in one visit, illness that are more complicated than anticipated, emergency phone calls, critical laboratory reports, doctor-to-doctor consultations, pharmacy calls, and patient calls. It is no wonder that I got kidney stones a few years ago. I don't have time to drink anything or pee!

Time is money for all of us. Patients are busy people, too, with lives and time commitments just like us. There has to be a common ground. Our patients should be informed that their visit may be delayed, but it is rarely appropriate to offer the reason, and most of the time we are too busy to make an announcement to the waiting room. If they see an ambulance pull up and a lot of activity, then they understand; but when their appointment time is becoming later and later, they start to get anxious.

Hopefully, my patients know that I am not sitting on my butt, drinking coffee with my feet up on the desk talking to my broker. When I enter the room for their visit, I do apologize and offer a general explanation for the delay and quickly get on with their visit in a friendly and non-rushed manner. Most patients understand about unanticipated delays; some do not. I say that I had a very sick child that took some additional time to adequately evaluated and treat and hope that they understand. Some day, I add, their child may need that extra time, too.

My patients are often shocked when I come into the room literally seconds after the medical assistant tells them I will be there "in a moment." I smile and tell them that this makes up for all the times in the past (and in the future) that they had to wait. I pay the price for seeing patients as promptly as I can. That price is that I delay doing my charting until lunch or after appointment hours. Last Monday, I came home at 10:30 PM, long after most of the patients that I saw that day were asleep.

Our group wants us to put up a white board in the waiting room that is frequently updated to let patients know the estimated delay. I guess that is better than having a number like the deli that says "Now serving number 4," or that annoying computer announcement that tells you the average waiting time for your call will be 18 minutes. The white board may work in a single-provider office, but we can have as many as a dozen medical providers working at the same time, each seeing 30-40 patients. That is nearly 500 opportunities for delays. We are going to need an electronic ticker tape circling the waiting room, like Wall Street.

Abby, one of my frequent ENT Board posters complained that she had to wait three hours to see her ENT and she was angry. One of our pediatric urologists routinely has patients waiting this long. Adults are one thing, but having a sick child (or ANY child) wait three hours is a nightmare. We certainly do better than this.

A family practice physician allowed his patients to select the number of ten minute increments of time that they thought THEY would need at their medical visit. Guess what? Patients were much more accurate in anticipating how much time their visit would require than the appointment schedulers or the doctor. Of course, this family practice physician charged accordingly for these ten minute increments. If you want your sore throat addressed, have a mole removed, and have a discussion about your divorce all on the same visit, then book as many slots as you need. Patients are charged accordingly. I really don't see a problem with this method. That's how my car mechanic does it.

An OB-GYN gives his patients a beeper, so they can shop or do other errands. Non-C-section babies arrive without appointments and pregnant ladies understand this.

Maybe we need to see fewer patients per day or hire more medical providers? Maybe we can build in more decompression, catch-up slots in our schedule? I don't really have the ultimate solution, but I would sure like to hear yours.

Today is my day off. I shouldn't even be thinking about this stuff.

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Anatomy of a Medical Visit

The Miserable Morning

Lindsey woke up in the morning with a terrible sore throat and fever. As she tried to get ready for work, it was clear that she was going to need some sort of medical care.

Did you know that the vast majority of medical care provided in the world is not provided by trained, medical professionals? Before accessing organized medicine, most people try and take care of themselves.

First, you have the issue of pain. Most people with a severe sore throat will reach for their trusty bottle of acetaminophen or ibuprofen. Some people even have a hoard of prescription pain medications lying around, such as codeine or Vicodin. If the pain is bad enough, you skip directly to the stronger medications.

Second, you try and remember what your parents told you to do for a sore throat. Ah, yes, gargling. You grab the box of salt and dump in a healthy amount into a glass of warm water and head for the bathroom. Of course, you soon realize that you have created a saline solution stronger than the Great Salt Lake or the Dead Sea. After a few attempts to gargle with this unbelievable salty solution, you give it up.

Third, you examine yourself. You find a flashlight and a mirror. The throat looks terrible. It is red, angry-looking; not normal at all. This is probably Strep, Lindsey concluded. She wanted to take her own temperature, but had no idea where she put the thermometer. Oh, well, she felt her forehead and concluded that she was hot; about 103 she estimated. Her glands hurt, too.

Again, she searched the medicine cabinet. It was filled with mostly-expired prescriptions that she never finished. Lindsey found some ciprofloxacin, but couldn't remember if it's an antibiotic or something she took for diarrhea. (It's an antibiotic). She had only one tablet anyway, so you swallowed it, even though she knew this was not a good practice.

