Dell 2100 N

I received my Dell netbook a little over a week ago. (I tried making a link, but it didn't work -- just go to Dell's site and search "2100 N", and don't forget the space between the number and the letter.) For the reason I bought it, it's been excellent. I'm not so fond of Ubuntu as a Linux distro, but plan to replace it (probably with Fedora 11) once I get my USB DVD drive.

One ongoing design issue is that the space bar is only millimeters away from the touchpad, but gradually I'm learning to position my hands (thumbs) differently. Key size is Ok ,and in general the layout is Ok. Battery life is excellent. As I'm making rounds I put it into suspend mode in between uses, and battery use is very minimal then. So I can carry it around with me all day and not have to recharge.

It's already reduced the headache of trying to remember who I've seen, and what their diagnosis is when I get to the office. I'm hoping to work with some other applications once I get the OS switched. In a pinch I can use it to log into the hospital's system, by way of first connecting with our office server, then running Internet Explorer, which is what the hospital's system requires. Sounds like it would be slow, but it's probably as fast as using my Windows computer at home.

I'll post more after I get used to using it.

Maelstrom

Obviously, I haven't posted in a while (whatever happened to May?). A course of events ensued, the outcome of which was that I rather suddenly (over the period of a few weeks) became the only neurologist seeing patients at my primary hospital. This is a 400-bed hospital, so my workload suddenly and rather dramatically shifted.

Actually, shifted is not the right word, since I didn't stop doing the other things I have been doing, like office work, doing some EMGs, and so on, so this was all just added on.

I'm not sure we ever had "enough" neurologists here, but in the last several years, some have left, but also there has been this redistribution, with various ones of us restricting our work to fewer places, some neurologists only seeing office patients, and a few only seeing hospital patients. It's most likely a combination of lifestyle issues, having a more dependable workday, but to some extent realizing that it's not efficient economically to be running around from one place to another, better to stay in one or a few places.

Now I've gone from a variable handful of patients at a time to having 6-8 new consults on any given day (sometimes more), and I may have a running list of 30+ patients to follow. It used to be I could keep what was going on with various patients in my head pretty well, but this is breaking down. After I see 5, 6, 7 new consults, then go to the office to submit the charges I can have a time remembering who each patient was, especially the earlier ones. I figure it out, but there goes some wasted time in the process.

Handing off patients to see for the weekend coverage also becomes a chore, but I had already set up a system where I make out a list with annotations and print it out. I just can't imagine going down a list verbally and the guy on the receiving end keeping things straight.

The worst time for me is at the end of a weekend, or this coming Sunday at the end of my vacation, getting some 20-30 patient list of people I don't have a clue about. Every followup becomes a chore as you have to review each chart to get the gist of what's been going on, even with the heads up info I will get from this or that person in the group.

Solutions?

I've ordered a netbook, something I can carry with me on rounds to keep track of things better. Sometimes it's a big help just to prioritize patients, like who needs to be seen first, who definitely needs to be seen today, and so on. The model I've ordered, a Dell 2100N, has a rubberized case and with the extra batteries will last for several hours on a charge, so I am hoping I can just have it running as I go on rounds and carry it along with my "black bag" -- I'm getting an optional carrying handle, so I won't need a case.

Like any hardware solution, it's not automatic or magical, so I've been trying to find software that can help. I think I've found it; it's something called basket, or I guess more formally BasKet Note Pads. It's a free-form note-taking app that works very fast. You work with a blank page, and simply by clicking on an open area you create a small text box that you can enter info into. You don't bother to save anything, it's all automatic in the background. If you shut down the computer with it running, it pops up right where you were when you start up again. Each page is called a basket, so I figure one basket per patient, then I just click from one to the next as I go.

So once I get it, I'll post about it after I've seen how this goes. Should be interesting.

Recherche du temps perdu

It has become shall we say "fashionable" to add a message in charts, either hand-written or dictated, avowing something along the lines of, "40 minutes was spent with the patient, 60% of which involved discussing the diagnosis and treatment." I realize the fashionable nature relates to issues of billing, since now we are urged to document what we do, so that maximum billing and reimbursement can occur.

I wonder if these statements can live up to the laws of the space-time continuum, though. No one seems to spend a mere 10 minutes with anyone, it's always something like 40 or 50. If a doctor such as this were tracked on a given day, and these amounts of time were totalled, how many hours of the day would be consumed? Would there be any time left for going from one place to another, eating meals, engaging in idle chitchat, sleeping? Would the time on occasion exceed the hours in the day?

Another thing I see, now with everyone using computers for wordprocessing, electronic medical records, is that it can be hard to tell the report of a followup visit from the initial one. Each report has a complete history, a complete physical exam, a complete discussion of the facts, and of course the obligatory "XX minutes was spent with the patient..." One reaction I have to this is that if one takes this at face value, that yes, all of this was done every single visit, this is an obsessive-compulsive person in need of treatment -- the doctor, not the patient.

But the reality check is that, once again, it's all about the billing, all about being able to justify that maximum category and charge in every single patient. On the receiving end of such reports one doesn't know what to believe...is it true that all of this history and exam was done? Sorry, I've got doubts about that.

Sooner or later, people will get called on this. Someone will do the math, check the office practices, the templates, the copied-over notes from one visit to the next. The results aren't going to be pretty, I'm afraid.

