Hitting a Nerve

I try hard not to duplicate tests. Unfortunately, in my experience, I’m in the minority.

When I started out, I ordered everything in the work-up for, say, neuropathy, at the first visit even if the patient said, "Dr. Smith just did some labs." I was impatient. I wanted to find out what was going on, so I just ordered a complete work-up. I didn’t want to wait a week or two to get the other doc’s results in, or go through the rigmarole of having the patient sign a release. In my younger days, I was in a hurry to figure the case out and didn’t care about money. So if a patient hadn’t brought his past stuff, I just did it all.

The longer you do this job, though, the more you realize how wasteful this is. Ordering labs costs the patient money, costs the insurance company money, and (by extension of increasing premiums) sooner or later costs me money. Plus, why put patients through painful procedures if you can avoid them? They appreciate that kind of thinking. I would, too.

So now, I wait. Most office cases aren’t urgent. I send a release when needed or call the referring physician for past test results. Usually, they show up in 1-2 weeks and I review them. Then, if things are missing, I write out a lab order to cover them and notify the patient.

I still run into younger docs who don’t do this, and just order everything right off the bat. Looking at it with the experience of 15 years in practice, that seems remarkably wasteful. Yes, occasionally you encounter results that should be repeated, but not often.

This is how it was taught in my residency, and still is today. Perhaps it’s an ivory tower view that the referring physician couldn’t possibly have ordered anything of value, or there’s an emphasis in training on quickly cracking the case, regardless of a lack of urgency.

It’s unfortunate that medical training, to a large extent, still doesn’t emphasize the financial realities of ordering duplicate tests. As we all try to provide better health care with fewer dollars, this kind of awareness becomes more important. I suppose it also could be seen as an argument for a centralized medical record system, so that we can all quickly see what’s been done, but I’ll leave that debate for another time.

The older I get, the easier it is to see these issues from the viewpoint of a patient. Who wants to waste money or blood on unnecessarily duplicated tests?

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

I try hard not to duplicate tests. Unfortunately, in my experience, I’m in the minority.

When I started out, I ordered everything in the work-up for, say, neuropathy, at the first visit even if the patient said, "Dr. Smith just did some labs." I was impatient. I wanted to find out what was going on, so I just ordered a complete work-up. I didn’t want to wait a week or two to get the other doc’s results in, or go through the rigmarole of having the patient sign a release. In my younger days, I was in a hurry to figure the case out and didn’t care about money. So if a patient hadn’t brought his past stuff, I just did it all.

The longer you do this job, though, the more you realize how wasteful this is. Ordering labs costs the patient money, costs the insurance company money, and (by extension of increasing premiums) sooner or later costs me money. Plus, why put patients through painful procedures if you can avoid them? They appreciate that kind of thinking. I would, too.

So now, I wait. Most office cases aren’t urgent. I send a release when needed or call the referring physician for past test results. Usually, they show up in 1-2 weeks and I review them. Then, if things are missing, I write out a lab order to cover them and notify the patient.

I still run into younger docs who don’t do this, and just order everything right off the bat. Looking at it with the experience of 15 years in practice, that seems remarkably wasteful. Yes, occasionally you encounter results that should be repeated, but not often.

This is how it was taught in my residency, and still is today. Perhaps it’s an ivory tower view that the referring physician couldn’t possibly have ordered anything of value, or there’s an emphasis in training on quickly cracking the case, regardless of a lack of urgency.

It’s unfortunate that medical training, to a large extent, still doesn’t emphasize the financial realities of ordering duplicate tests. As we all try to provide better health care with fewer dollars, this kind of awareness becomes more important. I suppose it also could be seen as an argument for a centralized medical record system, so that we can all quickly see what’s been done, but I’ll leave that debate for another time.

The older I get, the easier it is to see these issues from the viewpoint of a patient. Who wants to waste money or blood on unnecessarily duplicated tests?

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

I try hard not to duplicate tests. Unfortunately, in my experience, I’m in the minority.

When I started out, I ordered everything in the work-up for, say, neuropathy, at the first visit even if the patient said, "Dr. Smith just did some labs." I was impatient. I wanted to find out what was going on, so I just ordered a complete work-up. I didn’t want to wait a week or two to get the other doc’s results in, or go through the rigmarole of having the patient sign a release. In my younger days, I was in a hurry to figure the case out and didn’t care about money. So if a patient hadn’t brought his past stuff, I just did it all.

The longer you do this job, though, the more you realize how wasteful this is. Ordering labs costs the patient money, costs the insurance company money, and (by extension of increasing premiums) sooner or later costs me money. Plus, why put patients through painful procedures if you can avoid them? They appreciate that kind of thinking. I would, too.

So now, I wait. Most office cases aren’t urgent. I send a release when needed or call the referring physician for past test results. Usually, they show up in 1-2 weeks and I review them. Then, if things are missing, I write out a lab order to cover them and notify the patient.

I still run into younger docs who don’t do this, and just order everything right off the bat. Looking at it with the experience of 15 years in practice, that seems remarkably wasteful. Yes, occasionally you encounter results that should be repeated, but not often.

This is how it was taught in my residency, and still is today. Perhaps it’s an ivory tower view that the referring physician couldn’t possibly have ordered anything of value, or there’s an emphasis in training on quickly cracking the case, regardless of a lack of urgency.

It’s unfortunate that medical training, to a large extent, still doesn’t emphasize the financial realities of ordering duplicate tests. As we all try to provide better health care with fewer dollars, this kind of awareness becomes more important. I suppose it also could be seen as an argument for a centralized medical record system, so that we can all quickly see what’s been done, but I’ll leave that debate for another time.

The older I get, the easier it is to see these issues from the viewpoint of a patient. Who wants to waste money or blood on unnecessarily duplicated tests?

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

I hate epilepsy drug levels.

Other neurologists know what I’m talking about: Dilantin, Tegretol, and Depakote are the main ones we deal with. Levels for newer medications aren’t checked much, and phenobarbital is fading into the background.

I rarely check levels because 90% of the time they’re immaterial. If the patient isn’t having seizures and isn’t having side effects, who cares what the level is? It’s obviously just right for that patient (sort of like Goldilocks) regardless of what a number tells me it is.

Certainly there are exceptions to this: the well-controlled patient who suddenly goes downhill, for example. But in most cases, routinely checking drug levels serves no purpose, and often causes more harm them good.

In medical school, I was taught that you should never order a test unless the results will affect your plan of care. In a stable seizure patient, are you going to base your medication adjustments on how they’re doing, or a number?

