Hitting a Nerve

 

I’ve had to skip several paychecks this year to keep my practice afloat. That makes it hard to pay for my routine personal expenses, like a mortgage, so I have to take the money out of my family’s “rainy day” savings.

This gets old after a few years of the same cycle. I’m pretty sick of it.

Granted, I chose this path. Solo practice suits me. I’ve been in a large group, and it took me roughly 2 years to realize it was a poor fit for me. I’ve been on my own since 2000 and been pretty happy here.

I’ve come to accept that taking a vacation means a temporary drop in salary down the road. My family is important to me, and I don’t want them to remember me as the never-home father immortalized by Harry Chapin’s “Cat’s in the Cradle.”

Trouble is this: What if you still work hard, and find your income falling? I see patients from 8 to 4 most days, with a full schedule, but reimbursements keep dropping and costs keep climbing. Isn’t the idea that hard work will bring success central to the American Dream? Especially when you toss in 9 years of medical school and residency? Apparently not. The American Dream, whatever it is, is pretty much dead for most small-practice doctors.

These are tough times for solo docs, regardless of field. I’ve seen several posts on sites such as Sermo that show I’m not the only one in this boat, skipping paychecks to keep the door open and lights on. Most small practices are running into the same issue. Some, like me, are slugging it out and hoping things get better. Others are folding up and moving, or joining large groups, or signing up with a hospital system.

I’m not sure those last two are options I want. Most of the docs I know who’ve joined hospital outpatient systems are pretty unhappy with them, too. They talk about computer systems designed for billing rather than patient care; unrealistic amounts of time allotted to each patient by a nonmedical person; and jumping through hoops to get certain tests or treatments done.

I suspect it’s a combination of factors, though others see more sinister forces at work. Some posts I read suggest that it’s part of a government and/or insurance conspiracy to destroy small practices.

Regardless, it seems to be succeeding. Small practices are in crisis. Doctor suicides are up. And solo practice has been found to be a risk factor for suicide. There are days when I can see how that seems like the only way out for those who came here just to care for people, and now find that economic circumstances won’t let them.

I don’t have a castle, or drive a Rolls-Royce, or send my kids to private school. We live fairly modestly, but even then it’s getting hard to keep up with costs.

We’re in an election year, and, as always, medical care is bandied about by both parties as a bargaining chip to get votes. But I haven’t heard either side talk about this, nor do I get the impression that either major candidate really cares. Both of them, and members of Congress, get pretty top-notch care without having to worry about cost. This isn’t reassuring to me and all the other solo docs hanging on by our fingernails and trying to practice ethical, honest medicine.

I’m sure some will say it’s progress, but I think the gradual death of the American small and solo practice is sad. It’s a model that’s been the backbone of Western medicine for a few hundred years now, caring for people in big cities, small towns, and everywhere in between. Portrayed in fiction as Marcus Welby, Michaela Quinn, Joel Fleischman, and (my favorite, from Willa Cather’s “Neighbour Rosicky”) Ed Burleigh. Sometimes brilliant, sometimes quirky, sometimes all-too-human ... but still doctors, caring for their patients and communities.

Like the unnamed protagonist in Dr. Seuss’ “I Had Trouble in getting to Solla Sollew,” I tend to find that no matter where you go there will be troubles, and sometimes you’re best off staying in one place and fighting the ones you know.

And, for now, that’s where I am and hope to stay. But I’m scared.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

 

I’ve had to skip several paychecks this year to keep my practice afloat. That makes it hard to pay for my routine personal expenses, like a mortgage, so I have to take the money out of my family’s “rainy day” savings.

This gets old after a few years of the same cycle. I’m pretty sick of it.

Granted, I chose this path. Solo practice suits me. I’ve been in a large group, and it took me roughly 2 years to realize it was a poor fit for me. I’ve been on my own since 2000 and been pretty happy here.

I’ve come to accept that taking a vacation means a temporary drop in salary down the road. My family is important to me, and I don’t want them to remember me as the never-home father immortalized by Harry Chapin’s “Cat’s in the Cradle.”

Trouble is this: What if you still work hard, and find your income falling? I see patients from 8 to 4 most days, with a full schedule, but reimbursements keep dropping and costs keep climbing. Isn’t the idea that hard work will bring success central to the American Dream? Especially when you toss in 9 years of medical school and residency? Apparently not. The American Dream, whatever it is, is pretty much dead for most small-practice doctors.

These are tough times for solo docs, regardless of field. I’ve seen several posts on sites such as Sermo that show I’m not the only one in this boat, skipping paychecks to keep the door open and lights on. Most small practices are running into the same issue. Some, like me, are slugging it out and hoping things get better. Others are folding up and moving, or joining large groups, or signing up with a hospital system.

I’m not sure those last two are options I want. Most of the docs I know who’ve joined hospital outpatient systems are pretty unhappy with them, too. They talk about computer systems designed for billing rather than patient care; unrealistic amounts of time allotted to each patient by a nonmedical person; and jumping through hoops to get certain tests or treatments done.

I suspect it’s a combination of factors, though others see more sinister forces at work. Some posts I read suggest that it’s part of a government and/or insurance conspiracy to destroy small practices.

Regardless, it seems to be succeeding. Small practices are in crisis. Doctor suicides are up. And solo practice has been found to be a risk factor for suicide. There are days when I can see how that seems like the only way out for those who came here just to care for people, and now find that economic circumstances won’t let them.

I don’t have a castle, or drive a Rolls-Royce, or send my kids to private school. We live fairly modestly, but even then it’s getting hard to keep up with costs.

We’re in an election year, and, as always, medical care is bandied about by both parties as a bargaining chip to get votes. But I haven’t heard either side talk about this, nor do I get the impression that either major candidate really cares. Both of them, and members of Congress, get pretty top-notch care without having to worry about cost. This isn’t reassuring to me and all the other solo docs hanging on by our fingernails and trying to practice ethical, honest medicine.

I’m sure some will say it’s progress, but I think the gradual death of the American small and solo practice is sad. It’s a model that’s been the backbone of Western medicine for a few hundred years now, caring for people in big cities, small towns, and everywhere in between. Portrayed in fiction as Marcus Welby, Michaela Quinn, Joel Fleischman, and (my favorite, from Willa Cather’s “Neighbour Rosicky”) Ed Burleigh. Sometimes brilliant, sometimes quirky, sometimes all-too-human ... but still doctors, caring for their patients and communities.

Like the unnamed protagonist in Dr. Seuss’ “I Had Trouble in getting to Solla Sollew,” I tend to find that no matter where you go there will be troubles, and sometimes you’re best off staying in one place and fighting the ones you know.

And, for now, that’s where I am and hope to stay. But I’m scared.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

 

I’ve had to skip several paychecks this year to keep my practice afloat. That makes it hard to pay for my routine personal expenses, like a mortgage, so I have to take the money out of my family’s “rainy day” savings.

This gets old after a few years of the same cycle. I’m pretty sick of it.

Granted, I chose this path. Solo practice suits me. I’ve been in a large group, and it took me roughly 2 years to realize it was a poor fit for me. I’ve been on my own since 2000 and been pretty happy here.

I’ve come to accept that taking a vacation means a temporary drop in salary down the road. My family is important to me, and I don’t want them to remember me as the never-home father immortalized by Harry Chapin’s “Cat’s in the Cradle.”

