DIFFERENTIAL DIAGNOSIS

Pain is the result of an abnormality or injury.  True or false?

Pain can cause pain. True or false?

It is better to treat the cause of pain. True or false?

It is better to treat pain regardless of cause. True or false?

Doctors worry about treating pain. True or false?

Believe it or not, all of the above statements are true. So, which is more important, the cause of the symptom or the symptom itself? Patients usually focus on the symptom.   “Doc, I’m having terrible spasms in my right forearm causing excruciating pain.  I need something for the pain.”  Something for the pain usually translates to hydrocodone and prescribing hydrocodone makes docs nervous.

The doc’s job is to diagnose the cause for the pain, directing treatment at removing the source.  Using hydrocodone is the equivalent of putting a Band-Aid on a cut.  Finding the cause of the pain/spasm can be difficult and often, in many cases, requires a thorough history, exam and testing.

Take, for example, my forearm pain.  I’ve been getting excruciating right arm muscle spasms causing severe pain and disability. It’s gone on for week;s and, at times, it felt like the spasm would break my bones.  Initially, I thought my deep brain stimulator was causing the spasms as the pain would go away when the stimulator was turned down.  When the pain was severe, I turned off the stimulator. The pain persisted.  Obviously, the DBS was not the cause.  Right?

Wrong.  Remember, spasm can cause spasm and my spasm had gone on for weeks.  One spasm was accompanied by a loud pop in my elbow followed by an inability to fully extend the elbow.

As you can see from my example, the diagnostic process can be difficult.  Before you see your doc for a problem, make a list of your symptoms and any possible causes.  Please do not search the internet!  According to google, everyone has cancer and other rare diseases.  On occasion, all you’ll need is a Band-Aid.  When I practiced medicine, I preferred diagnosing the cause of the pain as opposed to applying a Band-Aid. If I could diagnose and treat the origin of the symptom, then I had a chance at a permanent cure.

The next time you see the doc, remember how complex diagnosis and treatment can be.

Here’s today joke:

My wife yelled from the bedroom asking, “Do you ever get a shooting pain across your body like someone’s got a voodoo doll of you and they’re stabbing it?” I replied, “No.”

She yelled back, “How about now?”

SCARE TACTICS

Scare tactics!  Yep, that’s what the commercial I just watched amounts to.  In response to candidates promising to reign in the cost of medicine, Pharma is threatening to stop research and production of new medications.  All I can say is, “Bull Shit!”

Pharma develops and sells medications on a worldwide basis.  Many of our most popular drugs are produced overseas.  Did you know that in many countries medication cost far less than in the United States?  Everyone knows about   Canada. 

So, if much of the world sells medication for less than we do, how come Parma continues to develop new meds?  The answer is easy.  Pharma has huge profit margins! 

Don’t let them scare you.  Vote for candidates who promise to cut the cost of medication.  Then hold their feet to the fire!  It’s time Congress keeps its promise.

PAY THE DOCTOR CASH

A recent article on KEVINMD.COM entitled, “Keep your medical insurance, but pay the doctor with cash,” was of particular interest to me.  My practice was unique in that I ran a Concierge practice side by side with a typical fee for service practice.  Comparing the two practices is easy.

The Concierge practice was fun.  If I needed a test or procedure, I could order it without many hassles.  Concierge patients bought their freedom by paying cash and were more appreciative of their care then their counterparts. 

Fee for service/insured patients relied on their insurance company and gave up their freedom, trading it for a copay.  Their care carried more overhead than the Concierge patients and they really didn’t understand how much back office work it took just to get them an x-ray.

You may not know it, but your doctor’s office is forced into taking insurance products and putting up with the insurers’ discounts.  Did you ever stop to think that your doctor is your banker, carrying your debt until the insurance company pays him/her?  Did you realize that your $10-$40 copay represented the majority of your family doc’s paycheck?  I bet you didn’t know that it cost me money every time I sent you a bill.

Giving a discount for cash paying patients makes sense.  The only drawback is a theoretical one.  Medicare and your insurance company could look at your doctors’ discounted fee as his/her real fee and claim that your doc over charged them.  Medicare could then claim that your bills were fraudulent and file criminal charges against your doc.  Sound insane? It is!

Insane rules created by your insurer and government guaranteed that your doc and their patients had little recourse when it came to arguing over billing and the cost of medicine.  While I was in private practice, I fought to keep costs down and to get my patients the referrals they needed.  I wonder who is going to fight for your rights in the corporate world of medicine that exists today.