Worse still, these levels are often used by specialties that don’t understand them. How many times have you seen well-controlled patients who had an unneeded level ordered – along with their annual lipid profile or thyroid panel, or because they went to the emergency department with pneumonia – and then had a nonneurologist adjust their dose based solely on the result? You often don’t find out about it until the patient calls you to report they seized or are suddenly drug-toxic.

I’m not an internist. In fact, I stink at general medicine, and don’t even pretend to understand the many drugs they have to start, adjust, and stop on an everyday basis. I don’t expect them to know as much about seizure medications as I do, anymore than they expect me to understand treatments for hypertension or diabetes. So I tell my patients that unless it’s an emergency, don’t let anyone else adjust their seizure medications. Just have them fax me the lab report, and I’ll deal with it.

At first, I was afraid this approach would ruffle feathers, but it hasn’t. Local internists have told me they’re glad to be able to take something off their list of concerns and punt it to me.

Modern medicine is full of things we can do, even when they’re just minor drug levels from a lab. But it’s still important to focus on what we should do, and to me, routinely checking drug levels should always be questioned.

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

I hate epilepsy drug levels.

Other neurologists know what I’m talking about: Dilantin, Tegretol, and Depakote are the main ones we deal with. Levels for newer medications aren’t checked much, and phenobarbital is fading into the background.

I rarely check levels because 90% of the time they’re immaterial. If the patient isn’t having seizures and isn’t having side effects, who cares what the level is? It’s obviously just right for that patient (sort of like Goldilocks) regardless of what a number tells me it is.

Certainly there are exceptions to this: the well-controlled patient who suddenly goes downhill, for example. But in most cases, routinely checking drug levels serves no purpose, and often causes more harm them good.

In medical school, I was taught that you should never order a test unless the results will affect your plan of care. In a stable seizure patient, are you going to base your medication adjustments on how they’re doing, or a number?

Worse still, these levels are often used by specialties that don’t understand them. How many times have you seen well-controlled patients who had an unneeded level ordered – along with their annual lipid profile or thyroid panel, or because they went to the emergency department with pneumonia – and then had a nonneurologist adjust their dose based solely on the result? You often don’t find out about it until the patient calls you to report they seized or are suddenly drug-toxic.

I’m not an internist. In fact, I stink at general medicine, and don’t even pretend to understand the many drugs they have to start, adjust, and stop on an everyday basis. I don’t expect them to know as much about seizure medications as I do, anymore than they expect me to understand treatments for hypertension or diabetes. So I tell my patients that unless it’s an emergency, don’t let anyone else adjust their seizure medications. Just have them fax me the lab report, and I’ll deal with it.

At first, I was afraid this approach would ruffle feathers, but it hasn’t. Local internists have told me they’re glad to be able to take something off their list of concerns and punt it to me.

Modern medicine is full of things we can do, even when they’re just minor drug levels from a lab. But it’s still important to focus on what we should do, and to me, routinely checking drug levels should always be questioned.

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

I hate epilepsy drug levels.

Other neurologists know what I’m talking about: Dilantin, Tegretol, and Depakote are the main ones we deal with. Levels for newer medications aren’t checked much, and phenobarbital is fading into the background.

I rarely check levels because 90% of the time they’re immaterial. If the patient isn’t having seizures and isn’t having side effects, who cares what the level is? It’s obviously just right for that patient (sort of like Goldilocks) regardless of what a number tells me it is.

Certainly there are exceptions to this: the well-controlled patient who suddenly goes downhill, for example. But in most cases, routinely checking drug levels serves no purpose, and often causes more harm them good.

In medical school, I was taught that you should never order a test unless the results will affect your plan of care. In a stable seizure patient, are you going to base your medication adjustments on how they’re doing, or a number?

Worse still, these levels are often used by specialties that don’t understand them. How many times have you seen well-controlled patients who had an unneeded level ordered – along with their annual lipid profile or thyroid panel, or because they went to the emergency department with pneumonia – and then had a nonneurologist adjust their dose based solely on the result? You often don’t find out about it until the patient calls you to report they seized or are suddenly drug-toxic.

I’m not an internist. In fact, I stink at general medicine, and don’t even pretend to understand the many drugs they have to start, adjust, and stop on an everyday basis. I don’t expect them to know as much about seizure medications as I do, anymore than they expect me to understand treatments for hypertension or diabetes. So I tell my patients that unless it’s an emergency, don’t let anyone else adjust their seizure medications. Just have them fax me the lab report, and I’ll deal with it.

At first, I was afraid this approach would ruffle feathers, but it hasn’t. Local internists have told me they’re glad to be able to take something off their list of concerns and punt it to me.

Modern medicine is full of things we can do, even when they’re just minor drug levels from a lab. But it’s still important to focus on what we should do, and to me, routinely checking drug levels should always be questioned.

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

Recently, Medicare released its 2012 payment data, showing that they paid $77 billion to doctors that year.

So, like many doctors, I got curious and ran my own numbers. If I’m doing the math correctly (which is always questionable), my share of it was $59,622. This is considerably less than the overall average of $87,500 that the 880,000 Medicare-accepting doctors received, and certainly nowhere near the $21 million that the nation’s No. 1 Medicare money recipient, Dr. Salomon Melgan (ophthalmology) of Florida raked in from Uncle Sam.

Now, unlike the popular press, I’m not going to knock Dr. Melgan. From what I’ve read, he uses a lot of Lucentis in his practice for macular degeneration. At roughly $2,000 (doctor’s cost) per dose, I’m sure his overhead is pretty high. I’ll leave those questions to the lawyers.

But it leaves me staring at my number and wondering if I’m doing something wrong. Granted, Medicare isn’t the only insurance I take, but still ... For comparison, that $59,662 doesn’t even cover the salaries of my two awesome, hard-working, staff members.

The trouble is that, like many other doctors, I work a pretty full schedule. Roughly 60-70 hours a week. Unlike the physicians of yore, I don’t take Wednesday afternoon off to go golfing (actually, I’ve never golfed on a real course in my life). I don’t double-book my appointment schedule. I don’t do frivolous procedures just for the billing (though I’m sure what I consider frivolous more successful doctors call necessary). I don’t charge level-5 visits for simple stuff. And I run a relatively low overhead. So why are most doctors today, including me, barely breaking even for trying to run an honest, ethical, practice?

Of course, venting this kind of thing in public is a no-win situation for doctors. We’re seen as either greedy or whiny. People in most other professions aren’t paying $30,000-$300,000 in malpractice insurance or coming out of school $200,000 in debt. Doctors who are actually charging for visits so they can pay their bills and support their families are terrible people because caring should be free.

Medicine is, in many respects, an intangible science. People may be horrified by what they’re charged for a 15-minute visit, but don’t see the 8-15 years (or more) of training behind them. And when they’re feeling better, we’re often forgotten or vilified for daring to charge them a copay.

