Y!IFMBA - Surgery Style

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I fantasize about bashing my laptop to pieces multiple times a day.
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I'm just gonna bump this thread because I'm on vacation and I can.

Catching up on movies:
The Invention of Lying
The Reader :)thumbup::thumbup:)
Julie and Julia :)thumbup:)
Forgetting Sarah Marshall :)thumbup::thumbup::thumbup:)
 
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most derivative movie ever. Mix Dances with Wolves, Matrix, Transformers, Titanic, etc. black vs white, good vs evil and you've got it. No wonder Cameron only does a movie every 10 years.

On a better note, the elderly man sitting next to me was snoring.
 
Winged Scapula said:
Avatar:

most derivative movie ever. Mix Dances with Wolves, Matrix, Transformers, Titanic, etc. black vs white, good vs evil and you've got it. No wonder Cameron only does a movie every 10 years.

On a better note, the elderly man sitting next to me was snoring.
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I thought it was basically Fern Gully but with special effects instead of cartoons.

Still worth seeing in 3D though.
 
LucidSplash said:
I thought it was basically Fern Gully but with special effects instead of cartoons.

Still worth seeing in 3D though.
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I did enjoy the colorfulness of it and the special effects. But either the 3D or the action made me nauseated, headachy and the volume was so high and I had to get up and leave with 20 mins left to go.

I think I'm getting old.
 
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Insurance companies are liars.

I know, I know...you're shocked.

For some reason, I decided to check my EOBs against a spreadsheet I made last year showing what the insurance companies told me was my contracted rate by CPT code.

Horrors of all horrors, can you believe that they are not actually paying me what they said they would?

I grudgingly accept that multiple procedures will only pay 50%, or that a bilateral procedure will sometimes not get paid for the second side. I expect the former and I expect my billing company to catch the latter and rebill it (which I have found they are not always doing). But if you tell me that my contracted rate for procedure X is $881.35, don't you think that would be the amount they'd pay? Why would $661.42, $449.72 or $717.57 or x make more sense? Is there some sort of parallel universe where they just throw darts at a board and that's what the check is cut for?

NOW they are in trouble because I have noticed and will take action. Most physicians don't. :ninja:
 
Winged Scapula said:
But if you tell me that my contracted rate for procedure X is $881.35, don't you think that would be the amount they'd pay? Why would $661.42, $449.72 or $717.57 or x make more sense? Is there some sort of parallel universe where they just throw darts at a board and that's what the check is cut for?
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It's probably something more like this....

[YOUTUBE]http://www.youtube.com/watch?v=julnt19Pl8E[/YOUTUBE]

Winged Scapula said:
Insurance companies are liars.

I know, I know...you're shocked.

For some reason, I decided to check my EOBs against a spreadsheet I made last year showing what the insurance companies told me was my contracted rate by CPT code.

Horrors of all horrors, can you believe that they are not actually paying me what they said they would?
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Interesting. This is especially interesting because there's been a recent "tide change" in this healthcare debate where more blame is being laid on physicians for rising healthcare costs. I feel like more people are feeling more sympathy towards the insurance companies (which....:wtf:), and are blaming physicians more. Doctors "order too many tests," try to do "too many procedures," and "only care about money."

These people have clearly never had to wrestle with insurance companies. They're not the ones who have had to spend 3 hours with different pharmacies and insurance company formularies trying to figure out which anti-depressant the patient's insurance would grudgingly cover. They weren't the ones getting 4 frantic phone calls over the weekend, because various people had found that their new insurance plans wouldn't cover the anti-hypertensive or oral diabetes medication that they'd been on for years. (And, needless to say, they won't be the ones called to the ER at 3 AM to take care of the patient who had the stroke after being unable to take these newly-unaffordable meds.)

(And, OF COURSE, they especially don't want to hear that patients may be to blame, because they bully the surgeon into doing a procedure that may not be fully necessary, or threaten to sue the ICU doctor who refuses to order CVVHD for their brain-dead, terminal, aged grandmother. That NEVER happens, right?)

Dealing with insurance companies has inspired a rage in me that I never knew existed. :laugh: I'm amazed that you manage to discuss this so calmly. I'm glad that you caught them shortchanging you and I hope you can kick some a** while trying to correct the situation. :xf:
 
LovelyRita said:
I'm just gonna bump this thread because I'm on vacation and I can.

