Hitting a Nerve

How often do you get requests to do telemedicine? I get a few per month, all offering money (usually $20-$30 per call) for me to manage patients by phone. I’m not talking about Viagra or Vicodin mills, but places that cater to patients who either can’t or won’t see a doctor.

I always say no. In my mind, this is just another way to cheapen our profession, but I also have serious concerns about it.

Photo ©Alliance/Fotolia.com

There’s a lot to worry about when trying to treat patients without seeing them. Most migraines are migraines, but what if you can’t examine the patient? You might miss papilledema, or a reflex asymmetry, or other signs that something is amiss. The same could be said for routine lumbar pain or carpal tunnel syndrome.

I don’t mind handling the occasional phone call for an office patient I’m familiar with. And, of course, we all have to deal with cross-cover calls on nonpatients. But to try and do a full history and physical by phone? That doesn’t work for me.

I’m not deluding myself into believing that my refusal to participate will keep these things from happening. Hungry physicians willing to take the legal risks will be hired, and may end up costing me a few patients who would have otherwise come to my office. I’ve been told that I should participate in this sort of thing so at least I can shape the way it develops.

But my belief in my field makes me reluctant to compromise. I also have a family to provide for, and medicine is a risky enough undertaking as it is without adding more potential liability. And I just don’t believe you can provide a decent level of care solely by phone.

Knowingly doing an incomplete job is never a good idea, especially in medicine. And the people who use such services, as in everything else, get what they pay for.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

How often do you get requests to do telemedicine? I get a few per month, all offering money (usually $20-$30 per call) for me to manage patients by phone. I’m not talking about Viagra or Vicodin mills, but places that cater to patients who either can’t or won’t see a doctor.

I always say no. In my mind, this is just another way to cheapen our profession, but I also have serious concerns about it.

Photo ©Alliance/Fotolia.com

There’s a lot to worry about when trying to treat patients without seeing them. Most migraines are migraines, but what if you can’t examine the patient? You might miss papilledema, or a reflex asymmetry, or other signs that something is amiss. The same could be said for routine lumbar pain or carpal tunnel syndrome.

I don’t mind handling the occasional phone call for an office patient I’m familiar with. And, of course, we all have to deal with cross-cover calls on nonpatients. But to try and do a full history and physical by phone? That doesn’t work for me.

I’m not deluding myself into believing that my refusal to participate will keep these things from happening. Hungry physicians willing to take the legal risks will be hired, and may end up costing me a few patients who would have otherwise come to my office. I’ve been told that I should participate in this sort of thing so at least I can shape the way it develops.

But my belief in my field makes me reluctant to compromise. I also have a family to provide for, and medicine is a risky enough undertaking as it is without adding more potential liability. And I just don’t believe you can provide a decent level of care solely by phone.

Knowingly doing an incomplete job is never a good idea, especially in medicine. And the people who use such services, as in everything else, get what they pay for.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

How often do you get requests to do telemedicine? I get a few per month, all offering money (usually $20-$30 per call) for me to manage patients by phone. I’m not talking about Viagra or Vicodin mills, but places that cater to patients who either can’t or won’t see a doctor.

I always say no. In my mind, this is just another way to cheapen our profession, but I also have serious concerns about it.

Photo ©Alliance/Fotolia.com

There’s a lot to worry about when trying to treat patients without seeing them. Most migraines are migraines, but what if you can’t examine the patient? You might miss papilledema, or a reflex asymmetry, or other signs that something is amiss. The same could be said for routine lumbar pain or carpal tunnel syndrome.

I don’t mind handling the occasional phone call for an office patient I’m familiar with. And, of course, we all have to deal with cross-cover calls on nonpatients. But to try and do a full history and physical by phone? That doesn’t work for me.

I’m not deluding myself into believing that my refusal to participate will keep these things from happening. Hungry physicians willing to take the legal risks will be hired, and may end up costing me a few patients who would have otherwise come to my office. I’ve been told that I should participate in this sort of thing so at least I can shape the way it develops.

But my belief in my field makes me reluctant to compromise. I also have a family to provide for, and medicine is a risky enough undertaking as it is without adding more potential liability. And I just don’t believe you can provide a decent level of care solely by phone.

Knowingly doing an incomplete job is never a good idea, especially in medicine. And the people who use such services, as in everything else, get what they pay for.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

Unless you’ve been living under a rock, you likely saw the New England Journal of Medicine paper last fall on the SAMMPRIS trial in which aggressive medical treatment beat intracranial stenting for patients with intracranial artery stenosis (N. Engl. J. Med. 2011;365:993-1003).

I’ve sent my share of patients for stenting. I’m sure you have, too. Sometimes, it’s even been against my better judgment. Patients (and doctors) often are infatuated with high-tech procedures, so when they come to me demanding a referral for such, it’s hard to refuse. Doing so runs the risk of losing a referral source.

