Alcohol Abuse, Love, and Frostbite

With the New Year ushering in, many of us will usher out for “celebration.” I won’t be one of them as most recent new years, being on call, I’ve managed cases of acute alcohol abuse, frostbite, and love.

Cliche dictates we brave the cold for a magical New Year’s kiss, for love essentially.

We brave the New York City street and Time Square, generally under-dressed: who wants to pay the extra money for the coat check, mess up their hair with a hat, sport boots in cocktail dresses? I don’t.

The US National Library of Medicine specifies alcohol as an independent risk factor for frostbite, here is the link if you don’t believe me: https://medlineplus.gov/ency/article/000057.htm.

Should love be added to the list of risk factors, displaying all of the aberrant behaviors of disease, the sleepless nights, the obsessions and compulsions of checking our Tinder and Facebook accounts, the mood fluctuations from elation to depression, I could go on.

I write as a physician wishing you a happy and healthy holiday. And as I query a recent question posed to me: Are you a “hopeless romantic?” I would answer “If it meant me risking frost bite for “true love” I suppose I am.

An aspirin a day keeps the heart attack (and colon cancer) away.

Aspirin, also known as acetylsalicylic acid (ASA), is a medication used to treat pain, fever, and inflammation and is an NSAID (Non-Steroidal Anti-Inflammatory Drug). It is often not grouped with other NSAIDs because of it’s blood thinning effect by binding platelets.

It went into mas production in 1899, sold by Bayer, and was a blockbuster, the Viagra of its day (and that’s an understatement).

Unlike it’s more commonly used competitors in the NSAID family like ibuprofen (Advil) or naproxen (Allve), aspirin 81 mg daily REDUCES THE RISK OF HEART ATTACK AND STROKE AND COLON CANCER in patients that have ANY risk factors for these conditions like high blood pressure, diabetes, obesity, male gender, the list goes on. [We can talk about the less discussed fact that most other NSAIDs like Advil and Alleve increase the risk of heart attack and stroke later, seems like some pharmaceutical companies don’t want this advertised, remember Bextra and Vioxx, I do].

Based on the United States Preventive Task Force a baby aspirin daily which is 81 mg is recommended ” for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC) in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years.” [https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/aspirin-to-prevent-cardiovascular-disease-and-cancer].

I turned 41 this past November and I take a baby aspirin daily. It is dirt cheap. Does not bother my stomach. And, depending on the study, can reduce risk of a heart attack or stroke or colon cancer (and possibly breast cancer, endometrial cancer, and prostate cancer) by up to 10%, maybe more, maybe less, it is all about how much risk you have for developing those diseases.

There is a lot of data coming out about the benefits and risks of aspirin despite the fact that it was around two centuries ago–you’d think they would have come up with something conclusive by now, right?

Anywho, if I’m your doctor or you want to play doctor as many patients do by educating themselves on the internet, tell me your thoughts.

How to verify a patient’s insurance information is accurate, especially on Christmas Day?

5:30 am in a dark New York City, four days after the winter solstice, I guess Santa is making his final rounds for all the good children but what about all the good doctors?

Would it not be nice if, because it’s Christmas, if the Health Insurance Fairy left a health insurance company’s fee schedule under my pilliow?

Being an out-of-network physician–meaning I have no contractual relationship with any third party insurance companies including Medicaid and Medicare–I am constantly forced to guesstimate what I will be paid for my medical procedures and time.

To make matters worse–as medical schools do not offer any significant classes in medical billing–I am self-taught, having learned the mumbo jumbo language of CPT codes, ICD-10 coes. modifier codes, all sorts of weird numbers and letter that change often that I put on a “1500 claim form” and send in to my patient’s insurance company. (If you don’t know what any of this stuff is and your a doctor considering private practice, start studying my friend or contact me with questions, as if there is anyone reading this?).

Dropping that form in the mail is like a Hail Mary in football, except I will not find out the compensation (if any) for the doctor services provided.