Catching up on movies:
The Invention of Lying
The Reader :)thumbup::thumbup:)
Julie and Julia :)thumbup:)
Forgetting Sarah Marshall :)thumbup::thumbup::thumbup:)
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U lot should watch Mrs March
American pie book of love
 
btw.... scrubs.... excellent show.
its getting me through the week.
 
I show dogs....and I like it....a lot. There, I said it.
 
SOLDIER said:
I heard the new season is ****ty?
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Season 8 is strong... Not at 9 yet. Although the stuff with jd leaving is ****ing killing me with the prospect of moving away from my home of 6yrs looming over thursday.
 
Buzz Me said:
Somehow I KNEW you'd be focusing on all those plain ol' frumpy shoes! :)
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Ha ha...yes, you know me well.

I cannot fathom how those girls can allow themselves to be seen on national tv wearing such frumpy clothes and shoes. Its an episode of "What Not to Wear" every time I watch. Talk about polyester explosion.
 
How about that show Dog Whisperer? That guy goes to people's homes and strangles their dogs for a couple of hours. Then walllaa! All the sudden the dog is obedient.

The Dog Whisperer whisperer whisperer whisperer . . .



(I heard that in a stand-up routine and thought it was hilarious)
 
Ok I have to vent about a family member's recent surgical experience.

1) cocky surgeon - I can handle that. He appears to be some hotshot although IMHO urologists have typically been less cocky. But whatever.

2) he is running 3 hours behind. Fine. I understand and explained to my family member all the reasons why surgeons run behind. But NO ONE from peri-operative staff came to apologize, explain, whatever. When the anesthesiologist came to interview him, she said, "I hope someone told you we were running behind." Uh no but we figured it out thanks..its now 330 and we're all starving and cranky.

3) the surgeon is not rounding on him. He had major surgery, is a young man with a malignancy and is letting all the post-operative care be done by the residents. He even said as much in the PACU to us that he wouldn't see him until the post-op visit. Doesn't even have a partner come in and round. :mad:

4) the residents don't introduce themselves when they come in; I can figure out who the intern is and who the Chief is, my family cannot. But really...they should be introducing themselves at least ONCE to the patient, even if just to say, "hey we're Dr. X's resident team here to check in on you and make sure you're doing well"

My family member is not fussed by all of this, but I think its just poor care. I always introduce myself, when I'm running late make an effort to have OR staff inform waiting patients and family members and I always round on my patients (and would even if I were in a teaching hospital). I don't want to shaft this guy or this well known hospital, but really if they asked my opinion I'll tell them they could do a lot better.
 
Cocky urologist...I'm sure there's a good joke in there somewhere

Sorry you had a bad experience. I wonder how the staff guy can get away without rounding on his patients? Better yet, why would he not want to see them? truly a shame how some surgeons abandon their patients post-operatively.
 
Winged Scapula said:
Ok I have to vent about a family member's recent surgical experience

...the surgeon is not rounding on him. He had major surgery, is a young man with a malignancy and is letting all the post-operative care be done by the residents...

...the residents don't introduce themselves when they come in...

My family member is not fussed by all of this, but I think its just poor care...
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Very unfortunate. I agree. We don't expect everyone to practice at our level.... but this is our practice:

1. we meet patients in pre-op AND completely introduce ourselves.
2. We have circulator call to waiting area and let family know when incision is made. We call again if things run long.
3. We call and let them know when we are closing.
4. We meet with family afterwards, at some point following case/s to discuss case and/or frozen path results.... usually culminates into a final hugging moment.

IMHO, you can eliminate 2 & 3 if you like. But, I think patients and family deserve #1 & #4 (maybe sans hugs). Be well WS. Our best wishes for you and family.
 
Pir8DeacDoc said:
Cocky urologist...I'm sure there's a good joke in there somewhere
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Heh...hadn't thought about that when I wrote my post this morning.