By the way, “Pay the doctor with cash” does not mean hand your doc a credit card.  Credits cards charge your doc a percentage of the amount charged.  For those of you old enough to remember cash, there is no charge for the use of cash.  Every little bit counts.

Here’s a true story to think about.  I was standing in the check-out line at the Vet’s office.  The man in front of me was told his dogs bill was $245 and included the doc’s time and lab work.  His dog had a urinary tract infection.   The man paid his bill.  He did not complain, he did not tell the office to bill his insurance.  In my office, the bill for a UTI would have been $200.  I would have gotten a $20 co-pay, billed insurance, and written off the insurer’s discount, collecting a grand payment of $100.  Many of my patients would have griped about the co-pay despite the savings. 

If you like your doc, pay your doc!  Use your insurance for big ticket items.

Here is today’s joke:

A bank robber gets hold of the cash he needs but before fleeing the scene he demands the regular customers to stand in a line

The bank robber asks the first guy in line: “Did you see what happened here?”

First guy: “I sure did! And I’m gonna tell the police exactly what happened and what you look like…”

The bank robber shoots him in the head and asks the next in line the same question.

Second guy: “I assure you I did not see a thing… but my wife here did”

I THOUGHT I HAD SEEN EVERYTHING

I thought I had seen everything.  I hadn’t!  Tonight, I saw a commercial for pubic hair.  That’s right, the cartoon character sang a song in which she proclaims how proud she was of her pubic hair.  In the next scene, the razor she used to sculpt her pubic hair was featured.  How long before we see actresses singing about their vaginas on commercials.  Perhaps the doc who’s on prime time touting her deodorant for private parts will commission a song about vagina pride.  Personally, I can’t wait till Hallmark has a National Pubic Hair Pride Day.  Perhaps we could have a Pubic Parade and shout, “Show us your pubes!”

The other thing I never thought I would see is mail order antidepressants and erectile meds.  The commercial is very reassuring stating that the meds are prescribed by licensed providers. You can be happy, hard and last longer! Depression can be a serious disorder and is best treated by counseling with appropriate follow-up with a MD.  Did it ever dawn on you that erectile dysfunction may be nature’s way of keeping you from screwing yourself to death?  ED is often related to vascular disease.  Lastly, erectile dysfunction is often the result of other disorders.  Sure, the medications are relatively safe but performing an exam over the phone is impossible.  While the rectum tolerates a finger, a cell phone or computer just won’t fit.  The commercials for ED are more than suggestive.  When I was young, they would have been considered pornographic. They certainly are better then the Playboy that used to hide under my mattress!

 The medical world moved to phone medicine during the pandemic.  It appears that phone medicine is being normalized and is here to stay.   I don’t like it.  Being able to see a patient in person, witness their demeanor, facial expressions, and interaction with others all help in making appropriate diagnosis and monitoring treatment success. 

Here’s today’s joke:

In Australia, a man set his pubic hair on fire;  I guess you could call that an “Australian bush fire.”

EXPENSE OF MEDS

According to a recent search of the internet, a scum bag is a “a contemptible or objectionable person .informal, derogatory.”  That would make the insurance agent I just talked to a “scum bag.”  Now that I think about it, I’ve dealt with a lot of scum bags over the last 40 years.

Many of you will think I’ve gone too far. I haven’t! I’ve watched my patients suffer at the hands of health insurers.  There are patients whose testing, labs, and hospitalizations have been refused by insurers who make money as if they were printing it ($100 million or more yearly for one well known insurer in one state).  I’ve watched patients go bankrupt trying to pay for the healthcare they needed that their insurers refused to pay.

In reality, insurers never deny care. They simply refuse to pay for care.  If your insurer refuses to pay for your care, contest their decision strenuously. 

Renee takes an inhaler that is essential if she wants to breathe.  Initially, the cost to her was $42 per month (about 10% of their retail cost of approximately $403).  This month her portion increased to about $102 per month (now 25% of their retail cost).  Their formula to determine when you have to pay more is based on their retail cost of the medication.  When you reach their set threshold of the retail cost of medication in a calendar year, you are moved into the next higher pay basket.  However, to get past the “Coverage Gap” into the “Catastrophic Coverage”, the basket change is based on out-of-pocket costs, not their retail prices.  It sounds like they are mixing apples and oranges.  Maybe they are just speaking two different languages to further confuse us.

