COVID is the Only Disease

Exhaustion. Anxiety. Insomnia. GERD/Reflux. Hair loss. Vaccines. To Mask or Not to Mask. To stay home vs. Run Wild. Beaucoup de face/ear/eyelid rashes--I will digress here--papules, pustules, chalazion, atopic dermatitis, angular cheilitis, impetigo, etc. The past 18 months have been like being on the amusement park ride without a restraint and flying upside down at any given and unknown moment. 

There will be oceans of words written about the experiment that we've been thrust into without our consent. I will only add my 0.02 cents here, as a practicing middle aged dermatologist. I am a digital immigrant. I still like to pick up the phone and talk to friends. More on this later....

The panic of dying from/with COVID is still present in a small minority of the my patients, and these are comprised mostly of elderly and immunosuppressed. I can't say I blame them. Their systems are vulnerable to the bacteria in their own colons and throat. Modern advanced procedures have them given them new years of life, with a tiny thread of mortality tugging at them that transforms into a ships' anchor rope tugging the off the cliff. A wild new virus will take them out, or at least give them major medical setbacks that may not be survivable. 

It's a still a virus that I don't understand. It's entirely unpredictable who will get severe symptoms and ICU/death, vs. a mild case of the sniffles. How can you "have it" and not even know it? How can you not have it and still die from it? Who has delta? who has mu? False positives? False negatives? Mild prior infection? Severe prior infection? Incomplete vaccine course? I can't do it anymore. I'm out of gas. I can't suppose anything. I don't know the truth. The data is soooo bad. The lies and manipulations are enormous. First we're told the hospitals are bursting with COVID. Then a few months later, ooops, about 30% of + patients in the hospital are asymptomatic carriers who only got tested upon admission--a rite of passage now--and got labeled as a COVID patient even if they were admitted for a broken hip. Then we can celebrate summer! No wait, even if you are vaccinated you must still wear a mask!!! Stay home NOW DAMMIT AND DO NOT EMERGE UNTIL YOU GET A VACCINE TO PROTECT THE OTHERS WHO ARE VACCINATED!!  

Is the White Rabbit in charge? Alice in Wonderland here is completely appalled and confused by the double, no, triplespeak. 

Bounties work. Call it a 'vid patient and the hospital gets a bonus. Hospitals have lost A LOT of money. Insurances are tightening the screws. Nurses and ancillary personal find that if they're exhausted and abused, they can quit and sign on with "traveling" agencies who provide staff for shortages and make double the money. Is there something like this for dermatology?

I read that in in New Zealand, you must not talk to your neighbor. The threat of catching it from a chat across the bushes in the yard is enormous and deadly! Stay in your room and play on your phone! Zoom your job, coworkers, friends!!

Many of my patients over the past 18 months have declined considerably in functional status, health, mental state. Dementia has increased. The once spry octogenarian who went to aqua aerobics twice a week now shuffles along with a walker and has long lank grey hair, afraid to go to a salon for a haircut. No more aqua aerobics because 'vid. No more hair salon visits. No more family or friends...they can kill you by breathing on you. 

As I type this stream of conscious flow of vignettes from my recent past, I feel incredibly sad. I'm crying. This is wrong. This is extreme. This is an experiment. 

I want everything and I want it NOW

The immediacy of our tech-bombed culture--you can text your gift certificate to your friend, you can schedule your manicure, automobile service, etc within seconds with an immediate gratification, an immediate "dzing" popping out of your little smartphone. But you can't get your colonoscopy tomorrow. And you certainly cannot demand that I drop other patients' appointments to accomodate your perceived emergency, which consists of skin tags or "a rash" present for 2 years, but THIS MORNING you got agitated about it and you want it erased. 

THE BODY DOES NOT GET YOUR TEXT MESSAGE. YOU CAN'T PING IT INTO SUBMISSION. 