Sorry you had a bad experience. I wonder how the staff guy can get away without rounding on his patients? Better yet, why would he not want to see them? truly a shame how some surgeons abandon their patients post-operatively.
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I don't know. I too would have expected that is a requirement of staff privileges - I wish I had thought of calling Med Staff offices before they closed today to ask if that was required. My partner said, "well you trained in a more hands-on environment but there are some places where the residents run the show. Maybe this is one of those places." Later today I talked to one of her former co-residents who agreed that could be the case but when you are operating on the family member of a fellow surgeon, you should always give a little extra attention to that patient. Professional courtesy or simply wanting to look like you give a damn, whatever. I agree with him.

Abandonment. That's exactly how it feels. I understand the surgeon's mother in law died the day of my family member's surgery but if he's unavailable to round, I'd expect his partner to. I cannot fathom wanting to see my patients post-op.

I had a half a mind this evening to call the resident on call but figured I was angry and didn't want to be one of those family members. But if anyone is in Georgetown tonight, you could do me a favor and kneecap a certain urologist. :p

JackADeli said:
Very unfortunate. I agree. We don't expect everyone to practice at our level.... but this is our practice:

1. we meet patients in pre-op AND completely introduce ourselves.
2. We have circulator call to waiting area and let family know when incision is made. We call again if things run long.
3. We call and let them know when we are closing.
4. We meet with family afterwards, at some point following case/s to discuss case and/or frozen path results.... usually culminates into a final hugging moment.

IMHO, you can eliminate 2 & 3 if you like. But, I think patients and family deserve #1 & #4 (maybe sans hugs). Be well WS. Our best wishes for you and family.
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I do 1, 2 (if running long), sometimes 3 (if I'm running long) and always 4. I didn't even get fussed when he said he'd have the results when he comes back for an office visit (I always call with results as soon as they are available, BEFORE the office visit). But not everyone gets it I suppose.

It was a good lesson on how those families feel sitting out in the waiting room/pre-op holding area.:mad:
 
Winged Scapula said:
...when you are operating on the family member of a fellow surgeon, you should always give a little extra attention to that patient. Professional courtesy or simply wanting to look like you give a damn, whatever...
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Other then maybe providing the family of a colleague with my personal cell number or home number, I try provide equal clinical care to all my patients [though, I still end up giving out these numbers to "stranger patients" with more complex then average cases or less levels of sophistication/comprehension; MY SO hates it when I get the calls...]. I do not want to feel the poor average-joe gets less clinically or social-clinical involvement because they aren't lucky enough to have a family member in medicine. It is amazing how many of our patients and patient families drag in some distant relative or neighbor's-cousin's-friend that is a nurse because they think it may get them an increased level of care. I like being able to look at them and say, "No, you are not getting x, y, z. It has nothing to do with your insurance status (or wealth or who you know). It is about what is good standards of care. We treat everyone the same; by providing excellent care..." I don't like VIP medicine cause it implicitly means I am giving the non-VIP less for whatever reason that makes them non-VIP. That idea adversely impacts my sleep!
Winged Scapula said:
...But not everyone gets it I suppose...
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I agree. These things are horrible. I find too many healthcare providers feeling up on a pedestal. They don't get it.... that is, the status and +/- higher then average income is payment for not just the operation but the actual personal and compassionate care. If you don't provide this human decency with excellent clinical care, IMHO you are worth less in the pay scheme... because you are selling an inferior product. It is a package deal.

Be well WS.
 
Winged Scapula said:
I don't know. I too would have expected that is a requirement of staff privileges - I wish I had thought of calling Med Staff offices before they closed today to ask if that was required. My partner said, "well you trained in a more hands-on environment but there are some places where the residents run the show. Maybe this is one of those places." Later today I talked to one of her former co-residents who agreed that could be the case but when you are operating on the family member of a fellow surgeon, you should always give a little extra attention to that patient. Professional courtesy or simply wanting to look like you give a damn, whatever. I agree with him.