Trouble is this: What if you still work hard, and find your income falling? I see patients from 8 to 4 most days, with a full schedule, but reimbursements keep dropping and costs keep climbing. Isn’t the idea that hard work will bring success central to the American Dream? Especially when you toss in 9 years of medical school and residency? Apparently not. The American Dream, whatever it is, is pretty much dead for most small-practice doctors.

These are tough times for solo docs, regardless of field. I’ve seen several posts on sites such as Sermo that show I’m not the only one in this boat, skipping paychecks to keep the door open and lights on. Most small practices are running into the same issue. Some, like me, are slugging it out and hoping things get better. Others are folding up and moving, or joining large groups, or signing up with a hospital system.

I’m not sure those last two are options I want. Most of the docs I know who’ve joined hospital outpatient systems are pretty unhappy with them, too. They talk about computer systems designed for billing rather than patient care; unrealistic amounts of time allotted to each patient by a nonmedical person; and jumping through hoops to get certain tests or treatments done.

I suspect it’s a combination of factors, though others see more sinister forces at work. Some posts I read suggest that it’s part of a government and/or insurance conspiracy to destroy small practices.

Regardless, it seems to be succeeding. Small practices are in crisis. Doctor suicides are up. And solo practice has been found to be a risk factor for suicide. There are days when I can see how that seems like the only way out for those who came here just to care for people, and now find that economic circumstances won’t let them.

I don’t have a castle, or drive a Rolls-Royce, or send my kids to private school. We live fairly modestly, but even then it’s getting hard to keep up with costs.

We’re in an election year, and, as always, medical care is bandied about by both parties as a bargaining chip to get votes. But I haven’t heard either side talk about this, nor do I get the impression that either major candidate really cares. Both of them, and members of Congress, get pretty top-notch care without having to worry about cost. This isn’t reassuring to me and all the other solo docs hanging on by our fingernails and trying to practice ethical, honest medicine.

I’m sure some will say it’s progress, but I think the gradual death of the American small and solo practice is sad. It’s a model that’s been the backbone of Western medicine for a few hundred years now, caring for people in big cities, small towns, and everywhere in between. Portrayed in fiction as Marcus Welby, Michaela Quinn, Joel Fleischman, and (my favorite, from Willa Cather’s “Neighbour Rosicky”) Ed Burleigh. Sometimes brilliant, sometimes quirky, sometimes all-too-human ... but still doctors, caring for their patients and communities.

Like the unnamed protagonist in Dr. Seuss’ “I Had Trouble in getting to Solla Sollew,” I tend to find that no matter where you go there will be troubles, and sometimes you’re best off staying in one place and fighting the ones you know.

And, for now, that’s where I am and hope to stay. But I’m scared.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

 

How many hours a day do you typically work?

I’m not just talking about seeing patients, although that’s included. I’m also thinking about all the time spent reviewing tests, filling out forms, returning calls, refilling meds, talking to your staff about what needs to be done for the patients who called with questions or problems, and (a big one) dictating and charting notes for the day.

I’m going to bet it’s a whole lot more than the time you spent seeing patients.

Sadly, the issue appears to be getting worse. A recent study in Annals of Internal Medicine found that for every hour you spend seeing patients, you’re spending another 2 hours working on the computer EHR doing ancillary stuff for the visits. I’m pretty sure insurance companies aren’t paying for that time.

That’s just in the office. The same study found most of us spend another 1-2 hours of our home time each night doing more office work to finish up what we didn’t get done during the day. So much for that work-life balance we hear so much about.

Ready for the breakdown? Here it is:

• Percentage of the total office day spent with patients = 27%

• Percentage of the total office day spent on charting and other EHR-related tasks = 49%

That’s just overall. Now let’s look at the time you’re actually with the patient in an exam room:

• Face-to-face with patient = 53%

• Time on the computer = 37%

So even in a room with a patient in front of you, over one-third of the time is still spent on the computer.

The degree of drudgery is surprising, too. How many mouse clicks are needed, in one system, to order and record a flu shot? Take a guess. 5? 10? 15? How about 32. Yeah, you read that right. No wonder your index finger hurts.

But let’s go back to the main point here, that 1 hour of patient time equals 2 hours of computer time ratio. At its core, it suggests that in order to get everything done, you should only be seeing patients for 3 hours a day because you’ll need at least another 6 hours to get all the computer stuff for them done. You think you can make a living, or even pay your overhead, billing for 3 hours of patient time a day? Me neither. I need to put in at least 8 hours of patient time, which means another 16 hours or so of computer time crammed in somewhere, overflowing into evenings and weekends. There are, quite literally, not enough hours in the day to practice good medicine and still get all the ancillary work done quickly and correctly.

With this kind of formula it’s only a matter of time before people get hurt. And the bean counters who run many medical practices these days will never see that aspect of medicine. The more patients, the more revenue, in their minds.

Rather than making life easier for us, EHRs have taken things the opposite way. In a profession where face-to-face time is the most critical part of what we do and the center of the doctor-patient relationship, it’s now second to face-to-screen time. That can’t be good for those who need our help.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

 

How many hours a day do you typically work?

I’m not just talking about seeing patients, although that’s included. I’m also thinking about all the time spent reviewing tests, filling out forms, returning calls, refilling meds, talking to your staff about what needs to be done for the patients who called with questions or problems, and (a big one) dictating and charting notes for the day.

I’m going to bet it’s a whole lot more than the time you spent seeing patients.

Sadly, the issue appears to be getting worse. A recent study in Annals of Internal Medicine found that for every hour you spend seeing patients, you’re spending another 2 hours working on the computer EHR doing ancillary stuff for the visits. I’m pretty sure insurance companies aren’t paying for that time.

That’s just in the office. The same study found most of us spend another 1-2 hours of our home time each night doing more office work to finish up what we didn’t get done during the day. So much for that work-life balance we hear so much about.

Ready for the breakdown? Here it is:

• Percentage of the total office day spent with patients = 27%

• Percentage of the total office day spent on charting and other EHR-related tasks = 49%

That’s just overall. Now let’s look at the time you’re actually with the patient in an exam room:

• Face-to-face with patient = 53%

• Time on the computer = 37%

So even in a room with a patient in front of you, over one-third of the time is still spent on the computer.

The degree of drudgery is surprising, too. How many mouse clicks are needed, in one system, to order and record a flu shot? Take a guess. 5? 10? 15? How about 32. Yeah, you read that right. No wonder your index finger hurts.

But let’s go back to the main point here, that 1 hour of patient time equals 2 hours of computer time ratio. At its core, it suggests that in order to get everything done, you should only be seeing patients for 3 hours a day because you’ll need at least another 6 hours to get all the computer stuff for them done. You think you can make a living, or even pay your overhead, billing for 3 hours of patient time a day? Me neither. I need to put in at least 8 hours of patient time, which means another 16 hours or so of computer time crammed in somewhere, overflowing into evenings and weekends. There are, quite literally, not enough hours in the day to practice good medicine and still get all the ancillary work done quickly and correctly.

With this kind of formula it’s only a matter of time before people get hurt. And the bean counters who run many medical practices these days will never see that aspect of medicine. The more patients, the more revenue, in their minds.

Rather than making life easier for us, EHRs have taken things the opposite way. In a profession where face-to-face time is the most critical part of what we do and the center of the doctor-patient relationship, it’s now second to face-to-screen time. That can’t be good for those who need our help.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

 

How many hours a day do you typically work?