Baby boomers...the generation we all love to hate. Gen-X physician here. I evaluate and treat baby boomers on a daily basis (there's just so many of them!) I will generalize and state that as a group, they're predictably the most narcissistic and consistently in-denial patients I see. When they need surgery, "what do you mean I need surgery? What do you mean my knees are shredded/I have skin cancer/arrythmias/I have to not bear weight for 2 weeks...yadda yadda yadda. The "greatest generation" tended to accept when they got old and frail and slid into senescence with benign acceptance. Boomers demand everything be done, immediately, and it cannot interfere with the upcoming cruise they booked, and they refuse to pay for it. They want Medicare to pay for face lifts. "it's important for my mental health to have a good looking face when I look in the mirror". Yes that may be true, but it isn't the financial responsibility of the American taxpayer. Go talk to your congressional reps...and they're smoking pot or getting their cannabis and pizza "just like I did in college in 1970" to care for their arthritic joints while they await the replacement. Paid for by you and me. Because they bungee jumped onto some rocks. Did they ruin the globe? maybe. "I'm a baby boomer but I don't want to be lumped in with these sociopathic morons"...the camel fails to see its own hump.

Noncompliance is bad for you and bad for the Doctor

It's always a challenge to discern why non-compliance occurs. One would think, you made the appointment, you showed up wanting/needing a doctors' help, you took advice, maybe had the test..then nada! I never see some of these patients again. Maybe they moved away. Maybe they got scared by the treatment, or by the fact they actually need to change a behavior in order to overcome illness. Maybe you, as the treating physician, just rubbed them the wrong way.

Communication gaps and expectation gaps are the two factors contributing to noncompliance. I see this popping up over and over. The patient didn't understand, or didn't WANT to understand, the illness or the treatment. Patients seek to apply their mental framework to their condition. "Doc, I know you say the biopsy showed it's a skin cancer, but I know I got bitten by a bug and I want to know how to avoid it".  They want to put things into their schema. They understand bugs...skin cancer is too abstract and scary. It's a struggle to try to get people to see that their own wishes are irrelevant in the aging process or the illness process. Dealing with an elderly population they bring their set-in-stone ways, in addition to their other concomitant medical issues which may make treatments more difficult or prolonged recoveries.

My most recent struggle is a patient I have seen a few times over a 2 year period. He's an octogenarian snowbird, which means he's physically present in my town for 6 months out of the year. He's loaded with skin cancers of the face, being of Scottish ancestry and a lover of golf in subtropical climes. He has numerous scars from skin cancer surgeries over decades of treatment. When he is in town, his life is consumed by golf games, bridge games, going out to lunch, board meetings with his condo association, and Caribbean cruises. It must be a nice life. But these lesions pop up on his nose and face and bleed incessantly and he comes to me for help. He is pleasant, nods his head, I prescribe treatments, I perform biopsies, he leaves my office in agreement, but then he cancels the follow up surgical appointment. The first time it happened I gave him the benefit of the doubt, called him, asked him to reschedule. He comes back 4 months later,  the skin cancer site has healed over and I can't find it, but lo and behold, there's a new one bleeding on his cheek. Out of side out of mind for this patient. If it bleeds it gets his attention. He is seemingly delusional and will not, despite my efforts, see that he has recurrent skin cancers. We've had conversations at every visit about his skin cancer propensity and condition and what to do to get it under control. But then he leaves for Ohio for 6 months; he's gone and it's beyond my efforts.  The most recent visit was a repeat of last years' pattern of behavior and diagnosis, so I advised the patient I cannot be his doctor under the parameters he has unfairly placed on me. Your skin cancer cannot be resolved in 1 visit. It can't be addressed when your priority is your golf game. You have to stay put for a suture removal. You have to pick one place to get care and stick to it. I will no longer be the one. I will no longer waste my time and block other patients' accessibility because we're holding an appointment for you.

I feel sorry that somehow I cannot pierce his delusion and I cannot treat him within the part-time residency /paradigm he has chosen in my sunshine state. Medicine and the human body is not a part time endeavor. It is full time and takes up your full attention and care. I wish there was a screening set of questions I could administer to gauge how motivated a patient is before they're scheduled for an appointment. This is unrealistic but I too can dream.

JCAHO and the Opioid Crisis

I remember in the 1990's when JCAHO and the NEW hospital administrators--oftentimes nurses fired from clinical duties and this was their new gig to avoid unions penalizing the HR hospital division--scolding physicians for withholding pain meds, patients were groaning in pain, you evil inhumane monsters!