Abandonment. That's exactly how it feels. I understand the surgeon's mother in law died the day of my family member's surgery but if he's unavailable to round, I'd expect his partner to. I cannot fathom wanting to see my patients post-op.
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I thought all post op patients required an attending note daily except on the day of discharge. We just had one of those dreaded billing compliance lectures and that was one of the messages: for billing purposes resident notes don't mean anything unless they are followed by an attending note. If the hospital bills without an attending seeing the patient it's basically insurance fraud....
 
chrisisinnocent said:
I thought all post op patients required an attending note daily except on the day of discharge. We just had one of those dreaded billing compliance lectures and that was one of the messages: for billing purposes resident notes don't mean anything unless they are followed by an attending note. If the hospital bills without an attending seeing the patient it's basically insurance fraud....
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I am not sure if its insurance fraud - after all, I believe that hospitals and surgeons are paid a "global surgical package" which includes the post-operative visits except in the case of Critical Care, which can be billed separate from the post-operative global care as long as the critical care was unrelated to the surgical procedure performed. I thought only attendings notes were required for Trauma patients for the critical care billing. I know no insurance company requirement that you see your post-operative patient X times.

Hospital policy may dictate that the attending sees the patient daily or that they must write a note.

It is my understanding that the global period includes post-operative care both in and out of the hospital related to routine recovery from surgery and includes care for complications, except those that require a return to the operating room.

Interestingly, critical care time cannot be counted if the care is not rendered in or near a critical care unit. Therefore, you cannot bill for a Family Conference held in the hospital chapel, or for time spent reviewing labs in one's office.

But I certainly recognize that I am no expert in these things and if someone can find some documentation about this (ie, are attendings really required to see and write daily notes on post-operative patients?) I'd be interested in seeing it. Bearing in mind that we are talking about *post-op* patients, not necessarily surgical patients who are not in the global period or consults (for whom you can bill daily for visits which require an attending note).

Here is what I found for a Medicare provider: https://www.highmarkmedicareservices.com/refman/chapter-22.html
 
Winged Scapula said:
Ok I have to vent about a family member's recent surgical experience....I don't want to shaft this guy or this well known hospital, but really if they asked my opinion I'll tell them they could do a lot better.
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I don't think you're being unreasonable. This attending is providing terrible post-op care, IMHO. Is he one of those guys who just runs the list with the chief every day in lieu of actually seeing his own patients?

:thumbdown:
 
Buzz Me said:
I don't think you're being unreasonable. This attending is providing terrible post-op care, IMHO. Is he one of those guys who just runs the list with the chief every day in lieu of actually seeing his own patients?

:thumbdown:
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Probably as he seems to know very little about what happened.

The story gets better...

1) my family member goes to see him today post-op; he doesn't have the path report because it isn't ready yet, but tells him the tumor is high grade clear cell and to "Google it" to read up on it;
2) apparently they haven't decided whether its T1 or T2 (the CT scan and his operative impression was that the lesion was 3.5 cm; a T2 is > 7 cm) but says "its academic" and that it doesn't matter. No its not *******; it upstages him to a Stage 2 and decreases the OS.
3) tells the family member that they will have the path in 3 days and will mail it to him; if they don't, "you should call us"; I am appalled and disgusted that he would mail a path report showing a malignancy and not review it with the patient, discuss staging and prognosis.
4) doesn't make another followup appointment to go over path when available but instead makes a F/U for 6 months;
5) complains about the pain medication that the residents gave him (well, perhaps you should have been there to oversee these things);
6) tells us that he doesn't know anything about any difficulty the family member had with breathing in the hospital, the "air on the lungs" or the suggestion by the Chief resident to repeat a CXR in 2 weeks to see if it had resolved (again, maybe if you were there)
7) and finally, doesn't examine him. He hasn't seen the incision since surgery.

My family member's wife is in tears and very frustrated. I cannot get anyone in the Dept of Surgery or Administration to tell me whether their surgeons are required to round on their patients. Looking for someone to take over his care.

Colleagues, please let this be a lesson to you:

we are not just technicians. We are supposed to provide peri-operative care to patients. We have a duty to do so and not just cut and run.
 
Winged Scapula said:
we are not just technicians. We are supposed to provide peri-operative care to patients. We have a duty to do so and not just cut and run.
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I would hope that no surgeon needs to be reminded of this - apparently some do. I am so sorry for your frustration and the way things have been handled. As surgeons, especially cancer surgeons (we do a lot of cancer surgery in our residency), we owe it to patients to understand their fears and not add extra stress to their lives. If you want to cut and run, you should do kidney stones or something, not deal with malignant disease.
 