I’m not just talking about seeing patients, although that’s included. I’m also thinking about all the time spent reviewing tests, filling out forms, returning calls, refilling meds, talking to your staff about what needs to be done for the patients who called with questions or problems, and (a big one) dictating and charting notes for the day.

I’m going to bet it’s a whole lot more than the time you spent seeing patients.

Sadly, the issue appears to be getting worse. A recent study in Annals of Internal Medicine found that for every hour you spend seeing patients, you’re spending another 2 hours working on the computer EHR doing ancillary stuff for the visits. I’m pretty sure insurance companies aren’t paying for that time.

That’s just in the office. The same study found most of us spend another 1-2 hours of our home time each night doing more office work to finish up what we didn’t get done during the day. So much for that work-life balance we hear so much about.

Ready for the breakdown? Here it is:

• Percentage of the total office day spent with patients = 27%

• Percentage of the total office day spent on charting and other EHR-related tasks = 49%

That’s just overall. Now let’s look at the time you’re actually with the patient in an exam room:

• Face-to-face with patient = 53%

• Time on the computer = 37%

So even in a room with a patient in front of you, over one-third of the time is still spent on the computer.

The degree of drudgery is surprising, too. How many mouse clicks are needed, in one system, to order and record a flu shot? Take a guess. 5? 10? 15? How about 32. Yeah, you read that right. No wonder your index finger hurts.

But let’s go back to the main point here, that 1 hour of patient time equals 2 hours of computer time ratio. At its core, it suggests that in order to get everything done, you should only be seeing patients for 3 hours a day because you’ll need at least another 6 hours to get all the computer stuff for them done. You think you can make a living, or even pay your overhead, billing for 3 hours of patient time a day? Me neither. I need to put in at least 8 hours of patient time, which means another 16 hours or so of computer time crammed in somewhere, overflowing into evenings and weekends. There are, quite literally, not enough hours in the day to practice good medicine and still get all the ancillary work done quickly and correctly.

With this kind of formula it’s only a matter of time before people get hurt. And the bean counters who run many medical practices these days will never see that aspect of medicine. The more patients, the more revenue, in their minds.

Rather than making life easier for us, EHRs have taken things the opposite way. In a profession where face-to-face time is the most critical part of what we do and the center of the doctor-patient relationship, it’s now second to face-to-screen time. That can’t be good for those who need our help.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I sometimes think about giving up my DEA certificate. I can’t be the only one.

It’s not strictly about the money. $731 every 3 years is small change, compared with my rent, staff salaries, and malpractice insurance, although the savings would be nice.

Part of it is the desire to unfetter myself from prescribing controlled substances. I wouldn’t have to worry about drug seekers hitting me up, or dealing with the paperwork and pharmacy calls, or doing background checks on the state monitoring site.

But, realistically, I can’t do that. Even though I try to limit my narcotic scripts, the DEA number covers many other things, such as Lyrica, Vimpat, and Klonopin for epilepsy patients; Provigil for MS fatigue; and Valium to help someone get through an MRI scan.

There are, of course, the occasional narcotics. I don’t have many patients on chronic narcotics any more, but I’m sure all of us have a few migraine patients who keep an emergency supply of some narcotic (say, 5-10 pills) on hand to be used in lieu of an ER trip. They may only get it filled once a year, which doesn’t seem unreasonable.

I think it would be unfair to make patients, many of whom I’ve seen for many years, have to find a new neurologist over such things.

But what if there were a graduated DEA license? Say, one that limited me to schedules III-V or even just level IV and V substances? That would probably make life easier. The latter would still allow tramadol and Stadol-NS for breakthrough migraines, while adding level III would still allow Tylenol with codeine No. 3. Either way, it would take oxycodone, hydrocodone, morphine, amphetamines, and other drugs of greater abuse potential out of my hands. A few less things to worry about.

There are pros and cons of this. From one view, it would limit the number of docs prescribing higher level substances, making them easier to track and control. On the other hand, patients who need them, many of whom are legitimately in pain, would be forced to change to a dwindling number of narcotic prescribers. Many of these doctors would likely start to work on a cash-only basis knowing the demand they’d be in. Who knows where that would lead? Like so many things in medicine, there are always going to be unintended consequences.

For the time being I have no plans to drop my DEA license, but it would be nice to have options besides all or nothing.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I sometimes think about giving up my DEA certificate. I can’t be the only one.

It’s not strictly about the money. $731 every 3 years is small change, compared with my rent, staff salaries, and malpractice insurance, although the savings would be nice.

Part of it is the desire to unfetter myself from prescribing controlled substances. I wouldn’t have to worry about drug seekers hitting me up, or dealing with the paperwork and pharmacy calls, or doing background checks on the state monitoring site.

But, realistically, I can’t do that. Even though I try to limit my narcotic scripts, the DEA number covers many other things, such as Lyrica, Vimpat, and Klonopin for epilepsy patients; Provigil for MS fatigue; and Valium to help someone get through an MRI scan.

There are, of course, the occasional narcotics. I don’t have many patients on chronic narcotics any more, but I’m sure all of us have a few migraine patients who keep an emergency supply of some narcotic (say, 5-10 pills) on hand to be used in lieu of an ER trip. They may only get it filled once a year, which doesn’t seem unreasonable.

I think it would be unfair to make patients, many of whom I’ve seen for many years, have to find a new neurologist over such things.

But what if there were a graduated DEA license? Say, one that limited me to schedules III-V or even just level IV and V substances? That would probably make life easier. The latter would still allow tramadol and Stadol-NS for breakthrough migraines, while adding level III would still allow Tylenol with codeine No. 3. Either way, it would take oxycodone, hydrocodone, morphine, amphetamines, and other drugs of greater abuse potential out of my hands. A few less things to worry about.

There are pros and cons of this. From one view, it would limit the number of docs prescribing higher level substances, making them easier to track and control. On the other hand, patients who need them, many of whom are legitimately in pain, would be forced to change to a dwindling number of narcotic prescribers. Many of these doctors would likely start to work on a cash-only basis knowing the demand they’d be in. Who knows where that would lead? Like so many things in medicine, there are always going to be unintended consequences.

For the time being I have no plans to drop my DEA license, but it would be nice to have options besides all or nothing.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I sometimes think about giving up my DEA certificate. I can’t be the only one.

It’s not strictly about the money. $731 every 3 years is small change, compared with my rent, staff salaries, and malpractice insurance, although the savings would be nice.

Part of it is the desire to unfetter myself from prescribing controlled substances. I wouldn’t have to worry about drug seekers hitting me up, or dealing with the paperwork and pharmacy calls, or doing background checks on the state monitoring site.

But, realistically, I can’t do that. Even though I try to limit my narcotic scripts, the DEA number covers many other things, such as Lyrica, Vimpat, and Klonopin for epilepsy patients; Provigil for MS fatigue; and Valium to help someone get through an MRI scan.

There are, of course, the occasional narcotics. I don’t have many patients on chronic narcotics any more, but I’m sure all of us have a few migraine patients who keep an emergency supply of some narcotic (say, 5-10 pills) on hand to be used in lieu of an ER trip. They may only get it filled once a year, which doesn’t seem unreasonable.

I think it would be unfair to make patients, many of whom I’ve seen for many years, have to find a new neurologist over such things.