The bottom line is that the money paid out by Medicare isn’t a fair assessment of our efforts. It’s a raw number, that doesn’t take into account the cost of drugs we have to purchase ($1,050 for a single bottle of Botox), the equipment we need to buy ($16,000 for a basic electromyogram/nerve conduction velocity machine), rent ($2,700 per month for me), malpractice insurance, staff salaries, billing services, office supplies, licensing fees. ... The list goes on, including a measure that you can’t put a price on: lives saved and improved.

Taken in this context, the $77 billion dollars is simply a tool that politicians and media pundits will twist to support whatever argument they want it to. Because, after all, most doctors are too busy helping others to defend themselves.

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

Recently, Medicare released its 2012 payment data, showing that they paid $77 billion to doctors that year.

So, like many doctors, I got curious and ran my own numbers. If I’m doing the math correctly (which is always questionable), my share of it was $59,622. This is considerably less than the overall average of $87,500 that the 880,000 Medicare-accepting doctors received, and certainly nowhere near the $21 million that the nation’s No. 1 Medicare money recipient, Dr. Salomon Melgan (ophthalmology) of Florida raked in from Uncle Sam.

Now, unlike the popular press, I’m not going to knock Dr. Melgan. From what I’ve read, he uses a lot of Lucentis in his practice for macular degeneration. At roughly $2,000 (doctor’s cost) per dose, I’m sure his overhead is pretty high. I’ll leave those questions to the lawyers.

But it leaves me staring at my number and wondering if I’m doing something wrong. Granted, Medicare isn’t the only insurance I take, but still ... For comparison, that $59,662 doesn’t even cover the salaries of my two awesome, hard-working, staff members.

The trouble is that, like many other doctors, I work a pretty full schedule. Roughly 60-70 hours a week. Unlike the physicians of yore, I don’t take Wednesday afternoon off to go golfing (actually, I’ve never golfed on a real course in my life). I don’t double-book my appointment schedule. I don’t do frivolous procedures just for the billing (though I’m sure what I consider frivolous more successful doctors call necessary). I don’t charge level-5 visits for simple stuff. And I run a relatively low overhead. So why are most doctors today, including me, barely breaking even for trying to run an honest, ethical, practice?

Of course, venting this kind of thing in public is a no-win situation for doctors. We’re seen as either greedy or whiny. People in most other professions aren’t paying $30,000-$300,000 in malpractice insurance or coming out of school $200,000 in debt. Doctors who are actually charging for visits so they can pay their bills and support their families are terrible people because caring should be free.

Medicine is, in many respects, an intangible science. People may be horrified by what they’re charged for a 15-minute visit, but don’t see the 8-15 years (or more) of training behind them. And when they’re feeling better, we’re often forgotten or vilified for daring to charge them a copay.

The bottom line is that the money paid out by Medicare isn’t a fair assessment of our efforts. It’s a raw number, that doesn’t take into account the cost of drugs we have to purchase ($1,050 for a single bottle of Botox), the equipment we need to buy ($16,000 for a basic electromyogram/nerve conduction velocity machine), rent ($2,700 per month for me), malpractice insurance, staff salaries, billing services, office supplies, licensing fees. ... The list goes on, including a measure that you can’t put a price on: lives saved and improved.

Taken in this context, the $77 billion dollars is simply a tool that politicians and media pundits will twist to support whatever argument they want it to. Because, after all, most doctors are too busy helping others to defend themselves.

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

Recently, Medicare released its 2012 payment data, showing that they paid $77 billion to doctors that year.

So, like many doctors, I got curious and ran my own numbers. If I’m doing the math correctly (which is always questionable), my share of it was $59,622. This is considerably less than the overall average of $87,500 that the 880,000 Medicare-accepting doctors received, and certainly nowhere near the $21 million that the nation’s No. 1 Medicare money recipient, Dr. Salomon Melgan (ophthalmology) of Florida raked in from Uncle Sam.

Now, unlike the popular press, I’m not going to knock Dr. Melgan. From what I’ve read, he uses a lot of Lucentis in his practice for macular degeneration. At roughly $2,000 (doctor’s cost) per dose, I’m sure his overhead is pretty high. I’ll leave those questions to the lawyers.

But it leaves me staring at my number and wondering if I’m doing something wrong. Granted, Medicare isn’t the only insurance I take, but still ... For comparison, that $59,662 doesn’t even cover the salaries of my two awesome, hard-working, staff members.

The trouble is that, like many other doctors, I work a pretty full schedule. Roughly 60-70 hours a week. Unlike the physicians of yore, I don’t take Wednesday afternoon off to go golfing (actually, I’ve never golfed on a real course in my life). I don’t double-book my appointment schedule. I don’t do frivolous procedures just for the billing (though I’m sure what I consider frivolous more successful doctors call necessary). I don’t charge level-5 visits for simple stuff. And I run a relatively low overhead. So why are most doctors today, including me, barely breaking even for trying to run an honest, ethical, practice?

Of course, venting this kind of thing in public is a no-win situation for doctors. We’re seen as either greedy or whiny. People in most other professions aren’t paying $30,000-$300,000 in malpractice insurance or coming out of school $200,000 in debt. Doctors who are actually charging for visits so they can pay their bills and support their families are terrible people because caring should be free.

Medicine is, in many respects, an intangible science. People may be horrified by what they’re charged for a 15-minute visit, but don’t see the 8-15 years (or more) of training behind them. And when they’re feeling better, we’re often forgotten or vilified for daring to charge them a copay.

The bottom line is that the money paid out by Medicare isn’t a fair assessment of our efforts. It’s a raw number, that doesn’t take into account the cost of drugs we have to purchase ($1,050 for a single bottle of Botox), the equipment we need to buy ($16,000 for a basic electromyogram/nerve conduction velocity machine), rent ($2,700 per month for me), malpractice insurance, staff salaries, billing services, office supplies, licensing fees. ... The list goes on, including a measure that you can’t put a price on: lives saved and improved.

Taken in this context, the $77 billion dollars is simply a tool that politicians and media pundits will twist to support whatever argument they want it to. Because, after all, most doctors are too busy helping others to defend themselves.

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

Recently, my alma mater, Creighton University, approached me to teach medical students. Sadly, I told them no.

I enjoy teaching. Medical students and residents always lift my spirits. I think I’m a good neurologist, with a decent grasp of practical issues (esoteric ones, not so much), and I like sharing it with those starting out on this road.

So why did I tell them no? It’s quite simple: I can’t afford it.

Solo practice in medicine is an "eat what you kill" world. You try to see patients, dictate notes, review tests, answer questions, and refill meds in a continuous blur from start to finish.