Winged Scapula said:
My partner said, "well you trained in a more hands-on environment but there are some places where the residents run the show. Maybe this is one of those places."
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I'm at a program where the residents run the show, with the chief running things by the attending (sometimes talking about all the patients, but sometimes just discussing issues-esp on trauma). For routine stuff I wouldn't be surprised if our attendings didn't do anything more than cosign our note (as required by the hospital-there is a bit that says they saw the patient, but doesn't indicate whether "looks ok from door" is sufficient). If it is a simple enough procedure they probably weren't even scrubbed in-so I would understand if they didn't feel ownership of the patient. However, in the case of a malignancy, or other complicated situation (technically or just management-wise), they would be more involved (although their follow up would be resident run, since each attendings isn't always available each clinic day. Then again, we are a county facility so no one really seems to recognize any difference between residents and attendings.
 
dpmd said:
I'm at a program where the residents run the show, with the chief running things by the attending (sometimes talking about all the patients, but sometimes just discussing issues-esp on trauma). For routine stuff I wouldn't be surprised if our attendings didn't do anything more than cosign our note (as required by the hospital-there is a bit that says they saw the patient, but doesn't indicate whether "looks ok from door" is sufficient). If it is a simple enough procedure they probably weren't even scrubbed in-so I would understand if they didn't feel ownership of the patient. However, in the case of a malignancy, or other complicated situation (technically or just management-wise), they would be more involved (although their follow up would be resident run, since each attendings isn't always available each clinic day. Then again, we are a county facility so no one really seems to recognize any difference between residents and attendings.
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I get it that this is the case in many places. My partner trained at couny facilities and her experience is different than mine, so she thought maybe I had high expectations.

But my brother was operated on in a fancy university hospital by a private practice surgeon and no residents assisted in the surgery, so I expected that he would have more ownership.

I don't have a problem with residents being involved, taking care of him in house but I did expect the attending to have actually *seen* the patient before discharge. And whether or not it is fair, yes I expected that given his patient had a family member in attendance who is a surgeon, that he would have spent a little time seeing him post-op.

Follow-up was in his fancy private practice office, not with residents or in the university hospital. This was no county facility. This was not an under/poorly insured patient. This is not an uneducated imbecile who couldn't understand complex medical issues.

As you note, this is a malignancy...not a cholecystectomy where you *might* mail the patient the path and tell him to Google it for more information. :thumbdown:
 
Winged Scapula said:
...we are not just technicians. We are supposed to provide peri-operative care to patients. We have a duty...
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Winged Scapula said:
...this is ...not ...where you ...mail the patient the path and tell him to Google it for more information. :thumbdown:
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I AGREE!

When you accept the role and practice of a physician you enter and industry and sell a product. The product you sell is a package. It includes an appropriate initial work-up, the appropriate treatment/therapies you may provide, the appropriate referrals for other healthcare services, and ABSOLUTELY includes appropriate interaction of human decency that any human being should expect. The entire scenario makes me nauceous.:(
 
Winged Scapula said:
But my brother was operated on in a fancy university hospital by a private practice surgeon and no residents assisted in the surgery, so I expected that he would have more ownership.
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Are there university hospitals in Phoenix? Legitimately curious, unless you're talking about UMC in Tucson.
 
Winged Scapula said:
5) complains about the pain medication that the residents gave him (well, perhaps you should have been there to oversee these things);
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Ergh, I've been on the other end of that. I was doing a patient's discharge med list on a weekend, and talked to the senior cross-cover resident and staff gastroenterologist about starting a certain drug cocktail, and they both told me to do it. In the patient's follow-up visit, my staff surgeon said in the clinic office note "Inexplicably, she was discharged home on these meds. I usually wait 6 weeks to re-start them." :mad: HOW ABOUT YOU TELL ME THAT? and how about you not play games like insulting people in the patient's official medical record. :rolleyes:
 
Are you guys trying to guess where he was operated on at? That was not the point of my venting...it is not important and would be disrepectful to him and even to his loser surgeon.

I appreciate the discussion about local hospitals but my brother does not live here and was not operated on here. He is on the east coast at a big name place with an undergraduate/graduate school, medical school, etc.