GIVE THE PATIENT NON ADDICTING PERCOCET AND YOU'LL KEEP YOUR JOB!!!

https://www.beckershospitalreview.com/opioids/7-things-to-know-about-the-history-of-the-joint-commission-pain-standards.html

20 years later we're in a big fat mess. Not created by any one player, but I would wager the regulatory push to count pain as the "sixth vital sign" along with rewards for prescribing--the latter no longer exists--now as penance they count the free pens a pharmaceutical co. may give out and post this online in compliance with "the Sunshine act" (because sunshine is the best disinfectant!). Too late, the cat is out of the bag. The addicted patients go to the local Kwik Stop convenience and with some hand and eye gestures a drug dealer can appear and proffers heroin from Mexico, for cheap. I see these transactions when I go to to get gas. The a"authorities" know but what is the use? Arrest, bail, back on the street in 10 days.

No one solution will correct this complicated monster. But it will have to start with enforcement of law. If lowly me can identify the drug pushers when I stop for 5 minutes to get gas for my car, so can "the authorities". Get serious about inspecting every single thing that crosses the border--animal, vegetable or mineral. And yes, stop counting pain as a vital sign. Distractions, breathing, ice, Tylenol...that's what my Mom did when I was a kid and I hurt myself. We're going to have to start saying NO to pills and NO to JCAHO and NO to patients that whine. And also NO to that truck coming from Guerrero, Mexico.

The 90 day Update

I wrote about this last year. The government mandate that states all physicians' demographic information must be updated every 90 days, even if no changes have occurred.
Now they send smooth and yet slightly threatening emails. Every time the 90 days have elapsed, when I log into the portal a big red box on the top of screen appears. Not enough. Email reminders now clog my inbox like hair on the shower drain. Harass harass harass.

Here's the screenshot:

Updating your profile early helps you avoid distractions Hello,  To ensure accuracy for patients, state and federal laws require health plans to check the information in their provider directories every 90 days. That means lots of phone calls, emails, faxes, and letters asking you to update and verify the information your payers have on file…every quarter. There’s an easy way to cut down on the noise. Use Availity to verify your profile, and we’ll send that information to all participating payers. You can even download your verified profile, then print or email it to your other payers when they call. It only takes about 15 minutes to get through the process, because we pre-populate the forms with the information payers already have about your business and physicians. So when something changes, it takes just a few clicks to make sure your payers are updated. Remember that it’s important to verify and update your profile each quarter, even if nothing has changed. So log in to the Availity Provider Portal now to verify and update your profile—we’ll update your payers, and you’ll have your day back. Just another example of the thousand paper cuts that results in the doctor becoming paralyzed.

the electronic medical records movement must END

Corroborating what practicing physicians have claimed, a recent study published in the Annals of Internal Medicine found that during office hours physicians spent nearly 50 percent of their time on electronic health record (EHR) tasks and desk work.

Researchers concluded that for every hour physicians provide direct clinical face time to patients, nearly two additional hours are spent on EHR and desk work within the clinic day. Outside of office hours, physicians spend another one to two hours of personal time each night doing additional computer and other clerical work.

The time and motion study, led Christine Sinsky, M.D. and her colleagues from the American Medical Association, was funded by the AMA.

The study was based on observations of 57 physicians who work in ambulatory care in four specialties—family medicine, internal medicine, cardiology and orthopedics, in four states, Illinois, New Hampshire, Virginia and Washington. Researchers observed how much time physicians spent on four specific tasks, direct clinical face time, EHR and desk work, administrative tasks and other tasks and self-reported after-hours work.

Researchers observed that during the office day, physicians spent 27 percent of their total time on direct clinical face time with patients and 49.2 percent of their time on EHR and desk work. While in the examination room with patients, physicians spent 52.9 percent of the time on direct clinical face time and 37 percent on EHR and desk work. In addition, about one-third of the physicians also completed after-hours diaries and they reported one to two hours of after-hours work each night, devoted mostly to EHR tasks.