Teaching – at least worthwhile teaching – takes time. Questions have to be answered, take-home points explained, and exam findings pointed out. The last time I did routine teaching (2001), it added 1-2 hours to the end of each day. I had to make up the office work on weekends, which didn’t sit well with my family.

The alternative is to schedule extra time on teaching days – like an open 30 minutes twice a day – to compensate, but the problem with that is then you have empty time where you aren’t seeing patients and, hence, not making money. In a small practice on a thin margin, cash flow is critical and can’t be ignored.

It doesn’t seem fair to ask medical students and residents to pay, say, $500 a week to cover that time. Their tuition is high enough as it is.

Of course, the program they pay tuition to doesn’t offer a stipend to cover this, either. I don’t know why. I’m not privy to their finances, but I assume they’re facing the same challenges I am. I’m not greedy. I’m just trying to make ends meet.

This bothers me because I think I’m a good teacher. Back when I did it more, in my early days of solo practice (before reality kicked in), electives with me got high ratings from those who took them. I liked sharing my personal knowledge and experience with the next generation of doctors, and I hope those who were there gained something from it.

But the current nature of the education system makes that impossible and limits teaching primarily to academic practices or those large enough to absorb the loss through other means. That is sad because small practitioners have a lot to contribute, too.

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

Recently, my alma mater, Creighton University, approached me to teach medical students. Sadly, I told them no.

I enjoy teaching. Medical students and residents always lift my spirits. I think I’m a good neurologist, with a decent grasp of practical issues (esoteric ones, not so much), and I like sharing it with those starting out on this road.

So why did I tell them no? It’s quite simple: I can’t afford it.

Solo practice in medicine is an "eat what you kill" world. You try to see patients, dictate notes, review tests, answer questions, and refill meds in a continuous blur from start to finish.

Teaching – at least worthwhile teaching – takes time. Questions have to be answered, take-home points explained, and exam findings pointed out. The last time I did routine teaching (2001), it added 1-2 hours to the end of each day. I had to make up the office work on weekends, which didn’t sit well with my family.

The alternative is to schedule extra time on teaching days – like an open 30 minutes twice a day – to compensate, but the problem with that is then you have empty time where you aren’t seeing patients and, hence, not making money. In a small practice on a thin margin, cash flow is critical and can’t be ignored.

It doesn’t seem fair to ask medical students and residents to pay, say, $500 a week to cover that time. Their tuition is high enough as it is.

Of course, the program they pay tuition to doesn’t offer a stipend to cover this, either. I don’t know why. I’m not privy to their finances, but I assume they’re facing the same challenges I am. I’m not greedy. I’m just trying to make ends meet.

This bothers me because I think I’m a good teacher. Back when I did it more, in my early days of solo practice (before reality kicked in), electives with me got high ratings from those who took them. I liked sharing my personal knowledge and experience with the next generation of doctors, and I hope those who were there gained something from it.

But the current nature of the education system makes that impossible and limits teaching primarily to academic practices or those large enough to absorb the loss through other means. That is sad because small practitioners have a lot to contribute, too.

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

Recently, my alma mater, Creighton University, approached me to teach medical students. Sadly, I told them no.

I enjoy teaching. Medical students and residents always lift my spirits. I think I’m a good neurologist, with a decent grasp of practical issues (esoteric ones, not so much), and I like sharing it with those starting out on this road.

So why did I tell them no? It’s quite simple: I can’t afford it.

Solo practice in medicine is an "eat what you kill" world. You try to see patients, dictate notes, review tests, answer questions, and refill meds in a continuous blur from start to finish.

Teaching – at least worthwhile teaching – takes time. Questions have to be answered, take-home points explained, and exam findings pointed out. The last time I did routine teaching (2001), it added 1-2 hours to the end of each day. I had to make up the office work on weekends, which didn’t sit well with my family.

The alternative is to schedule extra time on teaching days – like an open 30 minutes twice a day – to compensate, but the problem with that is then you have empty time where you aren’t seeing patients and, hence, not making money. In a small practice on a thin margin, cash flow is critical and can’t be ignored.

It doesn’t seem fair to ask medical students and residents to pay, say, $500 a week to cover that time. Their tuition is high enough as it is.

Of course, the program they pay tuition to doesn’t offer a stipend to cover this, either. I don’t know why. I’m not privy to their finances, but I assume they’re facing the same challenges I am. I’m not greedy. I’m just trying to make ends meet.

This bothers me because I think I’m a good teacher. Back when I did it more, in my early days of solo practice (before reality kicked in), electives with me got high ratings from those who took them. I liked sharing my personal knowledge and experience with the next generation of doctors, and I hope those who were there gained something from it.

But the current nature of the education system makes that impossible and limits teaching primarily to academic practices or those large enough to absorb the loss through other means. That is sad because small practitioners have a lot to contribute, too.

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

I’m a pill person. I admit it.

I hate being sick and dealing with the aches and pains of everyday life. I’m the first person to hit the medicine cabinet. When I’m dealing with patients, I don’t want my own body to distract me from theirs.

Courtesy of Dr. Allan M. Block

So in my office, I have this drawer. My secretary calls it "the pharmacy."

As you can see, I have pretty much everything covered: Sudafed, Zyrtec, NSAIDs, an expired Celebrex packet (it’s been a few years since they detailed neurologists), and generics for Tylenol, Excedrin, and Zantac. I even have a nail clipper, ChapStick, an old albuterol metered-dose inhaler, cough drops, Q-tips, and zinc lozenges. An old hemostat that somehow ended up in there; I use it to remove tough staples. (There used to be caffeine pills, but my staff threatened to kill me if I didn’t give them up.)

Does this make me less of a doctor? I hope not. If I don’t feel good, I can’t concentrate as well on the task at hand, and in my case that’s patient care. I don’t pop pills every day, but if I need to, I do.

My staff also occasionally comes in with the seasonal viral crud, or headaches from dealing with headaches, or back pain from carrying 45 pounds of aging x-ray films back to my office. It always helps if I can keep them in shape to handle these days. They know it’s back here if they need anything.

I’m not pushing this philosophy on patients. I always mention, in any medication discussion, that I can’t make them take anything they don’t want to. (I’m also not offering them anything from the drawer – that’s my stash.) But I do emphasize that medications are, in large part, what I have to offer.

But as for me? Physician, heal thyself.

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

I’m a pill person. I admit it.

I hate being sick and dealing with the aches and pains of everyday life. I’m the first person to hit the medicine cabinet. When I’m dealing with patients, I don’t want my own body to distract me from theirs.