In addition to trying to understand the double speak, the scum bag on the phone did not speak English intelligibly. She gave an explanation which boils down to two main points.  Reason number one: this insurer can set the cost of care whenever they want to because they can.  Reason number two: the insurer seems more concerned with stockholder profits than the health of its members.

Please understand that Renee was a medical office manager for 30 years.  If she had trouble understanding the agent’s explanation, do you think the average patient can understand the rules?  Of course not!  There is no transparency in pricing structures. The rule book that is available to the public and almost impossible to understand gives the insurer a huge advantage.  About 20 years ago, a Federal Judge was reduced to tears as he tried to get his medication released by his insurer.  He had asthma and needed his medication but refused to pay for it as the insurer dropped his medication from their formulary which had been a covered benefit for 20 years. He wanted “justice to prevail.”  All of his legal expertise was for naught when it came to dealing with the insurance industry.  He eventually won but at a great personal cost.

When I practiced medicine, I was afraid of the insurance companies.  I would not have written this article for fear of retribution. I’m still nervous! I’m also spending a significant amount of my retirement funds on medication and healthcare. I know I am not alone.  Many of us saved for retirement to be able to cover our medical expenses.  Little did we know what was coming.

Here is today’s joke:

The fitness trainer asked me “What kind of squats are you accustomed to doing?

I said, “Diddly !!”

TO PAY OR NOT TO PAY

A recent article on KEVINMD.COM entitled, “Keep your medical insurance, but pay the doctor with cash,” was of particular interest to me.  My practice was unique in that I ran a Concierge practice side by side with a typical fee for service practice.  Comparing the two practices is easy.

The Concierge practice was fun.  If I needed a test or procedure, I could order it without hassles.  Concierge patients bought their freedom by paying cash and appreciated the care they received.  For the most part, my Concierge patients were not wealthy.  Instead, they were hard-working middle-class individuals who prioritized their health above all else.

Fee for service/insured patients relied on their insurance companies and gave up their freedom trading it for a copay.  Their care carried more overhead than the Concierge patients and they really didn’t appreciate how much back office work it took just to get them an x-ray.

You may not know it, but your doctor’s office is forced into taking insurance products and putting up with the insurers’ discounts.  Did you ever stop to think that your doctor is your banker, carrying your debt until the insurance company pays him/her?  Did you realize that your $20-$40 copay represented the majority of your doctor’s income?  I bet you didn’t know that it cost me $10 every time I sent you a bill.

Giving a discount for cash paying patients makes sense.  The only drawback is a theoretical one.  Medicare and your insurance company could look at your doctors’ discounted fee as his/her real fee and claim that your doc over charged them.  Medicare could then claim that your bills were fraudulent and file criminal charges against your doc.  Sound insane? It is!

My suggestion is that, if possible, pay cash and ask for a discount.  In lieu of paying for your whole visit, make sure that your account is zero’d out every time prior to leaving the office. Recognize that if your insurance company requires “prior authorization” that it requires extra work and expense.  Make sure you show your appreciation.  A cake, cookies, etc. says thank you.

Personally, I think tipping your provider is appropriate but I’m in the minority!  Things are different today as many docs work for large corporations.  A five-star review says thanks in an acceptable way.

Frankly, I think it’s best to look for a concierge practice.    However you do it, don’t forget to say thanks.

Here’s today’s joke:

A man was admitted to hospital today with twenty-five toy horses stuffed up his rectum. doctors have listed his condition as ‘stable’.

LISTENING

The art of listening is a critical skill, not just in medicine but in all of life.  I expected some blow back from my last article as I inferred that finding a doc who would take the time to listen to you was both important and a difficult task.  After all, we all listen to you, don’t we?

Not really!  In my day, there was a study that showed that docs interrupted their patients’ telling of their stoies within seconds to minutes of entering the room.    Tuesday, I had two doctor appointments.  In both cases, a physician extender took my history without ever looking at me.  The assistant interfaced with the computer, not me.  My morning appointment was with the neurologist, and she not only listened to me, but reviewed her assistant’s note.

My second appointment was with the eye doc.  Again, as is the usual, a physician extender questioned me.  Unlike the first appointment, the eye doc flew through the door, did not introduce himself, examined me and left.  He did not review his assistant’s note nor expand on it[Ss1] . He did not question me.