I get back what is called an explanation of benefits (commonly called an EOB) from SOME insurance companies, not all. That is, in the last year, a few insurance companies like BCBS only send paperwork to the patient, not the doctor, so you have no idea if and when you’ve been paid unless you bug the patient to have them check their male and send you the EOB.

A few health insurance companies have even requested a HIPPA medical release for my office to determine claims and eligibility of a patient’s insurance plaa which is obviously ludicrous since the patient is not yet an established patient.

I can rant and rave for a while but this Christmas, my wish, some transparency from the insurance company “Matrix” unless there is a Neo out there?

So how to verify a patient’s insurance information is accurate, especially on Christmas Day? Would anyone reading this care to offer advice (and I know there are some automated systems that provide claims and eligibility but at least 50 percent of the time, in my experience, I need to speak to a human to get answers, yes, a human).

What do you call a house call doctor’s practice when the office is closed for vacation?

Question: What do you call a doctor’s practice when the office is closed for vacation?

Answer: Dead. Prognosis grave. Death imminent. Call the coroner.

My running joke since starting New York House Call Physicians: Your Doctor in the Family in 2005 is that I ask my patients to get sick only Monday-Friday 9am-5pm but they never listen.

Patients have the audacity to get sick on weekends and even on the holidays. The nerve. Can’t they respect a doctor’s time with their friends, family, religious and social obligations, etc?

These are all obviously rhetorical questions.

My patients want direct access to me when they are sick, period. Whether in rural Maine now where I am on my first “vacation” in a year or Christmas Day, my email and smart phone are alive and well with patients calling, labs coming in, prior authorizations that need me to sign off on, the normal rumblings of a medical practice/small business go on 24/7/365.

My office doesn’t close for vacation. i don’t close for vacation. Illness doesn’t close for vacation.

Bottom line: If you want to keep your practice alive and thriving, always pick-up the phone, a few minutes spent while on vacation will save hours of work when you get back.

Secrets of a House Call Doctor Part II

Secrets of a House Call Doctor Part II

A good house call doctor is only as good as the equipment carried with them including medications.

Let’s face it, as 21st century physicians, we can do little without our gear.

Not to be forgotten are the house call doctors that preceded us–which essentially means medical practice since Hippocrates as doctors performed house calls regularly historically.
Terms like “Urgent Care Facility” or “Tertiary Care Hospital” would not have been translatable easily to Galen or Liston.

One of my first house calls was for a sore throat, that was what the caller said anyway. Upon arrival, in addition to the sore throat, they mentioned they had “twisted their ankle” and could I “take a quick look at it and wrap it.” I’m thinking: “Why would I bring ace wraps for a sore throat, why didn’t you mention this when you called, I have plenty at the office.”

The ankle appeared mildly sprained. I hustled down to the nearest pharmacy, bought an ankle wrap for 10 dollars (they cost 1 dollar if that wholesale), and wrapped the ankle.

When I do home visits now, I have so much gear it actually scares most patients, seriously. Imagine calling for a headache and a doctor walking in, cargo patents bulging with equipment, rolling with more gear than two strapping paramedics might carry. That’s me. Better to have it and not need it than vice versa.

Alcohol Abuse Disorder vs Atherosclerotic Disease

While I do not drink alcohol, I treat many patients who suffer from alcoholism–the new politically correct term is Alcohol Abuse Disorder. Why medicine has to keep renaming it’s diseases is beyond me, I think so we can sounds smart at cocktail parties but in seriousness, because in the 21st century, we are realizing that many illnesses like Autism to Asperger’s are spectrum disprders, that is, some people have it worse than others.

So it is with alcoholism.

According to the National Institue on Alcoholism and Alcohol Abuse (link to https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-facts-and-statistics):

Nearly 88,0009 people (approximately 62,000 men and 26,000 women9) die from alcohol-related causes annually, making alcohol the fourth leading preventable cause of death in the United States.
In 2014, alcohol-impaired driving fatalities accounted for 9,967 deaths (31 percent of overall driving fatalities).

