The Annual Physical Exam

I have listened to health economists debate the value of an annual physical exam.  Is it cost effective?  Does it prevent disease?  It doesn’t matter.  It is an essential part of the development and continuation of the doctor patient relationship.

The annual physical exam is a form of benchmarking. It allows the doctor and patient to review all the pertinent aspects of your health history and physical exam and use the data to coordinate a care plan for you which is personalized.

The history of present illness illustrates any immediate and current concerns. The past history reviews previous illness and how those problems may affect your current and future health. A family history presents genetic data which may affect you and your loved ones in the future. It updates your physician on what changes have occurred in your family’s’ health that may affect you. The social history looks at your school and employment history as well as lifestyle choices. Are you working with industrial toxins or in a field prone to certain predictable and preventable disease?  Are you smoking?  How much alcohol is in your diet? Are you partaking in physical exercise?  Are you in a stable relationship?  All these factors influence your health and choices.  Do you have a living will?  Who is your health care surrogate and who are your emergency contacts?  It is a great time to review your allergies and medications both prescription and over the counter vitamins, minerals, herbs and supplements.  Last but not least we look at checkups, vaccinations and immunizations.  Are you current on tetanus shots?  Do you know about pneumonia vaccine and zostavax for shingles?  Have you had your eyes checked for glaucoma?  When did you last see a dentist?  What about skin checks, colonoscopies, mammograms, pap smears and bone densitometry?   The history session ends with a complete review of all your body systems. By asking a laundry list of questions we hope to jog your memory to discuss all those little items you meant to ask about but may have forgotten to bring up.

The physical exam is used to support the hypothesis and answer the questions raised during the history taking session. It should be thorough looking at you from the top of your head to the bottom of your feet without skipping any orifices in between. The findings of the exam, coupled with the history session, will determine which laboratory tests, if any, your doctor will choose to order.  In thirty years of practice, I am rarely surprised by the results of a blood test if I have done a thorough and complete history and exam. Patients seem to feel something magical about lab tests but the truth is that a thorough and experienced clinician usually knows what the findings will be before he orders the test.

The complete exam should be followed by a consultative review session during which the doctor explains the findings of the history, exam and lab and makes suggestions. A care plan should be established at that session and a defined follow-up plan suggested and scheduled.

During your physical exam the doctor is learning a great deal about you. From the way you dress, to the way you carry yourself to your speech pattern; the physician is seeing you while you are healthy. It is much easier to diagnose a problem if you have had the opportunity to see the patient when everything is normal.  This knowledge of your normal appearance is what allows your doctor to find a problem in its initial stages rather than a crisis requiring a visit to a hospital emergency department. It is all part of the concept of longitudinal long term care and relationship.

Find a doctor. Schedule your yearly checkups.  If you find a physician you trust and respect stick with them. It may save your life.

Medical Doctors versus Rumba Dancers

Being a patient instantly levels the playing field and provides the insight into why we as doctors, dentists and health care practioners do what we do.  I came back from a vacation with a throbbing in my jaw. I called my general dentist who came in early in the day to squeeze me into a crowded schedule. He quickly determined that an old root canal filling had failed and an abscess had formed above it. The choices were to remove the tooth or drain the abscess and try to re-do the root canal work.  He picked up the phone and called the endodontist who asked me to come right over because I was in pain. This kind gentleman suggested I start on an antibiotic to quiet down the inflammation and infection, take some pain medication and decide if I wanted to pull the tooth or repair it. He was concise and professional in saying the procedure to save the tooth only had about a 55% chance of success.  He suggested I think about it but call him back if the pain progressed.  I questioned the choice of the antibiotic because it had a significant chance of causing antibiotic related colitis. I believe he changed antibiotics from his choice which was more efficacious for this type of infection because he deferred to my concern.  Before I left his office he phoned the general dentist, discussed his findings and suggestions and made sure we were all on the same page. I was sent to the pharmacy and then back to the general dentist.