But what if there were a graduated DEA license? Say, one that limited me to schedules III-V or even just level IV and V substances? That would probably make life easier. The latter would still allow tramadol and Stadol-NS for breakthrough migraines, while adding level III would still allow Tylenol with codeine No. 3. Either way, it would take oxycodone, hydrocodone, morphine, amphetamines, and other drugs of greater abuse potential out of my hands. A few less things to worry about.

There are pros and cons of this. From one view, it would limit the number of docs prescribing higher level substances, making them easier to track and control. On the other hand, patients who need them, many of whom are legitimately in pain, would be forced to change to a dwindling number of narcotic prescribers. Many of these doctors would likely start to work on a cash-only basis knowing the demand they’d be in. Who knows where that would lead? Like so many things in medicine, there are always going to be unintended consequences.

For the time being I have no plans to drop my DEA license, but it would be nice to have options besides all or nothing.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Many patients we see need blood work as part of their evaluation. Although labs are cheap compared with other tests we order, they can still be frustrating to get.

It’s not hard to order them. Ordering any test is pretty easy.

But I hate duplicating tests. Patients often say they just had labs done, which “were all fine,” but that tells me nothing. For all I know, it was a lipid panel and PSA, entirely unrelated to what I’m seeing them for.

Occasionally, they bring labs in with them, or I’ve gotten them in advance, but usually I’m working blind.

Back when I was new to practice, I just ordered everything I wanted. I figured it was easier than trying to get the previous ones. I think we all do that sometimes. And there’s kind of an ivory-tower mentality we all have early in our careers that “I’m the doctor, and I’ll do what I want.”

I quickly learned that often backfires. If the same labs were done recently, many insurance companies won’t pay for them ... and the patients get a bill. Then they call my office and complain. It didn’t take me long to realize this approach was a waste of their time, money, and blood.

So now I always ask if they’ve had labs done since the symptoms started. If the answer is yes, I’ll call or fax the other doctor to get them. This can take (depending on the other office) a few hours to days. But the majority of outpatient neurology is nonurgent, and a extra few days usually doesn’t matter in the things I treat.

When I get the labs, it’s easy to make some quick notes on what was done and what still needs to be checked. I scribble out a lab order, mail or fax it, and have my staff notify the patient the ball is rolling. It’s not hard.

Patients appreciate it. I’m saving them time, blood, money, and maybe even a venipuncture. I get the tests I want, still in a timely fashion. It also keeps insurance costs down for all of us.

Obviously, there are some cases where urgency has to take priority. But for the majority of them, duplicating tests needlessly is a bad idea for all involved.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Many patients we see need blood work as part of their evaluation. Although labs are cheap compared with other tests we order, they can still be frustrating to get.

It’s not hard to order them. Ordering any test is pretty easy.

But I hate duplicating tests. Patients often say they just had labs done, which “were all fine,” but that tells me nothing. For all I know, it was a lipid panel and PSA, entirely unrelated to what I’m seeing them for.

Occasionally, they bring labs in with them, or I’ve gotten them in advance, but usually I’m working blind.

Back when I was new to practice, I just ordered everything I wanted. I figured it was easier than trying to get the previous ones. I think we all do that sometimes. And there’s kind of an ivory-tower mentality we all have early in our careers that “I’m the doctor, and I’ll do what I want.”

I quickly learned that often backfires. If the same labs were done recently, many insurance companies won’t pay for them ... and the patients get a bill. Then they call my office and complain. It didn’t take me long to realize this approach was a waste of their time, money, and blood.

So now I always ask if they’ve had labs done since the symptoms started. If the answer is yes, I’ll call or fax the other doctor to get them. This can take (depending on the other office) a few hours to days. But the majority of outpatient neurology is nonurgent, and a extra few days usually doesn’t matter in the things I treat.

When I get the labs, it’s easy to make some quick notes on what was done and what still needs to be checked. I scribble out a lab order, mail or fax it, and have my staff notify the patient the ball is rolling. It’s not hard.

Patients appreciate it. I’m saving them time, blood, money, and maybe even a venipuncture. I get the tests I want, still in a timely fashion. It also keeps insurance costs down for all of us.

Obviously, there are some cases where urgency has to take priority. But for the majority of them, duplicating tests needlessly is a bad idea for all involved.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Many patients we see need blood work as part of their evaluation. Although labs are cheap compared with other tests we order, they can still be frustrating to get.

It’s not hard to order them. Ordering any test is pretty easy.

But I hate duplicating tests. Patients often say they just had labs done, which “were all fine,” but that tells me nothing. For all I know, it was a lipid panel and PSA, entirely unrelated to what I’m seeing them for.

Occasionally, they bring labs in with them, or I’ve gotten them in advance, but usually I’m working blind.

Back when I was new to practice, I just ordered everything I wanted. I figured it was easier than trying to get the previous ones. I think we all do that sometimes. And there’s kind of an ivory-tower mentality we all have early in our careers that “I’m the doctor, and I’ll do what I want.”

I quickly learned that often backfires. If the same labs were done recently, many insurance companies won’t pay for them ... and the patients get a bill. Then they call my office and complain. It didn’t take me long to realize this approach was a waste of their time, money, and blood.

So now I always ask if they’ve had labs done since the symptoms started. If the answer is yes, I’ll call or fax the other doctor to get them. This can take (depending on the other office) a few hours to days. But the majority of outpatient neurology is nonurgent, and a extra few days usually doesn’t matter in the things I treat.

When I get the labs, it’s easy to make some quick notes on what was done and what still needs to be checked. I scribble out a lab order, mail or fax it, and have my staff notify the patient the ball is rolling. It’s not hard.

Patients appreciate it. I’m saving them time, blood, money, and maybe even a venipuncture. I get the tests I want, still in a timely fashion. It also keeps insurance costs down for all of us.

Obviously, there are some cases where urgency has to take priority. But for the majority of them, duplicating tests needlessly is a bad idea for all involved.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I refuse to do retreads.

This has nothing to do with my car. If a retread tire gives me the same performance and safety at a lower price, I’m all for it.

Sometimes patients fire me. This is often acrimonious, with them sending me a letter complaining about my competence, bedside manner, personal appearance, staff, office decor, phone system ... whatever. For some reason they weren’t happy with me and instead of just sending a release of records, they decided to let me know in no uncertain terms that they aren’t coming back. We all get these notes.

When I was younger this would really upset me. I took a lot of things personally when I first started out. Now, after almost 20 years on the neurology front lines, it’s just another day. I learned a long time ago that you can’t please everyone or be the doctor they all love. So I fax their chart to wherever they want and move on.

Surprisingly, a few times a year patients will try to come back. Maybe they didn’t like the new doc, or are sorry about their outburst, or can’t find someone else nearby who takes their insurance. So they call and try to make a follow-up. Not surprisingly, they never mention their previous letter. When it’s brought up, they typically claim we misinterpreted it, that they didn’t mean it, or that they’ve decided to forgive me.

This is what I call a retread. A patient who wants to come back after leaving under unpleasant circumstances. I don’t allow it.

To me the doctor-patient relationship is based on trust and objectivity. Once a patient sends an acrimonious letter, it’s very difficult to return to an impartial condition. The fact that they did it once means they may do it again, or think they can get their way with threatening or insulting behavior. These are not things that are good for the connection between us.

So I turn them away. Some just hang up. Others yell, and a few threaten me with legal action. But I don’t back down. Do you want to care for someone who’s done the same to you?