The point is, it doesn't matter *where* he was operated at, except that this was not some crappy county hospital or VA where you *might* expect to be treated like crap by the surgeon.

And yes we don't really have a university hospital here: Mayo Scottsdale is the closest it comes although we have several hospitals that have surgical residents: Banner Good Sam, Barrows, VA, Maricopa (but I would never send a family member there, please :rolleyes: ).
 
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TheProwler said:
Ergh, I've been on the other end of that. I was doing a patient's discharge med list on a weekend, and talked to the senior cross-cover resident and staff gastroenterologist about starting a certain drug cocktail, and they both told me to do it. In the patient's follow-up visit, my staff surgeon said in the clinic office note "Inexplicably, she was discharged home on these meds. I usually wait 6 weeks to re-start them." :mad: HOW ABOUT YOU TELL ME THAT? and how about you not play games like insulting people in the patient's official medical record. :rolleyes:
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Oh, I know it happens all the time and I agree...responses like that are insulting and unprofessional. I have to curb them myself when I see a patient in second opinion for whom I know got bad advice/treatment first time around.

Which is par for the course with my brother's surgeon - rather than complaining about what the residents prescribed (Oxycontin) and making some negative comment about how he would have given something less strong, he should have been there and communicated with the residents.
 
This dialogue has gotten me thinking. I'm just an MS3 here, but I have seen what I consider to be some very unprofessional things done by numerous interns, residents and attendings. Nothing major like sexually abusing patients, just things I see as common sense that seem to be either totally overlooked or purposefully ignored that show a lack of respect for the patient.

One small example, the other day I was in the room while a resident and attending were giving a relatively grim prognosis to a patient and her husband who were both crying profusely. They both stood to the side of the patient the entire time, didn't make any eye contact, failed to hand them a tissue etc. To me, doing things like that seem so easy and important. I wanted to scream at them to at least face the damn patient while you giving them bad news. There are many other similar examples.

What has gotten me thinking is whether or not this is a consequence of training and becoming jaded as a result, or if some people really just don't respect their patients. I hope it is the second option, and I have become really cognizant of my actions in hopes that I don't fall victim to what seems to be a loss of respect for the patient through training.
 
Dirt...

I would offer a 3rd option:

Some people just don't know how to really give bad news well. Its not that they don't respect their patients, it just doesn't occur to them that facing the patient, a hand on the shoulder, some tissues, talking slowly and softly, but not giving false hope, really makes it easier for the recipient. All they want to do is do the job and get out of the room as soon as possible.

I do this everyday and I'd like to think (and have been told) that I'm pretty good at it. But there were a few medical school and residency lectures on the art of breaking bad news; I think I "got it" before those lectures. Others never do (and there probably is some "becoming jaded/hardened" to it as well).
 
Just as an FYI, I merely mentioned that there is an academic medical center in Phoenix, that's all..I don't really care where the surgery was either.....

I'm glad you made the point of bringing up that some people aren't good at giving bad news. It's rather easy as a medical student to stand there and critique the players, it's an entirely different thing to be on the spot and have that discussion with a patient. Like WS I am pretty good at it, but it's a skill I am lucky to have, that not everyone does. It really doesn't mean anything about whether they care or not.
 
Pir8DeacDoc said:
I'm glad you made the point of bringing up that some people aren't good at giving bad news. It's rather easy as a medical student to stand there and critique the players, it's an entirely different thing to be on the spot and have that discussion with a patient. Like WS I am pretty good at it, but it's a skill I am lucky to have, that not everyone does. It really doesn't mean anything about whether they care or not.
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I watch my staff very closely when they have these discussions, and I make mental notes of what I think I should do, and what I definitely shouldn't. The worst one was a hospitalist when I was doing a medicine rotation in a lower-end hospital. The hospitalist had a thick accent, and the patient's husband was an immigrant, so there was a significant language barrier apparent, and the hospitalist just said without warning "Your wife might not even survive the night." (she had brain mets with a midline shift on CT) The husband was pretty stoic, but I can't imagine delivering news like that without the slightest warning.

I've got one staff surgeon that does a really good job of it, so I know who I'd like to emulate.
 
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