Now I’m sure there was an occasional patient who complained that I did not listen; but, for the most part, I interviewed the patient.  It was my responsibility to obtain a thorough history and my staff’s responsibility to note why the patient was in the office, knowing that I would build on the note they left me.

It was also my responsibility to provide for the patient’s needs as best I could and, if I could not, to know who could.  Sure, there were patients who had needs I could not meet, patients who were angry, frustrated and felt wronged; but, in all but one case, I was able to defuse the situation and help the patient find specialists who might better deal with their problems.

Yesterday’s article was on chronic pain, as is this one.  The number one cause for a dissatisfied patient is chronic pain.  It is also where listening is the most important.  Sometimes, treating chronic pain involves a bit of negotiation.  There is often a gap between the patient’s needs and the treatment options.  Sometimes, the only option is to live with pain, in which case a therapist skilled in helping individuals live with their disabilities is helpful.

Recommending a pain “psychologist” often elicits anger as the patient immediately responds that the pain is real, not in his mind.  Chronic pain is always real, is always a complex mixture of physical and emotional, and needs a combined approach.  When my back flares, the pain affects all of me. 

One thing I know for sure.  Shooting up a physician’s office, murdering the doc and his staff, is not a solution! If you have chronic pain and your doc is not meeting your needs for whatever reason, find a specialist who can help you.  If, like me, you have to live with pain, look to the alternative world for possible solutions.  If you are in Illinois, you might consider medical marijuana or its derivatives.

One last point, pain not only affects you; it affects your family and friends.  They may need assistance as well. What about the drug seeker/addict?  They are sick and need care also.  They often go from office to office when, in actuality, they need a referral to a rehab facility that will address the psychological and physical needs of drug addiction.

Here is today’s joke:

I asked my wife to rate my listening skills and she said, “You’re an 8 on a scale of 10.”

I still don’t get why she wanted me to urinate on a skeleton…


 [Ss1]

Chronic Pain

The problem with being an old, retired family doc is that, as your patients age along with you, your former patients die.  Years ago, I wrote an article about Ron’s hands.  Ron died on Tuesday; and even though I had not seen him since moving to North Carolina, I felt the loss. 

Ron was a paint contractor and jack of all trades.  In my hallway is the first piece of furniture I built.  I built it in his basement, under his tutelage.   Ron’s gift was his ability to make something out of nothing and examples of his work were present in my home and office.  Ron will be missed by many.

I have written several articles about the damage a physical job like Ron’s causes.  My carpenters, roofers, painters, etc.  built the homes and offices the rest of us lived and worked in.  Unfortunately, while building the structures we thrived in, they often injured their bodies, the cumulative effect leaving joint and back pain, as well as lung disease.  Convincing a young, healthy, strong craftsman that he needs to be cautious, wear protective gear and get help lifting heavy objects is not easy.

The result of years’ worth of repetitive injuries is chronic pain; and, unfortunately, current medical wisdom is to resist the use of “pain pills” and instead to treat the individual as if he/she was a “drug seeker” or had “psychosomatic” or “functional” pain.  So, what do you do if you find yourself in chronic pain from work related injuries and can’t find a doc who will treat your symptoms?

The answer is simple if you can get the doc to spend a few extra minutes listening to you.  Bring some of your tools with you.  Have your doc use a hydraulic impact hammer for a minute or two and then explain that you used it for 30 years.  A minute or two should cause a little discomfort and go a long way towards helping your physician understand the source and intensity of your problem. 

Each trade has its own culprits, so prior to seeing your doc spend a little time working on your presentation.  In 1984, I helped build my office.  I cut and installed ceiling tiles.  I did not wear a mask and quickly learned how necessary a mask was (I could have spat enough crap out of my airway to make a tile).  It was a valuable lesson.

I cut and installed the tile floors.  I did not wear knee guards.  Another valuable lesson.  I limped for weeks.  Cutting the wood for my furniture led to tendonitis.  Each experience helped me understand my patients’ pathologies and formulate treatment options.

Now all you must do is help your physician see your pain through your eyes.  Good luck.

Here is todays joke:

A sperm donor, a carpenter and Julius Caesar walked into a bar:

He came, he saw, he conquered.

PAIN PART 6

When I think about Frank, I have to smile.  Frank was elderly when I met him, meaning he was in his 70s as am I now.  Frank had a thick Italian accent and referred to his pain and body parts as “she.”  “My knee, she hurts me all the time,” was his usual complaint.