Courtesy of Dr. Allan M. Block

So in my office, I have this drawer. My secretary calls it "the pharmacy."

As you can see, I have pretty much everything covered: Sudafed, Zyrtec, NSAIDs, an expired Celebrex packet (it’s been a few years since they detailed neurologists), and generics for Tylenol, Excedrin, and Zantac. I even have a nail clipper, ChapStick, an old albuterol metered-dose inhaler, cough drops, Q-tips, and zinc lozenges. An old hemostat that somehow ended up in there; I use it to remove tough staples. (There used to be caffeine pills, but my staff threatened to kill me if I didn’t give them up.)

Does this make me less of a doctor? I hope not. If I don’t feel good, I can’t concentrate as well on the task at hand, and in my case that’s patient care. I don’t pop pills every day, but if I need to, I do.

My staff also occasionally comes in with the seasonal viral crud, or headaches from dealing with headaches, or back pain from carrying 45 pounds of aging x-ray films back to my office. It always helps if I can keep them in shape to handle these days. They know it’s back here if they need anything.

I’m not pushing this philosophy on patients. I always mention, in any medication discussion, that I can’t make them take anything they don’t want to. (I’m also not offering them anything from the drawer – that’s my stash.) But I do emphasize that medications are, in large part, what I have to offer.

But as for me? Physician, heal thyself.

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

I’m a pill person. I admit it.

I hate being sick and dealing with the aches and pains of everyday life. I’m the first person to hit the medicine cabinet. When I’m dealing with patients, I don’t want my own body to distract me from theirs.

Courtesy of Dr. Allan M. Block

So in my office, I have this drawer. My secretary calls it "the pharmacy."

As you can see, I have pretty much everything covered: Sudafed, Zyrtec, NSAIDs, an expired Celebrex packet (it’s been a few years since they detailed neurologists), and generics for Tylenol, Excedrin, and Zantac. I even have a nail clipper, ChapStick, an old albuterol metered-dose inhaler, cough drops, Q-tips, and zinc lozenges. An old hemostat that somehow ended up in there; I use it to remove tough staples. (There used to be caffeine pills, but my staff threatened to kill me if I didn’t give them up.)

Does this make me less of a doctor? I hope not. If I don’t feel good, I can’t concentrate as well on the task at hand, and in my case that’s patient care. I don’t pop pills every day, but if I need to, I do.

My staff also occasionally comes in with the seasonal viral crud, or headaches from dealing with headaches, or back pain from carrying 45 pounds of aging x-ray films back to my office. It always helps if I can keep them in shape to handle these days. They know it’s back here if they need anything.

I’m not pushing this philosophy on patients. I always mention, in any medication discussion, that I can’t make them take anything they don’t want to. (I’m also not offering them anything from the drawer – that’s my stash.) But I do emphasize that medications are, in large part, what I have to offer.

But as for me? Physician, heal thyself.

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

I don’t mind taking other doctor’s calls, even if they need to interrupt me with a patient. In this business, sometimes things are urgent.

Patients usually don’t mind either. They figure that, if it was them in an emergency, they’d want the doctor to be willing to get on the phone, too.

What really irks me is when they have me interrupted for bogus reasons. My secretary will come get me if a doctor says it’s urgent, and I have no problem with that. I’d rather err on the side of caution rather then miss a phone call about a true emergency.

Unfortunately, this privilege gets abused. I’ve been pulled away from patients for "urgent" calls from:

• Radiologists marketing their MRI facility,

• Dentists wanting to offer me a "special" on teeth cleaning for my family and staff,

• PhDs or MDs working for a pharmaceutical company who want to tell me of some new drug or indication, and

• Financial advisers posing as doctors ("your secretary wouldn’t let me talk to you otherwise") who don’t seem to realize this is not going to make a good impression.

Most recently, a doctor who read one of my columns here called "urgently" to get me to sell a line of vitamin supplements out of my office. He claimed to have read all these columns, but obviously missed the one where I talked about how I’m opposed to the vitamin schemes.

When this happens I get off the phone, fast, and turn my attention back to the patient with an apology. 

I don’t understand why people do this. Obviously, I have no interest in working with someone who’s dishonest enough to lie to my secretary about their true intentions or credentials. I can’t imagine they sucker other doctors, either, after an introduction like that.

Such behavior doesn’t lend itself to good business, good relationships, or good patient care. But I’ll keep taking their calls, because I’d rather hang up on 100 of them than miss one legitimate call from a doctor who needs my help in a pinch.

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

I don’t mind taking other doctor’s calls, even if they need to interrupt me with a patient. In this business, sometimes things are urgent.

Patients usually don’t mind either. They figure that, if it was them in an emergency, they’d want the doctor to be willing to get on the phone, too.

What really irks me is when they have me interrupted for bogus reasons. My secretary will come get me if a doctor says it’s urgent, and I have no problem with that. I’d rather err on the side of caution rather then miss a phone call about a true emergency.

Unfortunately, this privilege gets abused. I’ve been pulled away from patients for "urgent" calls from:

• Radiologists marketing their MRI facility,

• Dentists wanting to offer me a "special" on teeth cleaning for my family and staff,

• PhDs or MDs working for a pharmaceutical company who want to tell me of some new drug or indication, and

• Financial advisers posing as doctors ("your secretary wouldn’t let me talk to you otherwise") who don’t seem to realize this is not going to make a good impression.

Most recently, a doctor who read one of my columns here called "urgently" to get me to sell a line of vitamin supplements out of my office. He claimed to have read all these columns, but obviously missed the one where I talked about how I’m opposed to the vitamin schemes.

When this happens I get off the phone, fast, and turn my attention back to the patient with an apology. 

I don’t understand why people do this. Obviously, I have no interest in working with someone who’s dishonest enough to lie to my secretary about their true intentions or credentials. I can’t imagine they sucker other doctors, either, after an introduction like that.

Such behavior doesn’t lend itself to good business, good relationships, or good patient care. But I’ll keep taking their calls, because I’d rather hang up on 100 of them than miss one legitimate call from a doctor who needs my help in a pinch.

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

I don’t mind taking other doctor’s calls, even if they need to interrupt me with a patient. In this business, sometimes things are urgent.

Patients usually don’t mind either. They figure that, if it was them in an emergency, they’d want the doctor to be willing to get on the phone, too.

What really irks me is when they have me interrupted for bogus reasons. My secretary will come get me if a doctor says it’s urgent, and I have no problem with that. I’d rather err on the side of caution rather then miss a phone call about a true emergency.