The general dentist wanted to save the tooth. He said that even if the tooth needed an extraction, he wanted an oral surgeon to do it because of the post in the tooth and other complications. I was given my x-rays and referred to an oral surgeon.

The oral surgeon could not see me for two days. During that period of time, the pain had become significantly worse. I was taking ibuprofen frequently and applying topical anesthetic benzocaine often. I didn’t sleep the night before the oral surgery visit due to the pain.  When I arrived at the surgeon’s office I had expectations of the pain being relieved by tooth extraction or a tooth sparing procedure.  To my amazement, the oral surgeon said he didn’t have time for the procedure today. He wanted me on a different antibiotic and felt that on this antibiotic the pain would subside in 48 hours. He scheduled me for surgery in a week. I told him I didn’t think I could hold out a week. He offered no pain medications despite me saying the pain was close to a 15 on a pain scale of 1-10.

I filled the new antibiotic prescription and called my general dentist to tell him how disappointed I was in the oral surgeon. I could feel an abscess on my upper gum. It was the source of pain, was fluctuant and needed to be drained. I told my general dentist that obviously my expectations and the oral surgeons were not aligned but I didn’t think I could last a week.  That night the new antibiotic nauseated me. I threw my guts up all night and spent most of it awake hugging the toilet bowl with first productive and then dry heaves.

I called the oral surgeon who suggested I stop the antibiotic and stop the ibuprofen substituting milder acetaminophen (Tylenol). I told him Tylenol didn’t relieve this pain.   That night I was in agony. Despite an ice pack on a chipmunk like jaw the pain was overwhelming and the nausea and vomiting continued.  At 8 a.m. on Saturday I decided it was late enough to call the oral surgeon. I had made up my mind that something definitive needed to be done. I called his emergency number and he called right back.  He told me it wasn’t too early to call; in fact he was on the first tee at the golf course. After listening to my story he promised that after his round of golf he would check his schedule and move my procedure up from Wednesday to Monday (48 hours away.)  He promised to call me when he finished his round of golf.

I called my hospital ER, dizzy, dehydrated and feeling that in an effort to save the tooth we might kill the patient. The ER doc suggested I come in, get hydrated IV, get a shot for nausea and call the oral surgeons listed on the emergency call list. On the list was one who had worked on my children years before. I gave him a call by chance. When he called back in a few minutes he asked me to meet him at his office in twenty minutes. He opened the office himself, took a history, examined the tooth, figured out how to shoot an x-ray, anesthetized me using my wife and me as his assistants and drained the abscess.  He put me on a narcotic pain medication and continued the antibiotic.  He gave me detailed post procedure instructions and promised to call me later to check on my progress. He told me he couldn’t understand the actions of the other oral surgeon. “If you are a surgeon aren’t you supposed to use your training to ease pain and suffering?” I went home anesthetized and fell asleep for the first time in days.

The phone woke me up and it was this angel of mercy calling to check on me. He asked me to call him first thing Sunday morning and if I was not much better he would call in his team to his office and extract the tooth. If it was better, he promised to call the endodontist on Monday and discuss the tooth sparing procedure.  I thanked him and went back to bed.  Shortly after 9 p.m. the phone rang again. It was the original oral surgeon. He called (after completing his round of golf) to say he had checked his schedule for Monday and he couldn’t see me before the end of the day. I thanked him for the courtesy of the call and told him I had changed surgeons.

In my second year of medical school training, the Chief of the Department of Medicine at the very fine Brooklyn Jewish Hospital said there are different types of individuals with physician degrees. “There are Doctors and then there are rumba dancers.”  Doctors are compassionate and work to prevent and heal suffering. Rumba dancers have degrees in medicine, possess all the social skills, tear up the dance floors at the local country clubs and do little to go out of their way to help those in need.  It was very clear in my mind who the doctor was and who the rumba dancer was in my treatment plan.

