House calls

November 17

Arthur was a bitter and cantankerous old man, an incorrigible alcoholic and difficult to like. He was long divorced, estranged from his children and without friends. He became my patient when he was admitted with multiple rib fractures following a fall from being intoxicated. Because he had no one to care for him at home, his discharge was delayed until home health finally found him caregivers: a mother and her son.

Over time the pattern of binge drinking, falling and hospitalization repeated itself with alarming regularity. His caregivers tried their best and treated him well, but eventually Arthur drove them away too. He refused all help but was mentally competent and judged not to be a danger to himself, so he could not be put into a conservatorship or protective custody.

Since Arthur lived at the end of my rural road, I visited him weekly while out for one of my bicycle rides. He seemed to be surviving, had food and beer in the fridge and still had electricity. But he was marginal at best, and I remember wondering if he could drop dead without anyone knowing or caring.

Then I went on vacation and didn't return to Arthur's for three weeks. When I did, no one answered the door. Finding it unlocked, I let myself in and called out for him. No answer. A few steps inside, I nearly tripped over Arthur's rigor-mortified body, cold and black. It was a bit of a shock, and I was surprised at my surprise. Wasn't his death the logical outcome given his circumstances? Did I really expect to find Arthur up and about, washing his dirty dishes and asking me in for tea? But I was bothered. As his family physician, could I have done more? Maybe not. After all, how do we help someone who does not want help?

Arthur's condition was terminal, his death was messy but predictable, and I stopped browbeating myself as soon as I left his house.

Y2K and dinosaurs

November 30

It was with some trepidation that I approached upgrading my office-management software to make it Y2K compliant. It seems there was a date problem with my older version; it left out Feb. 29 in the year 2000. I asked Dave at technical support if I could just shut down the office that day, but he wasn't impressed with my solution.

The updates arrived a few days later and, after backing up my data in three different places, I tried to install the newer version. It installed, but when I tried to open it, it crashed. The ensuing feeling was something like missing a patient with an acute MI. A panic call back to technical support, some manipulations to what they called an .ini file (are there .outies too?), a restore of the old data, another attempt at the install and … the same error.

“What kind of system are you running?” Dave asked.

Proudly I said, “I've got a 16-bit, 486 machine with 4 megabytes of RAM and a 2400-baud modem running on Windows 3.1.”

“Are you kidding? They don't even take those at the dump anymore” he said. “Update or die” were his last words to me.

Undaunted, and not wanting to spend $1,000 on a machine with more horsepower just so I could get leap year on my calendar, I tried the install on my Pentium that I keep at home — and it worked! I then copied the entire program onto tape and restored it over the older version on my office machine — and it worked! I am now pleased to say I will greet the new millennium with my electronic dinosaur by my side.

Business 101

December 9

Being paid expediently is an economic imperative if we physicians are to stay in business. In my practice, we have developed a system that keeps us viable:

If the patient is private pay, we collect payment at the time of service. Failing to do that, we give the patient a walk-away bill or send out a statement that day. If the patient is insured, we collect the co-pay at the time of service and bill the patient for any remainder due on the day we receive payment and the explanation of benefits from the insurance company.

At the end of each month we follow up on all outstanding accounts. If the insurer hasn't received the bill, we immediately fax it to them. If they say our payment is being processed, we ask for the date we can expect to receive it.

Once insurance has paid its share, patients who are 30 days past due get friendly reminders on their bills. After 60 days, they get a telephone call. After 90 days, they go to our letter service. After 100 days, they go to collection. We're always willing to accept installment payments, but we don't tolerate being ignored.

I have seen too many colleagues fail at private practice not because they were poor physicians or had low patient demand but because they simply didn't know how to stay in business. What a pity they don't teach that in medical school.