In an accompanying editorial published in the Annals of Internal Medicine, Susan Hingle, M.D., from SIU School of Medicine, wrote, “Sinsky and colleagues confirm what many practicing physicians have claimed: Electronic health records, in their current state, occupy a lot of physicians' time and draw attention away from their direct interactions with patients and from their personal lives.”

I'm a Luddite. I do not use emr/ehr and I've got all of my medical records on paper. During Hurricane Irma when my office had no electricity and no internet for 8 days, it would have completely impossible to access patient records if I had been using one. My paper charts by a window letting in natural light worked. I was able to see a few patients in those conditions and I was able to diagnose, write notes, and write prescriptions, all on paper. 

Another patient came to me just last week asking I had received results from her internist. I had not. The patient was seen by her internist for a routine check up and a skin lesion was noted on her leg, which the internist took a culture of said lesion and put the patient on an oral antibiotic. The patient asked the internist to fax those details and results/records to me. The internist, whom I have had interactions with in the past and uses Mod Med, told the patient that due to his being so behind on his electronic notes he wouldn't guarantee that he would be able to get those records to me by fax. That had occurred 10 days prior to my visit with this patient. 

On the day I saw the patient, I had no information about the relevant and important medical encounter because the doctor was too behind on the electronic tasks placed in front of him. 

EMR’s hurt patients and physicians, after all, the Health Information Technology (HIT) company which sold us our EMR system, an expensive EMR used by 35% of the US dermatologists, had assured us that their software and hardware would make our practice more efficient, productive, safer, improve our outcomes and speed compliance with new Federal Regulations to avoid a host of looming Federal penalties and enhance value based care (outcomes/costs). The company only rents access to its software to physicians from the highest reimbursed medical specialties. Their advertisements and marketing state that their EMR is, "Transforming how healthcare information is created, consumed & utilized to increase efficiency & improve outcomes".

THESE ARE PITHY MORSELS FROM----

Michael Sherling, MD, MBA

CHIEF MEDICAL AND STRATEGY OFFICER

Dr. Michael Sherling is the co-founder and Chief Medical and Strategy Officer of Modernizing Medicine. In 2014 Michael, along with Dan Cane, received the U.S. Chamber of Commerce’s Leadership in Healthcare Award.

Michael is responsible for the strategy and medical innovation within Modernizing Medicine’s suite of products and services for dermatology, gastroenterology, ophthalmology, orthopedics, plastic surgery, otolaryngology and urology specialties. With Dan Cane, he has developed novel software solutions for EHR, MIPS and ICD-10 automation.

Under his leadership, Modernizing Medicine has established a user base of over 10,000 providers and raised over $318 million in capital.

Michael is a dynamic speaker and has had the honor of speaking at the 2017 Association of Dermatology Administrators & Managers (ADAM) Annual Meeting, the 2016 Dermatology Entrepreneurship Conference and 2015 Health 2.0 Conference’s “Tools to Fix the Clinical User Experience.”

Michael has been a practicing dermatologist since 2006 and currently practices in a comprehensive skin care dermatology group in Palm Beach County, Florida. Michael also serves on the Advisory Board for the Florida Atlantic University Charles E. Schmidt College of Medicine. Michael is board certified by the American Board of Dermatology. Prior to relocating to Florida, he was the Associate Director of Laser Medicine and Skin Health at Brigham and Women’s Hospital in Boston and served as the Associate Residency Program Director for Harvard Medical School’s Department of Dermatology. He has several publications in peer-reviewed medical literature.

Michael obtained his BS in Biology at Brown University with honors in 1996, his MD from Yale School of Medicine with honors in 2002 and his MBA from Yale School of Management in 2002. He received his clinical training at Harvard Medical School, where he served as chief resident in dermatology

ANOTHER PHYSICIAN STORY: the EHR links to Amazon and sends emails to the patient on the OTC recommended by the physician!!!

" The liability for interfering with optimal outcomes with EHR company linked OTC product purchases is borne solely by the physician, and the revenue for sales of Amazon's OTC products shared solely by the EMR company and Amazon. 

Whose data is it anyhow, the patient's? the doctors'? the government or the EHR companies? Our EHR Company claims all the chart data is theirs."

Oh oh, no straight answers. Nobody knows!!