Pharmaceuticals – Pads, Pens and Prescriptions

It has become stylish to trash doctors for accepting lunch, pens, pencils, pads or even samples from representatives of pharmaceutical companies.  The theory is that pharmaceutical marketing raises the cost of prescription medications to patients and the health care system. Once the patient gets started on a new medication, which costs more than generic products in the same medication class, they stay on the more expensive medicine. Ethics experts consider a discussion with a pharmaceutical representative unprofessional and unethical.

In certain states it is now illegal to receive any gift (I.e., a pen, paper, samples, etc.) from a pharmaceutical representative including a discussion of the new product line over lunch in your office provided by the pharmaceutical company for your staff.  Purists claim we should be learning about new products from the scientific medical literature.  Let me join the chorus of those who say this is pure nonsense.

Physicians are trained to be independent thinkers and evaluators. For thirty years of private practice I have taken the position that, unless I am dealing with an orphan drug for a lethal disease, I want the product out on the market in my community for at least a year before I will prescribe it to my patients. Let someone else’s patients be the community guinea pigs. After a year of reflection, evaluation, reading about the community experience and discussion with my colleagues, I will try the samples if the drug offers distinctive advantages over existing products.

Where do the pharmaceutical representatives fit in?  They let me know there is something new out there and they tell me why they think it is different and improved over existing products. That is the introduction that piques my interest in beginning my due diligence into the product with its benefits and risks.  I do not know how the rest of my colleagues treat new products but I am willing to bet their inquiries are similar. To think that because someone brings me a pen or a tuna fish sandwich for lunch I will give my cherished patient their new product without doing a background check first is an insult to my professionalism and my colleagues.

Articles and reviews in medical journals are outstanding for reviewing data on a product. The journals would be have far more credibility if they hadn’t compromised years ago and started selling full page glossy ads to pharmaceutical companies to cover their costs.  Reading about a product is not the same as using it. I give the analogy of two mechanics trying to service an automobile by reading the auto manual. Both are similarly inexperienced but one has a master mechanic at his side to guide him through the pitfalls. They both can read the manual but the one with some hands-on experience and guidance figures it out much quicker and with much less aggravation than the mechanic just using the written material.  New pharmaceutical samples give me an opportunity to gain some experience with the product without my patient incurring expenses. If the medication does provide a distinct advantage to the existing products I have helped my patient in my field trials. If the medication doesn’t live up to the billing then I do not use it again!

I have tried the computerized on line drug “detailing,” provided by pharmaceutical companies to replace human representatives, but frankly once you log in they don’t cover the material in a quick and timely fashion like our experienced drug representatives do. I don’t want to spend 15- 30 minutes online listening to the companies’ educational spiel. I want the “Cliff Notes” version as the basis for me beginning my investigation.

I am additionally tired of hearing lecturer’s at my CME courses disavow all relationships with pharmaceutical companies before beginning their lecture on a topic. I still believe that most speakers present a fair and objective viewpoint of the topic they are asked to speak about. Their presentation is only one piece of data for me to review and consider before I add that product to my repertoire or reject it.

The same “ethical” physicians attacking pharmaceutical advertising are using generic products with absolutely no knowledge of their true safety, efficacy or even their nation of origin. The last time I looked at this question I was told generic products had to have at least 80% of the “bioavailability” of the brand product. The actual research is done by the generic pharmaceutical company with the data submitted to the FDA for their review. Isn’t that like letting the fox into the chicken coop and asking it to maintain order?  Where are the double blind studies showing the efficacy of each generic as compared to the brand name product?  Where are the certified lab studies showing that with similar performance efficacy there are similar blood and tissue levels of the active agent and similar adverse effect profiles?

I think it’s high time that physicians and legislators realize it’s all about the money with insurance companies looking to keep their pharmaceutical costs down at all costs with as little investment in research and development as they can get away with.  I will continue to break bread with the pharmaceutical reps willing to bring in a lunch to my office staff while discussing a new product. I will wait a year for the new products to exhibit their benefits and risks in my community on someone else’s patients before I use them. I will perform my due diligence before subjecting my patients to a new product but I will not for one second feel any less professional for having accepted a pen or a pad or a bagel from a pharmaceutical representative while discussing a new product.