This is a high-stress field. I don’t need the additional distraction of dealing with a toxic medical relationship. If you don’t like me, I have no issue with that. Not everyone does. But once you’ve made that decision, you’re stuck with it.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I refuse to do retreads.

This has nothing to do with my car. If a retread tire gives me the same performance and safety at a lower price, I’m all for it.

Sometimes patients fire me. This is often acrimonious, with them sending me a letter complaining about my competence, bedside manner, personal appearance, staff, office decor, phone system ... whatever. For some reason they weren’t happy with me and instead of just sending a release of records, they decided to let me know in no uncertain terms that they aren’t coming back. We all get these notes.

When I was younger this would really upset me. I took a lot of things personally when I first started out. Now, after almost 20 years on the neurology front lines, it’s just another day. I learned a long time ago that you can’t please everyone or be the doctor they all love. So I fax their chart to wherever they want and move on.

Surprisingly, a few times a year patients will try to come back. Maybe they didn’t like the new doc, or are sorry about their outburst, or can’t find someone else nearby who takes their insurance. So they call and try to make a follow-up. Not surprisingly, they never mention their previous letter. When it’s brought up, they typically claim we misinterpreted it, that they didn’t mean it, or that they’ve decided to forgive me.

This is what I call a retread. A patient who wants to come back after leaving under unpleasant circumstances. I don’t allow it.

To me the doctor-patient relationship is based on trust and objectivity. Once a patient sends an acrimonious letter, it’s very difficult to return to an impartial condition. The fact that they did it once means they may do it again, or think they can get their way with threatening or insulting behavior. These are not things that are good for the connection between us.

So I turn them away. Some just hang up. Others yell, and a few threaten me with legal action. But I don’t back down. Do you want to care for someone who’s done the same to you?

This is a high-stress field. I don’t need the additional distraction of dealing with a toxic medical relationship. If you don’t like me, I have no issue with that. Not everyone does. But once you’ve made that decision, you’re stuck with it.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I refuse to do retreads.

This has nothing to do with my car. If a retread tire gives me the same performance and safety at a lower price, I’m all for it.

Sometimes patients fire me. This is often acrimonious, with them sending me a letter complaining about my competence, bedside manner, personal appearance, staff, office decor, phone system ... whatever. For some reason they weren’t happy with me and instead of just sending a release of records, they decided to let me know in no uncertain terms that they aren’t coming back. We all get these notes.

When I was younger this would really upset me. I took a lot of things personally when I first started out. Now, after almost 20 years on the neurology front lines, it’s just another day. I learned a long time ago that you can’t please everyone or be the doctor they all love. So I fax their chart to wherever they want and move on.

Surprisingly, a few times a year patients will try to come back. Maybe they didn’t like the new doc, or are sorry about their outburst, or can’t find someone else nearby who takes their insurance. So they call and try to make a follow-up. Not surprisingly, they never mention their previous letter. When it’s brought up, they typically claim we misinterpreted it, that they didn’t mean it, or that they’ve decided to forgive me.

This is what I call a retread. A patient who wants to come back after leaving under unpleasant circumstances. I don’t allow it.

To me the doctor-patient relationship is based on trust and objectivity. Once a patient sends an acrimonious letter, it’s very difficult to return to an impartial condition. The fact that they did it once means they may do it again, or think they can get their way with threatening or insulting behavior. These are not things that are good for the connection between us.

So I turn them away. Some just hang up. Others yell, and a few threaten me with legal action. But I don’t back down. Do you want to care for someone who’s done the same to you?

This is a high-stress field. I don’t need the additional distraction of dealing with a toxic medical relationship. If you don’t like me, I have no issue with that. Not everyone does. But once you’ve made that decision, you’re stuck with it.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Every 3 months I get a letter from the state, showing me how my controlled prescriptions stack up against those of other neurologists here.

I’ve always been in the “normal” range. Which is good, I guess. In this era, no one wants to be seen as running a pill mill.

But when I compare them over the last year, I notice that my narcotic prescriptions have been gradually declining. Am I reducing my scripts subconsciously, knowing that I’m being watched by regulatory agencies?

It’s quite possible. While I haven’t intentionally been cutting back on narcotics, I have been paying closer attention to who I’m writing them for. This has likely led me to use them more sparingly.

The trouble is that pain is a legitimate problem for many, and NSAIDs have numerous safety issues that limit their use. Acetaminophen has hepatic issues. My previous noncontrolled drug of choice, Tramadol, was reclassified as controlled in 2014.

Narcotic abuse and diversion are serious problems that need attention. But there are also people with legitimate noncancer pain who require them to function with a reasonable quality of life. We all have them in our practice. Sorting them out from abusers is never easy.

Unfortunately, the increased vigilance also affects those who need our help. A recent National Public Radio article noted the difficulty of finding a doctor in Montana who is willing to take on pain patients, with the result that some have to travel out of state to get help.

I’m sure they’re not the only ones, especially in states that have a low population density. And not all patients are going to have the financial resources to travel. Or afford the rates of the dwindling number of physicians willing to frequently prescribe narcotics. These people sadly become collateral damage in the drug wars.

Does this mean I’m going to increase my use of narcotics to help all who come to me? No.

Because, in a world where my licensure (and therefore livelihood) is potentially affected by my prescribing habits, I have to put my family first. This doesn’t mean I’m abandoning any of my current or even future patients, but it does mean I’ll be more vigilant on every controlled script I write.

I don’t know anyone who’d do otherwise in today’s climate.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Every 3 months I get a letter from the state, showing me how my controlled prescriptions stack up against those of other neurologists here.

I’ve always been in the “normal” range. Which is good, I guess. In this era, no one wants to be seen as running a pill mill.

But when I compare them over the last year, I notice that my narcotic prescriptions have been gradually declining. Am I reducing my scripts subconsciously, knowing that I’m being watched by regulatory agencies?

It’s quite possible. While I haven’t intentionally been cutting back on narcotics, I have been paying closer attention to who I’m writing them for. This has likely led me to use them more sparingly.

The trouble is that pain is a legitimate problem for many, and NSAIDs have numerous safety issues that limit their use. Acetaminophen has hepatic issues. My previous noncontrolled drug of choice, Tramadol, was reclassified as controlled in 2014.

Narcotic abuse and diversion are serious problems that need attention. But there are also people with legitimate noncancer pain who require them to function with a reasonable quality of life. We all have them in our practice. Sorting them out from abusers is never easy.

Unfortunately, the increased vigilance also affects those who need our help. A recent National Public Radio article noted the difficulty of finding a doctor in Montana who is willing to take on pain patients, with the result that some have to travel out of state to get help.

I’m sure they’re not the only ones, especially in states that have a low population density. And not all patients are going to have the financial resources to travel. Or afford the rates of the dwindling number of physicians willing to frequently prescribe narcotics. These people sadly become collateral damage in the drug wars.

Does this mean I’m going to increase my use of narcotics to help all who come to me? No.

Because, in a world where my licensure (and therefore livelihood) is potentially affected by my prescribing habits, I have to put my family first. This doesn’t mean I’m abandoning any of my current or even future patients, but it does mean I’ll be more vigilant on every controlled script I write.

I don’t know anyone who’d do otherwise in today’s climate.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Every 3 months I get a letter from the state, showing me how my controlled prescriptions stack up against those of other neurologists here.