Unfortunately, this privilege gets abused. I’ve been pulled away from patients for "urgent" calls from:

• Radiologists marketing their MRI facility,

• Dentists wanting to offer me a "special" on teeth cleaning for my family and staff,

• PhDs or MDs working for a pharmaceutical company who want to tell me of some new drug or indication, and

• Financial advisers posing as doctors ("your secretary wouldn’t let me talk to you otherwise") who don’t seem to realize this is not going to make a good impression.

Most recently, a doctor who read one of my columns here called "urgently" to get me to sell a line of vitamin supplements out of my office. He claimed to have read all these columns, but obviously missed the one where I talked about how I’m opposed to the vitamin schemes.

When this happens I get off the phone, fast, and turn my attention back to the patient with an apology. 

I don’t understand why people do this. Obviously, I have no interest in working with someone who’s dishonest enough to lie to my secretary about their true intentions or credentials. I can’t imagine they sucker other doctors, either, after an introduction like that.

Such behavior doesn’t lend itself to good business, good relationships, or good patient care. But I’ll keep taking their calls, because I’d rather hang up on 100 of them than miss one legitimate call from a doctor who needs my help in a pinch.

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

While doing some catch-up reading, I recently came across an article about the Ottawa screening tool for subarachnoid hemorrhage. It noted clinical factors that best predicted a bleed were as follows:

• Age 40 years or older.

• Neck pain or stiffness.

• Witnessed loss of consciousness.

• Onset during exertion.

• Thunderclap onset of headache.

• Limited neck flexion. (I’m not sure why this was separated from the second factor.)

In the validation cohort that the investigators used to devise the rule, these factors resulted in 100% sensitivity and 15% specificity for subarachnoid bleed, which increased to an overall sensitivity of 99.2% and a specificity of 99.6% when the derivation cohort and the validation cohort were combined

This is, admittedly, interesting, and certainly of value in a situation where imaging isn’t immediately available. But, realistically, how often does that happen in a modern ER?

Not to put down the research, but in everyday practice no one is going to rely on a basic guideline of this sort. Will it change the number of CT scans or lumbar punctures done? Probably not. The risk of missing a bleed is so potentially serious that CT scans are routinely done for most headache symptoms. "Well, the Ottawa SAH rule said ..." is unlikely to protect you in court.

So why do people keep coming up with scales of this sort? Part of it, I suspect is the disconnect between academic centers (where most of these are created) and front-line medicine. There’s also likely an element of "publish or perish," in which fellows have to come up with things like this.

But, realistically, do they change the way nonacademic medicine (which is most of it) is practiced? Probably not.

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

While doing some catch-up reading, I recently came across an article about the Ottawa screening tool for subarachnoid hemorrhage. It noted clinical factors that best predicted a bleed were as follows:

• Age 40 years or older.

• Neck pain or stiffness.

• Witnessed loss of consciousness.

• Onset during exertion.

• Thunderclap onset of headache.

• Limited neck flexion. (I’m not sure why this was separated from the second factor.)

In the validation cohort that the investigators used to devise the rule, these factors resulted in 100% sensitivity and 15% specificity for subarachnoid bleed, which increased to an overall sensitivity of 99.2% and a specificity of 99.6% when the derivation cohort and the validation cohort were combined

This is, admittedly, interesting, and certainly of value in a situation where imaging isn’t immediately available. But, realistically, how often does that happen in a modern ER?

Not to put down the research, but in everyday practice no one is going to rely on a basic guideline of this sort. Will it change the number of CT scans or lumbar punctures done? Probably not. The risk of missing a bleed is so potentially serious that CT scans are routinely done for most headache symptoms. "Well, the Ottawa SAH rule said ..." is unlikely to protect you in court.

So why do people keep coming up with scales of this sort? Part of it, I suspect is the disconnect between academic centers (where most of these are created) and front-line medicine. There’s also likely an element of "publish or perish," in which fellows have to come up with things like this.

But, realistically, do they change the way nonacademic medicine (which is most of it) is practiced? Probably not.

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

While doing some catch-up reading, I recently came across an article about the Ottawa screening tool for subarachnoid hemorrhage. It noted clinical factors that best predicted a bleed were as follows:

• Age 40 years or older.

• Neck pain or stiffness.

• Witnessed loss of consciousness.

• Onset during exertion.

• Thunderclap onset of headache.

• Limited neck flexion. (I’m not sure why this was separated from the second factor.)

In the validation cohort that the investigators used to devise the rule, these factors resulted in 100% sensitivity and 15% specificity for subarachnoid bleed, which increased to an overall sensitivity of 99.2% and a specificity of 99.6% when the derivation cohort and the validation cohort were combined

This is, admittedly, interesting, and certainly of value in a situation where imaging isn’t immediately available. But, realistically, how often does that happen in a modern ER?

Not to put down the research, but in everyday practice no one is going to rely on a basic guideline of this sort. Will it change the number of CT scans or lumbar punctures done? Probably not. The risk of missing a bleed is so potentially serious that CT scans are routinely done for most headache symptoms. "Well, the Ottawa SAH rule said ..." is unlikely to protect you in court.

So why do people keep coming up with scales of this sort? Part of it, I suspect is the disconnect between academic centers (where most of these are created) and front-line medicine. There’s also likely an element of "publish or perish," in which fellows have to come up with things like this.

But, realistically, do they change the way nonacademic medicine (which is most of it) is practiced? Probably not.

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

My office hours are possibly the most laid back in medicine. In a field like medicine, I try not to worry about such things.

I’ve intentionally never put regular hours on my office door or phone message, because in my small office they’re subject to change. If my secretary is tied up in traffic, the phone may not get rolled on time. But, as a general rule, we open between 8:45 and 9:00.

Once the starting gun goes off, I work straight through. No lunch break (sorry, drug reps). I’ve never been a lunch person, and would rather use the time for seeing people who need me. I see patients nonstop, squeezing in phone calls, refills, and test results in the cracks, and I try very hard to stay on time.

The day ends as quickly as it starts. As soon as the last patient is done, we’re done. Whether it’s at 4:00 (the usual time), 3:15, or (rarely) 2:00, we close. The phones are rolled, the lights out, and my secretary and I walk down to our cars.

I’m sure some feel we should be answering our phones until a specific time, but I don’t. I want to go pick up my kids. My secretary has a long drive home, and the sooner she hits the freeway, the better. If there are emergencies, patients will still be able to reach me. If they’re not having emergencies, they can call back when we reopen the next day. I’ll finish up the dictations when I come in early the next morning.

A medical practice is pretty stressful. There’s nothing wrong with calling it a day as soon as you can. And I do.

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

My office hours are possibly the most laid back in medicine. In a field like medicine, I try not to worry about such things.

I’ve intentionally never put regular hours on my office door or phone message, because in my small office they’re subject to change. If my secretary is tied up in traffic, the phone may not get rolled on time. But, as a general rule, we open between 8:45 and 9:00.