NICA, Florida’s Newborn Injury Compensation Act – 2010

In the early 1980’s there was a major medical malpractice insurance crisis in my home state of Florida.  Obstetricians and gynecologists could not afford to purchase medical malpractice insurance at the price it was being offered at, when it rarely was being offered. The fear was that an Ob-GGYN would deliver a deformed or injured child while performing his hospital required emergency department coverage and be sued for a staggering sum to pay the medical costs and damages for the infant for the rest of his or her life. Obstetricians stopped agreeing to see and treat pregnant women because of the risk involved.

The Florida State Legislature then came up with the idea of creating the Newborn Injury Compensation Act which created a fund to pay for the medical care and damages associated with injuries occurring during the childbirth process.  This fund was supposed to keep obstetricians out of court. This compromise legislation was initially supported by the Florida Medical Association as a short term solution to a problem. Every doctor in Florida was fined, or taxed, $250 per year to pay for birthing injuries while obstetricians paid $5000 per year. The first thing that happened after this was signed into law is that the Florida Trial Lawyers Association found away around it so they could continue to sue obstetricians for medical malpractice.  The second thing that has occurred in the twenty some odd years since its inception is that the NICA fund has never paid out anything to an injured party.

NICA is essentially an additional $250 per year tax on physicians for the privilege of practicing medicine in the State of Florida. The Legislature has decided that expectant mothers who live on a diet of barbecue potato chips, pineapple soda pop and Marlboro’s and has their first pre natal visit when in their ninth month and crowning are the legal responsibility of doctors only. The Florida Medical Association has been so busy with so many issues that it has not had the time or resources to work for the abolition of this unfair tax on physicians.

It’s time this unfair tax is repealed. Reproductive education, prenatal care and visits to a doctor when pregnant are not only the responsibility of the physicians’ community alone but of the public at large.

Prescription Medications and Insurance Company Oversight Plans

From the perspective of a practicing physician, patient and consumer; the free pass Congress has given the pharmaceutical and insurance industries in health care reform drives me crazy. Yes I heard about the voluntary relinquishing of 80 million dollars by the industry. That makes about as big a dent in their bottom line as me urinating in the Atlantic Ocean and trying to raise the tide.

It is unclear why prescription medications are so much cheaper in Canada and Mexico and overseas?  What is even more unclear is where all of our prescription medications are being manufactured and how do our domestic standards actually compare to products sold across the border?   You never see Consumer Reports do a review article on the quality and safety of prescription drugs produced outside the Continental USA and the locally produced products?   You never see a cost analysis of producing these meds here and abroad.  Yes, you see plenty of articles on vitamins, minerals and herbal products but absolutely no credible studies on their efficacy and safety either.

If I have a major beef as a physician and consumer it’s with the firms health insurance companies hire to oversee their prescription drug plans. The insurance companies know well that most of their patients get their health and insurance and drug plans through their place of employment. They additionally know that most years the plan changes as does the patients general medical doctor.  You see a new patient who is  obese, hypertensive individual with high cholesterol and prescribe them a cholesterol lowering medication only to receive a fax from the prescription drug plan over-site company asking you if the patient has failed on the generic lovastatin and or pravastatin?   They will not prescribe the drug you prescribed, even if it is on the formulary, without first checking that data. Of course you don’t have that data. You know the patient has had five different PCPs in five different years. You may know that the patient had some muscle aches on simvastatin.  The insurance companies don’t care. They know that each time they throw an obstacle in the prescription process; the patient will reach into their pocket book 70% of the time, or more frequently, and pay for the drug themselves rather than wait for the review process.