I’ve always been in the “normal” range. Which is good, I guess. In this era, no one wants to be seen as running a pill mill.

But when I compare them over the last year, I notice that my narcotic prescriptions have been gradually declining. Am I reducing my scripts subconsciously, knowing that I’m being watched by regulatory agencies?

It’s quite possible. While I haven’t intentionally been cutting back on narcotics, I have been paying closer attention to who I’m writing them for. This has likely led me to use them more sparingly.

The trouble is that pain is a legitimate problem for many, and NSAIDs have numerous safety issues that limit their use. Acetaminophen has hepatic issues. My previous noncontrolled drug of choice, Tramadol, was reclassified as controlled in 2014.

Narcotic abuse and diversion are serious problems that need attention. But there are also people with legitimate noncancer pain who require them to function with a reasonable quality of life. We all have them in our practice. Sorting them out from abusers is never easy.

Unfortunately, the increased vigilance also affects those who need our help. A recent National Public Radio article noted the difficulty of finding a doctor in Montana who is willing to take on pain patients, with the result that some have to travel out of state to get help.

I’m sure they’re not the only ones, especially in states that have a low population density. And not all patients are going to have the financial resources to travel. Or afford the rates of the dwindling number of physicians willing to frequently prescribe narcotics. These people sadly become collateral damage in the drug wars.

Does this mean I’m going to increase my use of narcotics to help all who come to me? No.

Because, in a world where my licensure (and therefore livelihood) is potentially affected by my prescribing habits, I have to put my family first. This doesn’t mean I’m abandoning any of my current or even future patients, but it does mean I’ll be more vigilant on every controlled script I write.

I don’t know anyone who’d do otherwise in today’s climate.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Buy our EHR. Come to a dinner and see our EHR. Our EHR is the best.

I hear that a lot, but am not rushing out to get one. Yes, I have an EHR, but it’s one I designed myself. It works very well for my dinky little practice, and I’m happy with it.

I get notes from practices that use commercial EHRs all the time. They’re usually a pile of gobbledygook, mixing labs, vital signs, medication lists, and ICD-10 codes that tell you absolutely nothing about the patient or the physician’s thought process.

Recently, while reviewing malpractice cases, I saw some where I thought that the EHR was contributing to the problem. Medication lists that showed everything a patient had ever taken, without showing when some were discontinued. Prescribing lists that allowed you to enter only certain doses or schedules, therefore blocking the physician from tailoring them to a specific person’s needs. Physical exam forms that allowed only positive or negative answers, with nowhere to comment on unusual findings.

Of course, I’m just one person, so I thought “maybe it’s just me.” After all, a lot of practices out there use EHRs.

But apparently I’m not the only one. A recent report by one of the nation’s largest doctor-owned malpractice companies found that EHRs may increase the risks of liability and medical errors. In 2013, The Doctor’s Company found 28 closed claims where the EHR contributed, and 26 in just the first half of 2014.

These include both technological problems with the systems and human error in their use. Troubles included erroneous medication dose and schedules, diagnosis-related errors, and the sadly common pitfall of cutting and pasting previous notes without modification.

Medicine has always been, and will always be, a thinking profession, and trying to have computers take part of this job off of us is never good. EHRs, while they have advantages in convenience and space savings, are as imperfect as those who write them.

Patients are not one-size-fits-all, and individual treatments have to be customized in ways that current systems often don’t recognize, sometimes with sad consequences for all involved.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Buy our EHR. Come to a dinner and see our EHR. Our EHR is the best.

I hear that a lot, but am not rushing out to get one. Yes, I have an EHR, but it’s one I designed myself. It works very well for my dinky little practice, and I’m happy with it.

I get notes from practices that use commercial EHRs all the time. They’re usually a pile of gobbledygook, mixing labs, vital signs, medication lists, and ICD-10 codes that tell you absolutely nothing about the patient or the physician’s thought process.

Recently, while reviewing malpractice cases, I saw some where I thought that the EHR was contributing to the problem. Medication lists that showed everything a patient had ever taken, without showing when some were discontinued. Prescribing lists that allowed you to enter only certain doses or schedules, therefore blocking the physician from tailoring them to a specific person’s needs. Physical exam forms that allowed only positive or negative answers, with nowhere to comment on unusual findings.

Of course, I’m just one person, so I thought “maybe it’s just me.” After all, a lot of practices out there use EHRs.

But apparently I’m not the only one. A recent report by one of the nation’s largest doctor-owned malpractice companies found that EHRs may increase the risks of liability and medical errors. In 2013, The Doctor’s Company found 28 closed claims where the EHR contributed, and 26 in just the first half of 2014.

These include both technological problems with the systems and human error in their use. Troubles included erroneous medication dose and schedules, diagnosis-related errors, and the sadly common pitfall of cutting and pasting previous notes without modification.

Medicine has always been, and will always be, a thinking profession, and trying to have computers take part of this job off of us is never good. EHRs, while they have advantages in convenience and space savings, are as imperfect as those who write them.

Patients are not one-size-fits-all, and individual treatments have to be customized in ways that current systems often don’t recognize, sometimes with sad consequences for all involved.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Buy our EHR. Come to a dinner and see our EHR. Our EHR is the best.

I hear that a lot, but am not rushing out to get one. Yes, I have an EHR, but it’s one I designed myself. It works very well for my dinky little practice, and I’m happy with it.

I get notes from practices that use commercial EHRs all the time. They’re usually a pile of gobbledygook, mixing labs, vital signs, medication lists, and ICD-10 codes that tell you absolutely nothing about the patient or the physician’s thought process.

Recently, while reviewing malpractice cases, I saw some where I thought that the EHR was contributing to the problem. Medication lists that showed everything a patient had ever taken, without showing when some were discontinued. Prescribing lists that allowed you to enter only certain doses or schedules, therefore blocking the physician from tailoring them to a specific person’s needs. Physical exam forms that allowed only positive or negative answers, with nowhere to comment on unusual findings.

Of course, I’m just one person, so I thought “maybe it’s just me.” After all, a lot of practices out there use EHRs.

But apparently I’m not the only one. A recent report by one of the nation’s largest doctor-owned malpractice companies found that EHRs may increase the risks of liability and medical errors. In 2013, The Doctor’s Company found 28 closed claims where the EHR contributed, and 26 in just the first half of 2014.

These include both technological problems with the systems and human error in their use. Troubles included erroneous medication dose and schedules, diagnosis-related errors, and the sadly common pitfall of cutting and pasting previous notes without modification.

Medicine has always been, and will always be, a thinking profession, and trying to have computers take part of this job off of us is never good. EHRs, while they have advantages in convenience and space savings, are as imperfect as those who write them.

Patients are not one-size-fits-all, and individual treatments have to be customized in ways that current systems often don’t recognize, sometimes with sad consequences for all involved.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I. Hate. ATVs.

The modern world is full of potentially dangerous things that we regulate – sometimes by the knowledge of the person giving it (medication) or by age (tobacco, alcohol, cars). Or sometimes we simply ban something altogether (illicit drugs).

After years of neurology practice, I’ve learned to hate ATVs. Outside of firearms, I don’t think I’ve seen any gadget that has such a devastating effect on young lives.

My first medical encounter with one was 20-some years ago during my neurosurgery rotation. It was a man in his mid-20s. He was young, muscular, and clearly in excellent condition. And here he was, flaccid below the neck, and permanently on a ventilator.