Making The Appointment

Lindsey looked at her watch. It was 8 AM, so she called her doctor's office. The phone rang constantly. After about 200 rings, a woman answered. Based on the distant, nasal tone of her voice, she knew it is the much-feared Doctor's Answering Service.

"What time does the office open?" She was told 8 AM, so she reminded the answering service that it WAS after 8 AM now. She was told to call back in little while later. She tried again at 8:15 AM, but the phone was now busy. She tried again; still busy. She called in sick for work; and tried yet again. This time the phone was answered but she was put on hold, less than one millisecond after the words "Doctor's Office. Please hold". She waited, clutching her sore throat. She waited some more. She started a load of laundry with the phone resting on her shoulder.

Eventually, the receptionist answered the call. Lindsey briefly explained her problem and asked for an appointment. She was offered an appointment in three weeks. This was unacceptable. She told the receptionist that she would prefer to be seen on the day she was ill; today. The sound of rapid keystrokes filled the silence.

"Can you be here in ten minutes?"

Standing in her robe; hair looking like she lost a dog fight, breath smelling like salted cod, she respond, "Yes, if I can find my time machine." Strep throat seemed to unusually sharpen her normally-suppressed sarcasm skills.

"Well, can you come in at 3:20 PM?"

"I guess I will have to, assuming that I do not die between now and then." The receptionist added her name to the other three people scheduled for the same appointment time.

As the morning progressed, she felt more and more like crap (Crap is a frequently used medical term for extreme malaise, body aches, fever, and frustration). She popped some more ibuprofen and gargled with the brine.

The Waiting Room

Lindsey arrived early, at 2:30 PM, hoping that her medical provider might fit her in earlier. She waded through a sea of coughing people, kids in strollers and approached the front desk. Another woman was complaining about her bill while simultaneously talking on her cell phone. She was told to sign in and be seated. She was also chastised for being early.

She couldn't help but notice the twelve people on the list in front of her whose names weren't crossed out. For one quick moment, she considered sneaking her name higher on the list and writing down an earlier time, but she didn't. She found a seat next to someone who was madly scratching. After sitting there a few minutes watching this display of digging, she spotted another chair near a greenish man holding a barf bucket. She decided to take her chances with the scratcher.

Leafing through a boating magazine, having nothing better to do, she wondered what kind of boat her doctor must have. Somehow, that ticked her off, but she was not sure why. She looked around the crowded waiting room, trying to guess what other people had. That woman definitely has Chlamydia or worse. Both of those children have pink eye. It doesn't take a medical degree to figure that one out. They were wiping their noses and eyes on the chair. An older woman with a walker smelled like pee. Oh, how she loved the waiting room.

Her appointment time of 3:20 came and went. She guessed that this is why it was called the Waiting Room. The barfing man and the scratcher had already been called back. Maybe, she was next. No...there went the pink eyes. It was now 4:00 PM, so she approached the front desk czar. She was told that the doctor was running a bit behind. Running behind what? A turtle? She sat back down.

The Indignities

At 4:18, a medical assistant, thirty years younger than her, mispronounced her first name. She was lead to a scale for the first of her ritual indignities. The medical assistant loudly announced weight so that everyone could hear. She ignored the fact that Lindsey's shoes weighed 16 pounds. A temporal thermometer streaked across her face and she was told that her temperature was normal. Damn! She shouldn't have taken that Motrin, she thought.

She was then led into a small examining room and asked why she was being seen today. Lindsey gave her a five-minute, detailed, chronological history of her current illness, her allergies, and her concern about Strep. After carefully listening, the medical assistant wrote down "sick" and headache on her chart and told her that the doctor will be with her in a moment. Lindsey did not tell her that she had a headache, but that was okay. She had one now.

The Doctor Arrives

A "moment" in doctor-time is really about a half-hour. She wished she still had that boating magazine. She stared mindlessly at the beige walls and the torn anti-smoking poster. Time stopped. A child is screaming in the distant.

Some time later, the doctor barged in without knocking, performed a cursory examination, and pronounced his verdict: It didn't look like Strep. It was just a virus. All she needed to do was take Motrin and gargle.

"Aren't you going to do a Rapid Strep Test?" she asked.

"If you want, but I think it is a waste of money." He swabbed her throat like he was cleaning out a rain gutter and left the room with the swab.

"It will just be a 'moment'," he said. She waited some more.

Another fifteen minutes dragged by.

"Your Strep test is positive, so you will need to go on some antibiotics. Are you allergic to anything?" He was writing before she answered.

He wrote out a quick prescription, and again tells her to gargle with salt water and take Motrin. He handed her a paper to take to the front desk to pay. It was now 5:45 PM.

The Tag Line

Office visit: $75. Strep test: $24. Prescription: $30. The fact that she proved him wrong about the Strep: Priceless.

On the way to the car, Lindsey started to scratch.

The End

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