Even quantities prescribed are an issue. The plans only dole out one months supply. Last month a patient of mine went on a midweek vacation about a two hours drive from home. Her life had been dramatically improved by the addition of Effexor XR for obsessive compulsive problems years before.  The drug helped greatly but if you miss a pill or two it produces a nasty withdrawal syndrome.   The patient, by mistake left her pill bottle at home. She called her pharmacist and asked if he could prescribe some of the medication for her at the local pharmaceutical chain outlet which was close to her hotel. He called me for permission and I approved. The problem was that the drug plan over-site firm had already prescribed a thirty day supply and would not approve the prescription.   How ridiculous. The patient paid for five additional pills at full price just to avoid the hassle.

It’s time for State Legislatures and State Insurance Commissions to put their foot down and start tightly regulating the insurers and the drug review companies. It’s clear our elected Congressional officials don’t have the backbone to do what is right for their constituents in the face of attractive campaign pledges. Thus, it’s time for consumers to act instead.

The Commandments of Physician Consulting

When I entered the medical profession in 1979 a wise and experienced internist taught me the lessons of consulting in the private world.  He told me to find a group of specialty physicians you trust and can communicate with.   He suggested that each time I send them a patient for an opinion, I communicate in advance with the consulting specialist and let him or her know what my concerns were and what questions I was asking.  Supplying the consultant with the available lab work and imaging data plus a concise history were important.  In those days most patients had minimal health insurance, of a catastrophic nature to cover hospitalizations, or they had none. They expected to pay for their visit. Sometimes you sent patients who could not pay very much if anything. That was all right as well because it was understood that if the consultant cared for your indigent patient you would send them a paying patient as soon as you could. At the same time, when they needed your opinion on an indigent patient you would provide it just like they had provided it to you.

When you received a consult you always thanked the referring doctor for extending you the courtesy of inviting you onto the case. You made sure to go see the patient in a very timely manner. When you had constructed your opinion, you called the referring physician and reported your findings directly.  You never just wrote a note and dictated a consult note and left.  You wanted to know the referring doctors concerns and plans and make sure the consulting opinion provided the answers the referring doctor needed to manage the case.

Very often family would request information from the consultant.  As a consultant you never spoke directly to the family without first obtaining permission to do so from the patient and the referring physician. You never wanted to upstage or criticize the care provided by the referring physician. You were never supposed to deliver clinical news and findings to the family BEFORE you discussed that information with the referring physician. It was very embarrassing to the referring physician to find out about a change in the patients clinical setting from the family via the consultant before you even knew about it.  In those days, we would arrange joint conferences with the family, the consulting physician and the referring attending physician if the family wished to discuss the case with the consultant. If the consult was an outpatient office based consult, the consultant made suggestions only to the referring physician in all non critical, non emergent, settings.  The only time the consultant would become the team leader was if the referring doctor asked him/her to assume care of the case. This did occur, but was never a surprise as it is today.

This culture of civility and collegial behavior changed with the rise of the insurance companies directing medicine. Reduced fee insurance plans set up panels of generalists and specialists. Your favorite two or three doctors to refer to in a specialty may very well “not be on the panel.”    When you now sent the patient to a different consultant to honor “the list on the panel” instead of them thanking you for the referral, you were more likely to be scorned for sending your full paying patients elsewhere but your discounted patients to the specialist on the panel. With the loss of civility over panels and plans came the loss of communication. Suddenly doctors were “too busy” to call the referring doctor with their findings and suggestions. They were too busy to suggest a diagnostic and treatment plan but had plenty of time to order tests and ancillary studies with their lab and equipment which was also on the plan before they discussed it with you.

It is long overdue for doctors to start using their cell phones and office phones and start communicating with their colleagues directly. Direct communication eliminates mistakes. Hand writing in the chart is difficult to decipher.  Talking provides for better patient care.  Despite the high volume and time constraints doctors need to be better direct communicators for our patients benefit. Consultants need to offer suggestions and opinions and only assume control of the case if they are asked to.  Referring doctors need to supply the consultant with the reason for the consult and the data to analyze it. The culture of communication needs to improve.

Whatever Happened To Nursing Care and Communication?