Once the starting gun goes off, I work straight through. No lunch break (sorry, drug reps). I’ve never been a lunch person, and would rather use the time for seeing people who need me. I see patients nonstop, squeezing in phone calls, refills, and test results in the cracks, and I try very hard to stay on time.

The day ends as quickly as it starts. As soon as the last patient is done, we’re done. Whether it’s at 4:00 (the usual time), 3:15, or (rarely) 2:00, we close. The phones are rolled, the lights out, and my secretary and I walk down to our cars.

I’m sure some feel we should be answering our phones until a specific time, but I don’t. I want to go pick up my kids. My secretary has a long drive home, and the sooner she hits the freeway, the better. If there are emergencies, patients will still be able to reach me. If they’re not having emergencies, they can call back when we reopen the next day. I’ll finish up the dictations when I come in early the next morning.

A medical practice is pretty stressful. There’s nothing wrong with calling it a day as soon as you can. And I do.

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

My office hours are possibly the most laid back in medicine. In a field like medicine, I try not to worry about such things.

I’ve intentionally never put regular hours on my office door or phone message, because in my small office they’re subject to change. If my secretary is tied up in traffic, the phone may not get rolled on time. But, as a general rule, we open between 8:45 and 9:00.

Once the starting gun goes off, I work straight through. No lunch break (sorry, drug reps). I’ve never been a lunch person, and would rather use the time for seeing people who need me. I see patients nonstop, squeezing in phone calls, refills, and test results in the cracks, and I try very hard to stay on time.

The day ends as quickly as it starts. As soon as the last patient is done, we’re done. Whether it’s at 4:00 (the usual time), 3:15, or (rarely) 2:00, we close. The phones are rolled, the lights out, and my secretary and I walk down to our cars.

I’m sure some feel we should be answering our phones until a specific time, but I don’t. I want to go pick up my kids. My secretary has a long drive home, and the sooner she hits the freeway, the better. If there are emergencies, patients will still be able to reach me. If they’re not having emergencies, they can call back when we reopen the next day. I’ll finish up the dictations when I come in early the next morning.

A medical practice is pretty stressful. There’s nothing wrong with calling it a day as soon as you can. And I do.

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

I like to start early. How early? Usually I get up around 4:00 a.m.

Years ago I did this so I’d have time to round at the hospital. My inpatient days are (mostly) behind me now, but after years of my alarm clock waking me at 4:00, my internal alarm has long since taken over. It wakes me within 5 minutes of 4:00 every weekday, and I no longer set my clock (let’s hear it for the suprachiasmatic nucleus).

Does this bother me? Not at all. It gives me a degree of peace in my day. I drive the 2 miles to my office on empty roads. My office is quiet. I can play music on my computer without bothering anyone. I make tea.

It gives me time to finish the previous day’s dictations and paperwork. In a modern medical practice there’s always something to do: notes to dictate, forms to complete, refills to authorize, test results to review and make decisions on, and outside records to read. So I sit at my desk, listen to music, drink tea, and catch up.

Even when that’s all done, there’s still stuff to do, such as refreshing myself on test results and my notes on patients coming in that day, ordering office supplies, and reading through the occasional legal case.

I don’t mind this. It beats coming in 5 minutes before the first patient to find that my secretary has three urgent messages for me, there’s nine prescription refills to do, and an established patient just walked in to say he felt weak on the left.

Getting up early doesn’t solve the day’s problems, but getting a head start on them helps. It also lets me leave the office when my last patient is done to do more important things, like picking up my kids after school and going to their activities.

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

I like to start early. How early? Usually I get up around 4:00 a.m.

Years ago I did this so I’d have time to round at the hospital. My inpatient days are (mostly) behind me now, but after years of my alarm clock waking me at 4:00, my internal alarm has long since taken over. It wakes me within 5 minutes of 4:00 every weekday, and I no longer set my clock (let’s hear it for the suprachiasmatic nucleus).

Does this bother me? Not at all. It gives me a degree of peace in my day. I drive the 2 miles to my office on empty roads. My office is quiet. I can play music on my computer without bothering anyone. I make tea.

It gives me time to finish the previous day’s dictations and paperwork. In a modern medical practice there’s always something to do: notes to dictate, forms to complete, refills to authorize, test results to review and make decisions on, and outside records to read. So I sit at my desk, listen to music, drink tea, and catch up.

Even when that’s all done, there’s still stuff to do, such as refreshing myself on test results and my notes on patients coming in that day, ordering office supplies, and reading through the occasional legal case.

I don’t mind this. It beats coming in 5 minutes before the first patient to find that my secretary has three urgent messages for me, there’s nine prescription refills to do, and an established patient just walked in to say he felt weak on the left.

Getting up early doesn’t solve the day’s problems, but getting a head start on them helps. It also lets me leave the office when my last patient is done to do more important things, like picking up my kids after school and going to their activities.

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

I like to start early. How early? Usually I get up around 4:00 a.m.

Years ago I did this so I’d have time to round at the hospital. My inpatient days are (mostly) behind me now, but after years of my alarm clock waking me at 4:00, my internal alarm has long since taken over. It wakes me within 5 minutes of 4:00 every weekday, and I no longer set my clock (let’s hear it for the suprachiasmatic nucleus).

Does this bother me? Not at all. It gives me a degree of peace in my day. I drive the 2 miles to my office on empty roads. My office is quiet. I can play music on my computer without bothering anyone. I make tea.

It gives me time to finish the previous day’s dictations and paperwork. In a modern medical practice there’s always something to do: notes to dictate, forms to complete, refills to authorize, test results to review and make decisions on, and outside records to read. So I sit at my desk, listen to music, drink tea, and catch up.

Even when that’s all done, there’s still stuff to do, such as refreshing myself on test results and my notes on patients coming in that day, ordering office supplies, and reading through the occasional legal case.

I don’t mind this. It beats coming in 5 minutes before the first patient to find that my secretary has three urgent messages for me, there’s nine prescription refills to do, and an established patient just walked in to say he felt weak on the left.

Getting up early doesn’t solve the day’s problems, but getting a head start on them helps. It also lets me leave the office when my last patient is done to do more important things, like picking up my kids after school and going to their activities.

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

Over the past holidays I spent a few hours tinkering with my office website. My goal was to completely remove the word "Botox" from it.

In 2009, I decided to start using Botox for migraine. I took a few classes, and Dr. David Dodick down the street was kind enough to let me watch him for an afternoon. I figured it was something else I could offer my patients and help with office revenue.

