If it walks like a duck …

I’d become spoiled by our new hospitalist system, taking my own call Monday through Thursday then having Friday through Sunday off, and hadn’t had an admission in over a month, when the phone rang just as I was leaving on a dirt bike ride late one afternoon. It was the ER, calling about my patient Sandra. She was an obese woman who had taken my advice to exercise and had, in fact, lost 60 pounds. While doing laps in the pool earlier in the day, she had experienced textbook crushing substernal chest pain. She had improved on a potpourri of oxygen, nitroglycerin, Toradol and Pepcid, but her pain was still a 4 on a 10-point scale and the ER doc wanted to admit her as a rule out.

On the way in, I tried to recollect Sandra’s risk factors. She was still grossly overweight and had been a heavy smoker before she quit two years ago, but that was it. Her office chart revealed her mother had died of emphysema at age 65 and her father of cirrhosis at age 44. She had neither hypertension nor diabetes, and her cholesterol was 187 with an HDL of 48. She had moderate COPD, a bipolar disorder and arthritis, but she had never complained of chest pains and had never had a stress test. It was puzzling.

At the bedside, when asked about her family history, she admitted her father had had a major MI at age 42. “You never told me that before,” I complained.

“Well,” she said, “you only asked me what he died of. He didn’t die of his heart attack.”

Of great interest to me was her cardiogram; it showed a new right bundle branch block and ST depressions in some anterior chest leads. Her pain was diminished to a 2, so I had the nurse start a nitro drip and it went away. A post nitro EKG was normal! I faxed both to Dave, the cardiologist on call for our referral group, and he was concerned. “She may have had a posterior-lateral MI,” he said.

“Isn’t that the one you diagnose by holding the cardiogram upside down and backwards and looking at lead 1?” I asked.

“Something like that,” he said. “You could send her down for a cath or do an imaging study up there.”

“Why wait?” I said. “What else could this be but an acute coronary syndrome?”

Sandra remained on a nitro drip throughout the night. Although her first two sets of cardiac enzymes were negative, the drip had to be increased to control her pain. Early the next morning she was air-ambulanced to Santa Rosa for an 8 a.m. angiogram. “Good save,” the ICU nurse told me.

“Normal coronaries,” Dave called to tell me two hours later. “I’ll get an axial chest CT to rule out a pulmonary embolism, but I’ll probably be discharging Sandra tomorrow morning.”

Somewhat embarrassed, but glad for the patient and realizing that you have to take out some normal appendixes so you don’t miss a ruptured one, I wondered what exactly you can take to the bank in this business. I’d missed an MI once that had presented with just dizziness and now this. Well, I thought, isn’t this what makes medicine fascinating? Quack, quack.

Statements and stickers

At the beginning of every month, my practice sends out patient statements. It’s one of our many office rituals, such as sending weekly electronic claims and biweekly birthday cards. We usually begin with statements for our private-pay patients, move on to those with Medicare and perhaps a secondary insurance, and finally, before lunch, set our computer program to print out all the rest. When we return, there is a thick stack of bills waiting to be mailed, which I always get a kick out of, remembering the time when all billing had to be done by hand. Letting the computer tackle serious work in the office, while my office manager and I are enjoying our repast, makes me feel extremely efficient besides.

Of course stuffing the bills in envelopes and mailing them remains, but first we need to apply our stickers. Dalia trots out boxes of them. They are small, multicolored, self-adhesive labels that direct our patients’ attention to the messages we wish them to hear. If, for example, a patient hasn’t paid us after one billing cycle, his sticker reads, “We missed your monthly payment. Won’t you please send it in now?” After two cycles it says, “Please, tell us if there is any reason why payment has not been sent to us. Thank you.” If we suspect financial hardship, the sticker reads, “If you are unable to pay in full, please send a partial payment.” Or, if we want to be cute, we attach a sticker with colorful bugs drawn on it that says, “Don’t like to bug you, but could we please be paid?” After 90 days of ignoring us, they get a sticker in red that proclaims, “Past due. We would appreciate your payment today!” Finally, after 120 days out, we paste one on their bill that shouts, “Final notice! If payment is not received in 10 days we will send your account to our collection service.” The Spanish version reads, “Ultimo aviso de pago!” If they put something on their account, we commend them with yet another sticker.

I’m not sure our stickers have improved our collection rate, but they make me feel better and sure make sending statements a lot more fun.