By the time Frank first saw me, he had seen a half dozen other docs and had lots of tests.  He was told he had arthritis and was on Advil.  “Doc, you got to help me, the pain, “she” is too much for me.”  “She” keeps me up all night.”

After reviewing all of Frank’s test and examining Frank, I told him the pain in his knee was most probably from his back and we would need to do a few more test.  “Doc, the pain she is in my knee, she no in my back,” was what I heard for months.  Frank finally consented to back surgery.  I’ll never forget what he said when he woke up after surgery, “Doc, the pain, she no is in my knee.  Now she in my back!”

The first lesson to learn is that pain can be referred from body parts remote to the one that hurts.  Renee’s shoulder pain may be coming from her neck.  My hip pain may be coming from my back.  The second lesson is that, according to Frank, pain is feminine in nature.

Seriously, diagnosing the source of any given pain is not easy and treating pain effectively is highly dependent on what the source is.  It’s important to keep an opened mind and explore all possibilities. 

Here’s today’s joke:

A couple was invited to a swanky costume party. Unfortunately, the wife came down with a terrible headache and told her husband to go to the party alone. He being a devoted husband protested, but she argued and said she was going to take some aspirin and go to bed and there was no need for his good time being spoiled by not going. So he took his costume and away he went. The wife, after sleeping soundly for about an hour, awakened without pain and, as it was still early enough, decided to go the party. Since her husband did not know what her costume was, she thought she would have some fun by watching her husband to see how he acted when she was not with him. She joined the party and soon spotted her husband cavorting around on the dance floor, dancing with every nice woman he could, and copping a little touch here and a little kiss there. His wife sidled up to him and being a rather seductive babe herself, he left his current partner high and dry and devoted his time to the new babe that had just arrived. She let him go as far as he wished…Naturally, (since he was her husband.) Finally, he whispered a little proposition in her ear and she agreed. So off they went to one of the cars and had a quickie. Just before unmasking at midnight, she slipped away, went home, put the costume away and got into bed, wondering what kind of explanation he would make for his behaviour. She was sitting up reading when he came in, and she asked what kind of a time he had. He said: “Oh, the same old thing. You know I never have a good time when you’re not there.” “Did you dance much ?” “You know, I never even danced one dance. When I got there, I met Pete, Bill Browning and some other guys, so we went into the den and played poker all evening. But you’re not going to believe what happened to the guy I loaned my costum

COST OF MEDICINE PART 3

A former patient wrote recently.  He was hoping I could give him advice as to what he could do to help control the price of medicine and medical care. He thought he would write his congressional leaders and ask for their help as well.

In the 45 years since I started in medicine, I have heard many congressional leaders promise to take on pharma and the insurance industry.  In the 45 years since I started in medicine, things have gotten worse, not better!  Is pharma more powerful than Congress and the president?  Or does campaign rhetoric simply fall by the wayside after our leaders are elected?

I believe we have many problems that effectively guarantee that pharma will continue to rake in obscene profits at our expense.  Today, I’ll address the top two problems. The number one problem is that pharma contributes large amounts of money to candidates running for office. 

According to an article in Newsweek, “The pharmaceuticals and health products industry has donated more than $5.9 million to Biden’s presidential campaign, according to OpenSecrets.org, a site run by the Center for Responsive Politics, which tracks political donations.”  Can I independently verify this information?  Of course not.  Does it surprise me?  Of course not.  Has Biden done anything to reign in Pharma?  Again, the answer is no! Imagine how much Pharma spends on political campaigns if they spent $5 million on Biden alone.

While we buy into campaign promises, there is no mechanism for assuring that the candidates keep their promises once they are elected.  To make matters worse, we tend to re-elect the same individuals despite their lack of performance. 

As I see it, the second problem is that our leadership is covered by the same insurance available to an average citizen but that their policies are at the “Gold” level; and they are reimbursed by the federal government for 72% of their costs.  Until they feel the pain of paying $750 for a months’ worth of medication, they will not be incentivized to pass legislation aimed at controlling the cost of medicine. Perhaps the answer is not only to assess the candidates platform but, if he/she is an incumbent, to pay close attention to how many of their former promises they have kept.

In a future article, I’ll address tort reform and the role lawsuits play in increasing medical costs across the board.

Joke of the day – If con is the opposite of pro, then is Congress the opposite of progress?

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