THERE IS HOPE!

THANK YOU AND GODSPEED!!!!!! The bill in the FL House is HB 723 and the Senate Bill number is pending. Fl Rep. Dr. Julio Gonzalez and Sen. Jeff Brandes. are co sponsoring. Here is the bill's text, simple and direct:

HB 723 2017 CODING:
 Page 1 of 3 F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
1 A bill to be entitled
2 An act relating to maintenance of certification;
3 creating ss. 458.3113 and 459.0056, F.S.; providing
4 definitions; providing legislative intent; prohibiting
5 the Boards of Medicine and Osteopathic Medicine,
6 respectively, and the Department of Health, health
7 care facilities, and insurers from requiring certain
8 certifications as conditions of licensure,
9 reimbursement, employment, or admitting privileges;
10 providing construction; providing an effective date.
11
12 Be It Enacted by the Legislature of the State of Florida:
13 14 Section 1. Section 458.3113, Florida Statutes, is created
15 to read: 16 458.3113 Conditions of licensure, reimbursement,
17 employment, or admitting privileges.—
18 (1) For purposes of this section, the term:
19 (a) "Maintenance of certification" means a periodic
20 testing regimen, proprietary self-assessment requirement, peer
21 evaluation, or other requirement imposed by a recognizing agency
22 approved by the board pursuant to rule 64B8-11.001, Florida
23 Administrative Code.
24 (b) "Recertification" means a subsequent recognition or
25 certification of educational or scholarly achievement beyond
26 initial board certification in a subspecialty by a recognizing
27 agency approved by the board pursuant to rule 64B8-11.001,
28 Florida Administrative Code.
29 (2) It is the intent of the Legislature to further improve
30 the efficiency of the health care market and eliminate
31 unnecessary administrative and regulatory requirements.
32 (3) Notwithstanding any other provision of law, the board,
33 the department, a health care facility licensed under chapter
34 395, or an insurer as defined in s. 624.03 may not require
35 maintenance of certification or recertification as a condition
36 of licensure, reimbursement, employment, or admitting privileges
37 for a physician who practices medicine and has achieved initial
38 board certification in a subspecialty pursuant to this chapter.
39 (4) This section may not be construed to prohibit the
40 board from requiring continuing medical education pursuant to
41 rule 64B8-13.001, Florida Administrative Code.
42 Section 2. Section 459.0056, Florida Statutes, is created
43 to read:
44 459.0056 Conditions of licensure, reimbursement,
45 employment, or admitting privileges.—
46 (1) For purposes of this section, the term:
47 (a) "Maintenance of certification" means a periodic
48 testing regimen, proprietary self-assessment requirement, peer
49 evaluation, or other requirement imposed by a recognizing agency
50 approved by the board pursuant to rule 64B15-14.001
51 Administrative Code.
52 (b) "Recertification" means a subsequent recognition or
53 certification of educational or scholarly achievement beyond
54 initial board certification in a subspecialty by a recognizing
55 agency approved by the board pursuant to rule 64B15-14.001,
56 Florida Administrative Code.
57 (2) It is the intent of the Legislature to further improve
58 the efficiency of the health care market and eliminate
59 unnecessary administrative and regulatory requirements.
60 (3) Notwithstanding any other provision of law, the board,
61 the department, a health care facility licensed under chapter
62 395, or an insurer as defined in s. 624.03 may not require
63 maintenance of certification or recertification as a condition
64 of licensure, reimbursement, employment, or admitting privileges
65 for an osteopathic physician who practices medicine and has
66 achieved initial board certification in a subspecialty pursuant
67 to this chapter.
68 (4) This section may not be construed to prohibit the
69 board from requiring continuing medical education pursuant to
70 rule 64B15-13.001, Florida Administrative Code.
71 Section 3. This act shall take effect July 1, 2017.

The MOC control bill would do the following:
1.       Prohibit MOC for Florida Medical License
2.       Prohibit mandatory MOC participation for membership on hospital medical staff.
3.       Prohibit mandatory MOC participation as condition to be included in Insurance physician panel.

PLEASE PASS THIS BILL TO STOP MOC IN FLORIDA!!