The hospitalist

Our medical service wants a hospitalist. After 20 to 30 years of call, most of us are ready to retire into our offices and untether ourselves from our beepers and telephones. The only problem is that the hospitalist we are considering wants an income guarantee from the hospital. The hospital is not convinced the position will be “income-neutral,” so a committee was formed a while ago to deal with it. So far, I'm still taking call.

It occurred to me to talk to my colleague Adam about the position. He's a good internist and has been fairly open in expressing his dissatisfaction that his take-home pay seems to be less than that of an entry-level drug rep. “I know this is old-fashioned, and I don't want to disturb negotiations in progress,” I said, “but if these guys can't come to terms, why don't you say you'll be the hospitalist and do it fee for service? That would clear the playing field.”

He was intrigued but dubious as to whether fee for service would support him. “Adam,” I said, “there are 10 doctors willing to sign out all their inpatients to you plus all the medical admit call for unassigned patients. You'll be rich.”

“But I don't know anything about billing,” he complained. So I offered to help him — in exchange for weekends off and vacation time.

“Do you really think it will work?” he asked earnestly.

“Trust me, Adam. I'm a doctor.”

Verbal abuse

A patient's wife called Isabel, my office manager, to inquire about her husband's bill today. The patient only owed $6.25 but was fuming because we billed his insurance $50 for a flu shot, blood pressure check and medication adjustment. Few patients appreciate the difference between billed and allowed charges, and although his bill showed an insurance adjustment of $20, he failed to understand we were only making $30 for the visit. Instead, he wrested the phone away from his wife, with whom Isabel had just spent five minutes painstakingly explaining the bill, and unloaded a fusillade of obscenities culminating with his promise to find another physician. Then he hung up on her.

Isabel knows angry patients may be assuaged, but when their anger leads to verbal offense, she will not put up with it. She was right back on the phone and, getting only the answering machine, left instructions regarding how the patient could transfer his records. She ended by telling the patient that his behavior was inappropriate and disrespectful. I supported her entirely. Patients are certainly free to question their bills, but I will not tolerate rudeness to my staff from anyone. The only way he will get back in our good graces is if he apologizes to Isabel — and if she accepts his apology.

Chest pains

Donna called me at the start of my day to say she was having chest pain. She was not the patient I would have predicted to call with that complaint. She was only 45 years old, and her sole risk factors for heart disease were mild hypertension adequately controlled with atenolol and an LDL of 145. “Does it feel like pressure?” I asked.

“No,” she said.

“Does it radiate?”

“No.”

“Does it make you sweat or feel short of breath?”

“No.”

The little man inside me told me not to blow this one off. “You probably should come in and let me check you out anyway,” I said. She said she would stop by during her lunch hour.

Donna didn't appear until 5 p.m. The pains had gone away but returned after lunch, and she felt as though she couldn't leave her job at the bank. I was half out the door but returned to run an ECG. What I saw gave me cause for concern: ST depressions in the lateral chest leads, different from her echocardiogram of nine years earlier. “Donna,” I said, “you need to be in the hospital.”

The first creatine kinase was 312 with an MB of 48 and a relative index of 15.4 — enough to make the diagnosis of subendocardial infarction. I put her on Lovenox and a nitro drip and arranged for her transfer the next day for a cardiac catheterization. A branch off her left anterior descending was completely occluded, so she was stented and did well, with a good post-catheterization ejection fraction and near normal left-ventricular function. Piqued, I had her come in for a homocysteine and lipoprotein(a); both were normal.

“I don't understand this,” I told her at her last visit. “I have 300-pound smokers with high cholesterol and blood pressure and family histories of heart problems, and they don't have heart attacks.”

“Yeah,” she agreed. “Life's a bitch.”