To give you some perspective, nearly 800,000 people in the United States die annually from diseases related to artery clogging like heart attacks and strokes. That is 2,191 deaths every day in the United States from a preventable illness to some degree (there are those with genetic predispositions and bad luck). For perspective, about 2996 people died in the attacks on the Twin Tower on 9/11 [Source: https://en.wikipedia.org/wiki/Casualties_of_the_September_11_attacks].

My point: alcohol is certainly a problem but tobacco, uncontrolled blood pressure, diabetes, obesity–all the risk factors for artery clogging are the real killers statistically in the United States and the media seems to overlook this on a daily basis.

In my opinion, the headline of every newspaper every day should be “Thousands more die from Heart Attacks again today, again”

Trade secrets of a house call doctor

Now that I am no longer the only doctor in New York City doing house calls, I figured I’d spread the wealth and teach some of you newbies on some secrets of house call medicine.

A good house call physician does two things better than any other doctor:

1. He (or she) answers the phone when called NO MATTER WHAT (this includes email, mms, text, vm–welcome to the 21st century–no need to make sure your horse is well fed so you can hustle off in your buggy.

2. Know how to improvise. Since we are only as good as our knowledge and the gear we carry with us, improvisation in clutch.

Further details to follow, off to administer cefepime IM to a patient with pneumonia (that’s right, I wrote IM or intramuscularly, not IV)–cefepime can be mixed in lidocaine and given IM with equal efficacy to IV form. And you then do not have to fuss with the IV and the drip and wait around for 30 to 60 minutes to run the drip–time is money. I am out of here?

WHY CHOOSING A DOCTOR COULD BE DONE BY A 6 YEAR OLD?

Let’s face it, children have good intuitions. As we age, these get muddied by things like co-pays, co-insurances, prior authorizations, long hold times on the telephone listening to recorded messages telling yo how great the doctor’s office is.

A 6 year old would know to ignore all this.

An adult seeking a new medical doctor for themselves or a loved one could learn a lot form simple childhood observation.

For example, we all know we should wash our hands and stay clean. A doctor with a dirty lab coat is a bad sign, stay away.

Another example: 6 year olds learn to read and write neatly. Bad sloppy writing equates with bad medicine. This is not just my opinion. This is shared by JCAH0 (https://www.jointcommission.org/) who insist on neat writing or electronic medical records, no medical jargon, no latin, and no abbreiviations.

Other examples I always look out for both as a doctor and patient:

  1. Is there a plate of security glass between me and the receptionist. If so, why? Do you really think I am going to steal your stapler or the multitude of redundant forms you are going to make me complete?
  2. When I call or email or text my doctor, does he answer the phone and get back to me in a timely manner? This sounds straightforward for a 6 year old but really, we live in the 21st century, a time of ultra-accessibility. Pick up your phones doctor and loose the pagers!
  3. Speaking of pagers, if you doctor uses one, he probably should be placed in a time machine like Back to the Future.
  4. My 4 year old daughter wants everything NOW. You know what, so do I as a New Yorker, especially when I am sick. If you doctor makes you wait for more than 5-15 minutes in the waiting room, then has their medical assistant put you in a paper gown and sit in a tiny room by yourself freezing for another 30 to 60 minutes, this is a bad sign–in fact, it sounds like you are about to be hosed down before entering prison!M FYI my office has no waiting room. The term is an oxymoron. Patients are seen on time. In New York City where space is precious, why dedicate so much of it to a room full of old National Geogrpahics that nobody wants?
  5. How many pages of redundant paperwork asking the same questions did your doctor’s office give you to complete. Plus, some offices also make you complete information on a tablet or ipad. Why ask me my name, birthday, and what medicines I am allergic to a dozen times. Makes no sense. My office paperwork is completed by my stafff so the patient only need sign their HIPPA medical record release and r=then we go right into practicing medicine.

More examples and good stuff to follow, be well.