When I completed my training and joined the staff of our local community hospital to practice General Internal Medicine, every floor was run by a charge nurse. I had learned in medical school and during residency that if you wanted to get things done in a timely manner and get nights sleep while on call, you learned the rules and regulations on Mr. or Mrs. Jones floor and followed them.

In the late 1970’s and early 1980’s when you arrived to make patient rounds, the floor nurse would gather the medication list, the patient vital signs and go with you to the bedside. You would greet the patient, take a brief history, perform an exam and discuss the problems of the previous night with the patient and the nurse. You would receive a direct verbal report from the day shift nurse or departing night shift nurse of the patient’s concerns and the nursing staffs’ insights, thoughts and concerns. By the time you moved on to the next patient you had answered all questions, reviewed all medications, discussed the plans and goals for the day and reviewed the lines of communication .  These nurses had graduated high school and gone on to a two year nursing school. They received on the job training and supervision from senior staff who had been working at that hospital on that floor for decades. These nurses could change a sheet and bedding on a patient immobilized in bed in traction. They took vital signs by holding the patient’s hand and looking into the patient’s eyes and feeling if the pulse was healthy and brisk and if the hand temperature was warm and dry. The therapeutic nature of the hand holding and human touch was grossly underestimated by administrators and economists

In the mid nineteen eighties, as health insurance companies began to rule the care of patients at a discounted rate, things changed. At the local corporate hospital nurses stopped coming to the bedside. In fact they stopped getting a direct verbal report from the outgoing nursing shift.  The outgoing shift left their report on tape recorders for the incoming shift to listen to when they had a chance. Gone was the stability of tenured and experienced nurses replaced by per diem nurses from temporary agencies who could be practicing in one hospital on Monday and four others the rest of the week.  These nurses might be seasonal employees flown in from Scandinavia or Canada to service the increased winter seasonal volume in South Florida. They were no longer great care givers. Most of them were now going from high school to four year colleges to study nursing. Many were then encouraged to go on and get graduate nursing degrees.  Nurses with a four year degree were not looking to empty bed pans, change bedding or even change bandages unless wound care was their designated specialty. Outside the critical care units, they were primarily administrative, directing “aides” with little or no formal school training and no nursing school training. BP cuffs were replaced at the bedside by robots. No longer were hands held to check vital signs. No longer did the nurse have time to go to the bedside with the doctor to review the patient’s progress and identify the problems and goals for the day.

They became so well educated that nursing couldn’t keep them in the profession. They wanted more. They became physician assistants and nurse practitioners so that with their advanced degrees they could be given more clinical responsibility and allowed more clinical decision making. The problem is that they were not given the formal training one need to have to make these decisions. They were not given the arduous clinical oversight of a large volume of cases one needs over a prolonged training period to become a trained clinician.  They were supposed to assist primary care doctors and generalists and expand the ability of our small primary care population to see patients. Unfortunately, these PA’s and NP’s soon realized that there was no money in primary care and most generalists could not afford to employ them anyway. It was much nicer to work for a plastic surgeon and orthopedist and do their entire pre op and post op care so they could stay in the OR and generate more revenue. It was much easier to leave the bedside and go work for hospital administration or a medical equipment manufacturer in sales then become a supervisor of under educated aides while filling out paper work all day long.

I miss the days of going to the bedside with the nurse and the medication sheets. We made fewer errors. The communication and rapport were better. The nurses were our eyes and ears watching and caring for our patients while we were in the office. The technology and training was supposed to improve communication not make it more difficult. I would love to see the two year nursing program for care givers return. We need doctors and nurses going back to the bedside. We need nurses who are allowed to care for patients rather than supervise others and fill out checklists.

Healthcare Regulations ……………….