I sat at the nurses station for a long time, looking at him and thinking about how a young life can go so horribly wrong so quickly. He hadn’t been drunk at the time. He’d simply had a wreck, the cause of which I never found out. After a few days, he was shipped off to a long-term ventilator facility, and I never saw him again.

Cars are dangerous, too, but are bigger and have gadgets to try to improve safety. ATVs are exposed, with only minimal, if any, protection for their riders. Their use is most typically by the young, meaning a disproportionate number of serious injuries will affect those at the beginning of adulthood.

Sadly, banning ATVs won’t stop injuries. There will always be people who do risky things in the name of being daring and having fun.

What’s changed is that 100 years ago they’d likely have died of their injuries soon afterward. Today they’ll probably survive, debilitated long term because of medical advancements.

These are the situations where I feel helpless. There are all kinds of horrible diseases we handle that have no known cause or cure. That’s one kind of helpless. But the ones with easily avoidable risk factors (ATVs, illegal drugs, tobacco) that occur are just plain frustrating for us and tragic for the patients and families.

In the land of the free, freedom to endanger your own life and health are pretty deeply entrenched. The best we can do is present people with the facts and let them make informed decisions about risky behaviors (sadly, the young often believe they’re immortal). If we ban ATVs, we still won’t stop people from making bad decisions on motorcycles or in cars, or with firearms or illegal drugs.

Like so much in medicine, there are no easy answers, and there likely never will be.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I. Hate. ATVs.

The modern world is full of potentially dangerous things that we regulate – sometimes by the knowledge of the person giving it (medication) or by age (tobacco, alcohol, cars). Or sometimes we simply ban something altogether (illicit drugs).

After years of neurology practice, I’ve learned to hate ATVs. Outside of firearms, I don’t think I’ve seen any gadget that has such a devastating effect on young lives.

My first medical encounter with one was 20-some years ago during my neurosurgery rotation. It was a man in his mid-20s. He was young, muscular, and clearly in excellent condition. And here he was, flaccid below the neck, and permanently on a ventilator.

I sat at the nurses station for a long time, looking at him and thinking about how a young life can go so horribly wrong so quickly. He hadn’t been drunk at the time. He’d simply had a wreck, the cause of which I never found out. After a few days, he was shipped off to a long-term ventilator facility, and I never saw him again.

Cars are dangerous, too, but are bigger and have gadgets to try to improve safety. ATVs are exposed, with only minimal, if any, protection for their riders. Their use is most typically by the young, meaning a disproportionate number of serious injuries will affect those at the beginning of adulthood.

Sadly, banning ATVs won’t stop injuries. There will always be people who do risky things in the name of being daring and having fun.

What’s changed is that 100 years ago they’d likely have died of their injuries soon afterward. Today they’ll probably survive, debilitated long term because of medical advancements.

These are the situations where I feel helpless. There are all kinds of horrible diseases we handle that have no known cause or cure. That’s one kind of helpless. But the ones with easily avoidable risk factors (ATVs, illegal drugs, tobacco) that occur are just plain frustrating for us and tragic for the patients and families.

In the land of the free, freedom to endanger your own life and health are pretty deeply entrenched. The best we can do is present people with the facts and let them make informed decisions about risky behaviors (sadly, the young often believe they’re immortal). If we ban ATVs, we still won’t stop people from making bad decisions on motorcycles or in cars, or with firearms or illegal drugs.

Like so much in medicine, there are no easy answers, and there likely never will be.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I. Hate. ATVs.

The modern world is full of potentially dangerous things that we regulate – sometimes by the knowledge of the person giving it (medication) or by age (tobacco, alcohol, cars). Or sometimes we simply ban something altogether (illicit drugs).

After years of neurology practice, I’ve learned to hate ATVs. Outside of firearms, I don’t think I’ve seen any gadget that has such a devastating effect on young lives.

My first medical encounter with one was 20-some years ago during my neurosurgery rotation. It was a man in his mid-20s. He was young, muscular, and clearly in excellent condition. And here he was, flaccid below the neck, and permanently on a ventilator.

I sat at the nurses station for a long time, looking at him and thinking about how a young life can go so horribly wrong so quickly. He hadn’t been drunk at the time. He’d simply had a wreck, the cause of which I never found out. After a few days, he was shipped off to a long-term ventilator facility, and I never saw him again.

Cars are dangerous, too, but are bigger and have gadgets to try to improve safety. ATVs are exposed, with only minimal, if any, protection for their riders. Their use is most typically by the young, meaning a disproportionate number of serious injuries will affect those at the beginning of adulthood.

Sadly, banning ATVs won’t stop injuries. There will always be people who do risky things in the name of being daring and having fun.

What’s changed is that 100 years ago they’d likely have died of their injuries soon afterward. Today they’ll probably survive, debilitated long term because of medical advancements.

These are the situations where I feel helpless. There are all kinds of horrible diseases we handle that have no known cause or cure. That’s one kind of helpless. But the ones with easily avoidable risk factors (ATVs, illegal drugs, tobacco) that occur are just plain frustrating for us and tragic for the patients and families.

In the land of the free, freedom to endanger your own life and health are pretty deeply entrenched. The best we can do is present people with the facts and let them make informed decisions about risky behaviors (sadly, the young often believe they’re immortal). If we ban ATVs, we still won’t stop people from making bad decisions on motorcycles or in cars, or with firearms or illegal drugs.

Like so much in medicine, there are no easy answers, and there likely never will be.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I get the occasional heartfelt thank you note from a patient. I also get hate mail, but fortunately the thank yous predominate.

I still have all of them, going back to residency, in an old Nike box. They sit in a closet at home, taken out here and there – on bad days.

You know what I mean. The days where you screwed up, or had an angry patient get on your nerves and/or in your face. Where the schedule was accidentally double booked and you were running behind from the start. When you question your abilities and wonder why you still do this to yourself.

At the end of those days, I go home, dig out the box, and quietly read a few of the notes. Their neatly folded pages of gratitude remind me why I’m here, why I chose this path, why I need to be clear and ready for the patients depending on me the next day. They help me realize that there’s more good than bad in this job; that an unhappy, albeit vocal, few don’t represent most patients; and that I really do know what I’m doing, regardless of what Mr. I’m-going-to-complain-about-you-on-Yelp says.

Of course, there are other reminders of what you have to be thankful for, like families and dogs. But sometimes you need a reminder directly from the people you make a difference for every day, to let you know that this isn’t just a job. It’s why you once volunteered at a hospital, fought through organic chemistry, wrote out 20 (or more) drafts of a personal statement and studied for the MCAT. Because, once upon a time, this job was just a dream.

I don’t spend a lot of time with the notes – maybe 10 minutes reading a randomly pulled handful – but it’s enough to get me out of a funk. Then the old shoe box is carefully returned to my closet. Until I need it again.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I get the occasional heartfelt thank you note from a patient. I also get hate mail, but fortunately the thank yous predominate.

I still have all of them, going back to residency, in an old Nike box. They sit in a closet at home, taken out here and there – on bad days.

You know what I mean. The days where you screwed up, or had an angry patient get on your nerves and/or in your face. Where the schedule was accidentally double booked and you were running behind from the start. When you question your abilities and wonder why you still do this to yourself.