©DenGuy/iStockphoto.com

So, for 2-3 years, I did it. It never became a huge part of my practice – I did two to three cases a month – but I had some patients who it helped. I never looked into the other uses for Botox because my practice is small and I try to keep things simple. And now, I’m done with it.

In the last 2 years, the process of getting it approved became increasingly difficult. Insurance companies put up more and more restrictions to a point that it became near impossible to get it covered. Between the paperwork and rising costs, I had more and more patients deciding to stop.

In 2013, I hit the wall. A lady who’d met every single one of her insurer’s criteria for it had a claim turned down after she’d already had the treatment. By that time, the specialty pharmacy had already shipped the bottle to me, so I’d used it. The insurance claimed the specialty pharmacy hadn’t been authorized to ship it, and that they should have to pay for the error. The pharmacy said that the insurance company had okayed sending me the bottle, and so it was their bill. So guess who had to eat the $1,500 cost for the bottle and procedure? The patient (who’s a grade school teacher) and me.

A few months later, after submitting the usual boatload of paperwork, I received a written authorization to order Botox for a patient. So I dialed up Allergan to get a bottle.

The next morning my fax machine had a paper that came in overnight from the insurance company rescinding the previous authorization. It said that, after further review, the company felt the patient didn’t qualify for Botox and was changing its mind.

In a small practice, you can’t afford to get stiffed for $1,500 too often. Fortunately, Allergan was understanding and was able to cancel the delivery and have it returned.

At that point, enough was enough. The little bit of extra money I’d made doing Botox was no longer worth the headaches (pardon the expression) of dealing with insurance companies. I could go along with the previous rules: If I got the authorization, I could do it. Now, even that was worthless.

The few Botox patients I still had were disappointed, but they understood and moved to other practices. We continued to get occasional phone calls because it was on my website, so I used a few hours over the holidays to delete the information.

I don’t think Botox is a great migraine treatment, nor do I think it’s a bad one. Like anything else I have to offer, it has pros and cons, but the insurance headaches now outweigh any benefit it has to a small practice. I don’t miss it.

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

Over the past holidays I spent a few hours tinkering with my office website. My goal was to completely remove the word "Botox" from it.

In 2009, I decided to start using Botox for migraine. I took a few classes, and Dr. David Dodick down the street was kind enough to let me watch him for an afternoon. I figured it was something else I could offer my patients and help with office revenue.

©DenGuy/iStockphoto.com

So, for 2-3 years, I did it. It never became a huge part of my practice – I did two to three cases a month – but I had some patients who it helped. I never looked into the other uses for Botox because my practice is small and I try to keep things simple. And now, I’m done with it.

In the last 2 years, the process of getting it approved became increasingly difficult. Insurance companies put up more and more restrictions to a point that it became near impossible to get it covered. Between the paperwork and rising costs, I had more and more patients deciding to stop.

In 2013, I hit the wall. A lady who’d met every single one of her insurer’s criteria for it had a claim turned down after she’d already had the treatment. By that time, the specialty pharmacy had already shipped the bottle to me, so I’d used it. The insurance claimed the specialty pharmacy hadn’t been authorized to ship it, and that they should have to pay for the error. The pharmacy said that the insurance company had okayed sending me the bottle, and so it was their bill. So guess who had to eat the $1,500 cost for the bottle and procedure? The patient (who’s a grade school teacher) and me.

A few months later, after submitting the usual boatload of paperwork, I received a written authorization to order Botox for a patient. So I dialed up Allergan to get a bottle.

The next morning my fax machine had a paper that came in overnight from the insurance company rescinding the previous authorization. It said that, after further review, the company felt the patient didn’t qualify for Botox and was changing its mind.

In a small practice, you can’t afford to get stiffed for $1,500 too often. Fortunately, Allergan was understanding and was able to cancel the delivery and have it returned.

At that point, enough was enough. The little bit of extra money I’d made doing Botox was no longer worth the headaches (pardon the expression) of dealing with insurance companies. I could go along with the previous rules: If I got the authorization, I could do it. Now, even that was worthless.

The few Botox patients I still had were disappointed, but they understood and moved to other practices. We continued to get occasional phone calls because it was on my website, so I used a few hours over the holidays to delete the information.

I don’t think Botox is a great migraine treatment, nor do I think it’s a bad one. Like anything else I have to offer, it has pros and cons, but the insurance headaches now outweigh any benefit it has to a small practice. I don’t miss it.

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

Over the past holidays I spent a few hours tinkering with my office website. My goal was to completely remove the word "Botox" from it.

In 2009, I decided to start using Botox for migraine. I took a few classes, and Dr. David Dodick down the street was kind enough to let me watch him for an afternoon. I figured it was something else I could offer my patients and help with office revenue.

©DenGuy/iStockphoto.com

So, for 2-3 years, I did it. It never became a huge part of my practice – I did two to three cases a month – but I had some patients who it helped. I never looked into the other uses for Botox because my practice is small and I try to keep things simple. And now, I’m done with it.

In the last 2 years, the process of getting it approved became increasingly difficult. Insurance companies put up more and more restrictions to a point that it became near impossible to get it covered. Between the paperwork and rising costs, I had more and more patients deciding to stop.

In 2013, I hit the wall. A lady who’d met every single one of her insurer’s criteria for it had a claim turned down after she’d already had the treatment. By that time, the specialty pharmacy had already shipped the bottle to me, so I’d used it. The insurance claimed the specialty pharmacy hadn’t been authorized to ship it, and that they should have to pay for the error. The pharmacy said that the insurance company had okayed sending me the bottle, and so it was their bill. So guess who had to eat the $1,500 cost for the bottle and procedure? The patient (who’s a grade school teacher) and me.

A few months later, after submitting the usual boatload of paperwork, I received a written authorization to order Botox for a patient. So I dialed up Allergan to get a bottle.

The next morning my fax machine had a paper that came in overnight from the insurance company rescinding the previous authorization. It said that, after further review, the company felt the patient didn’t qualify for Botox and was changing its mind.

In a small practice, you can’t afford to get stiffed for $1,500 too often. Fortunately, Allergan was understanding and was able to cancel the delivery and have it returned.

At that point, enough was enough. The little bit of extra money I’d made doing Botox was no longer worth the headaches (pardon the expression) of dealing with insurance companies. I could go along with the previous rules: If I got the authorization, I could do it. Now, even that was worthless.

The few Botox patients I still had were disappointed, but they understood and moved to other practices. We continued to get occasional phone calls because it was on my website, so I used a few hours over the holidays to delete the information.

I don’t think Botox is a great migraine treatment, nor do I think it’s a bad one. Like anything else I have to offer, it has pros and cons, but the insurance headaches now outweigh any benefit it has to a small practice. I don’t miss it.

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