The Republicans
Poster Children for Unintelligent Behavior

As far as I can tell, the Republicans are working very hard, very hard at digging themselves a deeper hole and thereby further alienating themselves from the public as a whole. It seems to be a rather graphic illustration of how out of touch they are. I suppose that if you believe that the most important thing is having access to media like Fox News whenever you want to engage in political commentary, which seems to be any time of day anymore, then this becomes an end in itself.

Part of the behavior that they have chosen is to start with the premise that the American people have no memory. No memory of the Republican policies that caused some of the problems we have, so they pretend that it was the Democrats that caused them. Not smart.

Another part is absolutely no acknowledgement that anything that Obama is doing has any good to it. Also not smart. Even W didn't do everything completely bad. When you get to the point of sounding like you're against everything Obama wants, like less dependency on foreign oil, better relations with other countries, a better environment, better healthcare, you'd better sound like you have some sensible alternatives. Here's a clue: the old policies got us where we are now, so suggesting we go back to them is not sounding like there are signs of intelligent life in the Republican party.

It's easy, very easy to be anti-something else. But it's also very dumb to be anti-everything about someone else. Sooner or later you have to be for something, or you'll be dismissed come the next election. Maybe the Republicans will go the way of the Whigs, and simply become irrelevant. It's up to them.

Scribus
The Official Manual

Here it is, my book. Strictly speaking, not just my book, but the collaborative book I blogged about, I don't know when.

It's been an interesting experience, and no one's going to get rich from it. In fact, I'm donating any money I might have made to the software project that wrote the software that the book is about.

So, if you're interested desktop publishing, you might check out Scribus, and the book.

Health Insurance Reform

Health care reform seems to be on the horizon, and I think like many, I would say it's hard to be optimistic. Doctors are perceived to be the source of a lot of problems, even though we're just out here trying to follow the rules we are compelled to accept, meanwhile the primary ones liable when something goes wrong.

Health care reform needs to begin with health insurance reform. As I look at various other ways countries around the world manage or try to, I think we don't necessarily have to adopt anyone else's method, but perhaps some modification of the German system is worth a serious look.

Here are the features of reform as I see it should happen:

• Everyone must have health insurance, regardless of age, health status, employment or lack thereof. This encompasses a responsibility of the insured to obtain it, and to insurance companies, who cannot deny coverage to anyone.
• There needs to be free access to whatever plan you choose, and it shouldn't be any more guaranteed if you are working for a major corporation than if you are self-employed or unemployed. There will likely be a need for government subsidy of those in lower economic brackets. You should be allowed to switch insurance companies at least quarterly, if not more often.
  
• Private insurance companies should be the main source of health insurance. This allows for competition, and helps prevent some massive bureaucracy from eating up health care dollars.
  
• There needs to be tight regulation of insurance company profits. When profits increase, they need be reflected in lower premiums to policyholders. Bonuses to health insurance executives for increased profits are forbidden. This is a conflict of interest. Similarly, doctors and other providers should not make more money by denying care.
• In general, the goal of the system should be to ensure that a high percentage of health care premiums are spent on health care, not administration of benefits, not to shareholders. This will require a simplified process for reimbursement.
• There should be a level playing field for reimbursement. This may or may not necessarily involve identical fees countrywide, but there should be little or no variation in fees paid by one insurance company versus another for a given region or to one provider versus another. This simplified billing and payment process by itself will save a very large amount of money. Thus you can also eliminate the possibility that a given provider may or may not accept your insurance.
  
• When healthcare is delivered, fees are paid, and in a timely manner. There can be room for questioning the legitimacy or necessity of care which is delivered, but this occurs after the fees are paid, with any decision affecting future billing, not already paid fees.

Regarding this last point, if there are questions regarding the care that a doctor delivers, regarding necessity and other questions that we now face from health insurance companies, these should be handled by licensing boards and other standards of care organizations. We don't need to try to affect the quality of care by the way reimbursements are paid, since too many times we see that withholding payment is more about profit than it is about the needs of the patients.

Doing Nothing

It can be hard to do nothing when you see someone. Nothing meaning nothing. No tests, no treatment, empiric or otherwise, or at least not change any treatment. Many, maybe most patients expect you to do something.

One of the situations where I mostly do nothing is with the late at night call about someone found on the floor, known to have fallen, banged something in a transfer, something in that category. Many times the nurse might say, "We found Mr. X on the floor. Looks like he was trying to get up by himself and slipped. Do you want us to order any Xrays?"

Uh, X-ray what?

"Well, he might have hit his head or his back."

Is there any scrape or bruise or tenderness, or...

"No."

So are we going to X-ray his whole body? Why? Unless someone has had a fall that was of itself clearly serious, you need some help in knowing what to X-ray, what to look for, what to be worried about. Furthermore, what are we going to do about it at 3am in the morning? Nothing. So you put them to bed, wait until morning to assess the patient and ask for feedback about something somewhere that's not right.

Last week I had a patient tell me that her foot got twisted during a transfer. I checked the foot. It looked Ok, had no pain with palpation, no pain with motion, so I decided to just wait, ie, do nothing. Within the next few days, the foot became tender with weight bearing, and an X-ray showed a metatarsal fracture, so now she's wearing a boot.

Do I feel bad about "missing" the fracture? No. I needed to have some indication of what to look for, and there wasn't anything lost by waiting to know what to look for and do it efficiently. And this one fracture occurred as a rarity given all the other patients with a similar story who subsequently had no problems, so in the end I've saved a lot of money on unnecessary X-rays.