I went to see my patient recovering from major intestinal rerouting surgery called a Whipple’s procedure at a local skilled nursing facility. The surgery was performed at the University of Miami Miller School of Medicine Jackson Memorial complex to remove my patient’s pancreatic cancer and extend his life. At eighty years old I had advised against the surgery because I thought the recuperative period would eat up most of the time this elderly and chronically ill gentleman had left. The patient chose to go out fighting and found a surgeon willing to do the work at a Center of Excellence.  After five weeks in the Surgical Intensive Care Unit at Jackson Memorial Hospital the surgeon transferred him directly to our local rehab nursing facility. He had two intestinal tubes in place with one providing hydration and nutrition, was not strong enough to swallow on his own and couldn’t lift his head off the pillow because he was so weak.

Caring for patients at a nursing home is a responsibility of the profession but clearly is fraught with disaster. The ratio of nurses to patients may be as high as 1:40. The quality of the nurses is usually no where near as good as you see in your community hospital or office.  The first thing you notice on your way to the SNF is that everyone is looking to sue them for elder abuse.  The buses are lined with huge advertisements suggesting that your loved one should sue for damages if they were hurt at a facility. The phone book cover shows trial lawyers recruiting you to sue for elder abuse. The television ads encourage you to sue for elder abuse. To say that these facilities are under pressure to produce is an understatement. Regulation after regulation at the State, Local and Federal level is in place to insure the health of your loved one. In fact there are so many people looking after the rules and regulations you wonder if there is actually anyone left to take care of the patients. So much money is devoted to dotting “I’s” and crossing “T’s” that, when do they actually have time to interact and nurse the patients?

If you look at the census of patients at these facilities there are generally two types. Both are usually elderly and infirm. One group is recovering from an acute hospitalization and hoping to recuperate and return to their life in their home. This is a temporary stay for them. The other group is custodial and too infirm to be cared for at home. These are elderly people in the last stages of life who deserve comfort, care and the best quality of life we can provide them as they live out their life. If only it were so simple. All the rules and regulations make it difficult.  If mom scrapes her knee and needs some peroxide and a band aid with an ice pack, nothing can be done without calling the doctor first. If “mom” has indigestion from a spicy meal, she can’t take a Tums or Rolaids without first calling her doctor and obtaining an order. If dad wants to eat a cookie and he is on a diabetic diet, he can not eat it until they call his doctor.  It doesn’t make a difference what hour of the day it is. I routinely receive calls at 3AM saying, “Dr Reznick I am sorry to call so late but Mrs. Smith slipped and went to the floor on the way to the bathroom. SHE HAS NO APPARENT INJURIES but we are required to call you and inform you. Good night.”

If a poor patient actually gets sick with a cough and a fever and is having no respiratory distress the facilities first activity is to “Dial 911 and copy the chart for transfer.”  By the time they call a physician, the patient is in the ambulance on the way to the ER. The thought of examining the patient and getting vital signs, listening to their lungs, checking for consolidation, getting a bedside O2 saturation is not in the vocabulary of my local SNF’s.  Giving some Rocephin and starting a Z pack with gentle pulmonary treatments is unheard of. It’s always 911 and off to the ER.    The Fire Department doesn’t complain because the more trip-runs they make the higher the budgetary allowance they can ask for next year. The ER doesn’t complain because these are Medicare beneficiaries and Medicare pays well in Florida. The only ones who complain are the parents of the infant who was found apneic in his crib and the response  time by 911 is delayed because they are carting a demented 95 year old with a cough to the ER instead.

This all occurs because of liability and over regulation.  It’s time for some common sense to prevail. These facilities need fewer regulations and more staff to provide hands-on, day to day care. Medicare funds should not be used to pay for these patients unless there is a living will and or medical directive and or health care surrogate who clearly designate the patients’ resuscitation status and health care goals in advance of a crisis. Care should be provided at the facility with the ER used only for those patients who need an acute care hospital to relieve their pain and suffering and have designated directly or through their surrogates that they want to be sent back to the hospital.

Let the facilities spend money on care instead of bureaucracy. Let market forces and word of mouth and Internet websites like “TripAdvisor” for hotels be created so people can discuss where the care and service are good and where it isn’t.