At the end of those days, I go home, dig out the box, and quietly read a few of the notes. Their neatly folded pages of gratitude remind me why I’m here, why I chose this path, why I need to be clear and ready for the patients depending on me the next day. They help me realize that there’s more good than bad in this job; that an unhappy, albeit vocal, few don’t represent most patients; and that I really do know what I’m doing, regardless of what Mr. I’m-going-to-complain-about-you-on-Yelp says.

Of course, there are other reminders of what you have to be thankful for, like families and dogs. But sometimes you need a reminder directly from the people you make a difference for every day, to let you know that this isn’t just a job. It’s why you once volunteered at a hospital, fought through organic chemistry, wrote out 20 (or more) drafts of a personal statement and studied for the MCAT. Because, once upon a time, this job was just a dream.

I don’t spend a lot of time with the notes – maybe 10 minutes reading a randomly pulled handful – but it’s enough to get me out of a funk. Then the old shoe box is carefully returned to my closet. Until I need it again.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I get the occasional heartfelt thank you note from a patient. I also get hate mail, but fortunately the thank yous predominate.

I still have all of them, going back to residency, in an old Nike box. They sit in a closet at home, taken out here and there – on bad days.

You know what I mean. The days where you screwed up, or had an angry patient get on your nerves and/or in your face. Where the schedule was accidentally double booked and you were running behind from the start. When you question your abilities and wonder why you still do this to yourself.

At the end of those days, I go home, dig out the box, and quietly read a few of the notes. Their neatly folded pages of gratitude remind me why I’m here, why I chose this path, why I need to be clear and ready for the patients depending on me the next day. They help me realize that there’s more good than bad in this job; that an unhappy, albeit vocal, few don’t represent most patients; and that I really do know what I’m doing, regardless of what Mr. I’m-going-to-complain-about-you-on-Yelp says.

Of course, there are other reminders of what you have to be thankful for, like families and dogs. But sometimes you need a reminder directly from the people you make a difference for every day, to let you know that this isn’t just a job. It’s why you once volunteered at a hospital, fought through organic chemistry, wrote out 20 (or more) drafts of a personal statement and studied for the MCAT. Because, once upon a time, this job was just a dream.

I don’t spend a lot of time with the notes – maybe 10 minutes reading a randomly pulled handful – but it’s enough to get me out of a funk. Then the old shoe box is carefully returned to my closet. Until I need it again.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Family meetings are never easy.

They’re difficult, and often held to discuss the case of a demented patient. In these situations, the family doesn’t want the patient to hear their concerns or is afraid they’ll be embarrassed or angry. Sometimes getting the patient to the appointment is simply too difficult.

Of course, most discussions of this type can be done by phone ... in theory. In practice, it doesn’t work that way.

It’s the subject matter that makes the impersonal nature of the phone difficult. Families have hard questions and want real answers at these times. A face-to-face meeting, with the human interaction, is often the best way to get things across clearly and still with compassion. It avoids the problem of the phone being passed around, having to repeat yourself to each person, and wondering who just asked what. Very few families, in my experience, want to do this on the phone.

These meetings are never quick, either. Depending on family and circumstances, they can take 30-60 minutes. Getting an insurance company to pay for that time is near impossible. Most plans only want to pay for visits where the patient is actually present, when in these cases the family is trying to avoid that. While there is a Medicare payment code for “advance care planning,” it doesn’t cover treatment discussions or other neurological issues they may bring up, and many patients are on non-Medicare plans.

I bill people for these times and have found that most families are willing to pay. I’m not fond of doing so, and certainly not trying to get rich off of them. But it’s still time that I’m in my office and have to pay my rent, staff, and utilities.

Part of this job – a big part – is helping patients and their loved ones understand and deal with difficult situations. Realistically, this is the best way to do it. Families understand that as well as I do.

Why won’t insurance companies cover them? I suppose their excuse is that they cover the patient, not the questions or emotional needs of their caregivers. Of course, those things are as important to the care of the patient as any treatment, but the bean counters don’t want to pay for them.

That is unfortunate, because someone has to. Good medical care depends on good communication with all involved.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Family meetings are never easy.

They’re difficult, and often held to discuss the case of a demented patient. In these situations, the family doesn’t want the patient to hear their concerns or is afraid they’ll be embarrassed or angry. Sometimes getting the patient to the appointment is simply too difficult.

Of course, most discussions of this type can be done by phone ... in theory. In practice, it doesn’t work that way.

It’s the subject matter that makes the impersonal nature of the phone difficult. Families have hard questions and want real answers at these times. A face-to-face meeting, with the human interaction, is often the best way to get things across clearly and still with compassion. It avoids the problem of the phone being passed around, having to repeat yourself to each person, and wondering who just asked what. Very few families, in my experience, want to do this on the phone.

These meetings are never quick, either. Depending on family and circumstances, they can take 30-60 minutes. Getting an insurance company to pay for that time is near impossible. Most plans only want to pay for visits where the patient is actually present, when in these cases the family is trying to avoid that. While there is a Medicare payment code for “advance care planning,” it doesn’t cover treatment discussions or other neurological issues they may bring up, and many patients are on non-Medicare plans.

I bill people for these times and have found that most families are willing to pay. I’m not fond of doing so, and certainly not trying to get rich off of them. But it’s still time that I’m in my office and have to pay my rent, staff, and utilities.

Part of this job – a big part – is helping patients and their loved ones understand and deal with difficult situations. Realistically, this is the best way to do it. Families understand that as well as I do.

Why won’t insurance companies cover them? I suppose their excuse is that they cover the patient, not the questions or emotional needs of their caregivers. Of course, those things are as important to the care of the patient as any treatment, but the bean counters don’t want to pay for them.

That is unfortunate, because someone has to. Good medical care depends on good communication with all involved.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Family meetings are never easy.

They’re difficult, and often held to discuss the case of a demented patient. In these situations, the family doesn’t want the patient to hear their concerns or is afraid they’ll be embarrassed or angry. Sometimes getting the patient to the appointment is simply too difficult.

Of course, most discussions of this type can be done by phone ... in theory. In practice, it doesn’t work that way.

It’s the subject matter that makes the impersonal nature of the phone difficult. Families have hard questions and want real answers at these times. A face-to-face meeting, with the human interaction, is often the best way to get things across clearly and still with compassion. It avoids the problem of the phone being passed around, having to repeat yourself to each person, and wondering who just asked what. Very few families, in my experience, want to do this on the phone.

These meetings are never quick, either. Depending on family and circumstances, they can take 30-60 minutes. Getting an insurance company to pay for that time is near impossible. Most plans only want to pay for visits where the patient is actually present, when in these cases the family is trying to avoid that. While there is a Medicare payment code for “advance care planning,” it doesn’t cover treatment discussions or other neurological issues they may bring up, and many patients are on non-Medicare plans.

I bill people for these times and have found that most families are willing to pay. I’m not fond of doing so, and certainly not trying to get rich off of them. But it’s still time that I’m in my office and have to pay my rent, staff, and utilities.

Part of this job – a big part – is helping patients and their loved ones understand and deal with difficult situations. Realistically, this is the best way to do it. Families understand that as well as I do.

Why won’t insurance companies cover them? I suppose their excuse is that they cover the patient, not the questions or emotional needs of their caregivers. Of course, those things are as important to the care of the patient as any treatment, but the bean counters don’t want to pay for them.

That is unfortunate, because someone has to. Good medical care depends on good communication with all involved.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.