Neurology, by nature, is a very tech-dependent field. We live by MRI, EEG, EMG/NCV [electromyography and nerve conduction velocity], and a bunch of other alphabet soups. Human nature leads us to believe that more expensive/invasive/high-tech treatments are better, compared with "take an aspirin and call me in the morning."

I have the highest respect for my colleagues in neurosurgery and interventional radiology. They often do incredible things.

However, technology isn’t always the best answer, even though it’s certainly the flashiest. Since 2004 the Wingspan intracranial stent has been available in the United States for humanitarian cases (people who had failed all other reasonable treatments). But in March 2012, an FDA advisory panel seriously questioned the device after the SAMMPRIS study was stopped prematurely. The fancy stent had a 14.7% incidence of death and early recurrent stroke (within 30 days of use), compared with 5.8% with boring old pills.

Cardiac disease treatments often lead to cerebrovascular treatments because of the similarities between the two systems. But that isn’t always the case. The combination of clopidogrel (Plavix) plus aspirin is routinely used in cardiology and, for many years, in neurology. But, as time has gone by, we’ve found this practice has no benefit, and greater risks, in stroke prevention. So it’s falling by the wayside.

Perhaps the best lesson to learn from this applies to all areas of life: bigger, newer, and more expensive doesn’t always mean better and can sometimes mean quite the opposite.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

Unless you’ve been living under a rock, you likely saw the New England Journal of Medicine paper last fall on the SAMMPRIS trial in which aggressive medical treatment beat intracranial stenting for patients with intracranial artery stenosis (N. Engl. J. Med. 2011;365:993-1003).

I’ve sent my share of patients for stenting. I’m sure you have, too. Sometimes, it’s even been against my better judgment. Patients (and doctors) often are infatuated with high-tech procedures, so when they come to me demanding a referral for such, it’s hard to refuse. Doing so runs the risk of losing a referral source.

Neurology, by nature, is a very tech-dependent field. We live by MRI, EEG, EMG/NCV [electromyography and nerve conduction velocity], and a bunch of other alphabet soups. Human nature leads us to believe that more expensive/invasive/high-tech treatments are better, compared with "take an aspirin and call me in the morning."

I have the highest respect for my colleagues in neurosurgery and interventional radiology. They often do incredible things.

However, technology isn’t always the best answer, even though it’s certainly the flashiest. Since 2004 the Wingspan intracranial stent has been available in the United States for humanitarian cases (people who had failed all other reasonable treatments). But in March 2012, an FDA advisory panel seriously questioned the device after the SAMMPRIS study was stopped prematurely. The fancy stent had a 14.7% incidence of death and early recurrent stroke (within 30 days of use), compared with 5.8% with boring old pills.

Cardiac disease treatments often lead to cerebrovascular treatments because of the similarities between the two systems. But that isn’t always the case. The combination of clopidogrel (Plavix) plus aspirin is routinely used in cardiology and, for many years, in neurology. But, as time has gone by, we’ve found this practice has no benefit, and greater risks, in stroke prevention. So it’s falling by the wayside.

Perhaps the best lesson to learn from this applies to all areas of life: bigger, newer, and more expensive doesn’t always mean better and can sometimes mean quite the opposite.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

Unless you’ve been living under a rock, you likely saw the New England Journal of Medicine paper last fall on the SAMMPRIS trial in which aggressive medical treatment beat intracranial stenting for patients with intracranial artery stenosis (N. Engl. J. Med. 2011;365:993-1003).

I’ve sent my share of patients for stenting. I’m sure you have, too. Sometimes, it’s even been against my better judgment. Patients (and doctors) often are infatuated with high-tech procedures, so when they come to me demanding a referral for such, it’s hard to refuse. Doing so runs the risk of losing a referral source.

Neurology, by nature, is a very tech-dependent field. We live by MRI, EEG, EMG/NCV [electromyography and nerve conduction velocity], and a bunch of other alphabet soups. Human nature leads us to believe that more expensive/invasive/high-tech treatments are better, compared with "take an aspirin and call me in the morning."

I have the highest respect for my colleagues in neurosurgery and interventional radiology. They often do incredible things.

However, technology isn’t always the best answer, even though it’s certainly the flashiest. Since 2004 the Wingspan intracranial stent has been available in the United States for humanitarian cases (people who had failed all other reasonable treatments). But in March 2012, an FDA advisory panel seriously questioned the device after the SAMMPRIS study was stopped prematurely. The fancy stent had a 14.7% incidence of death and early recurrent stroke (within 30 days of use), compared with 5.8% with boring old pills.

Cardiac disease treatments often lead to cerebrovascular treatments because of the similarities between the two systems. But that isn’t always the case. The combination of clopidogrel (Plavix) plus aspirin is routinely used in cardiology and, for many years, in neurology. But, as time has gone by, we’ve found this practice has no benefit, and greater risks, in stroke prevention. So it’s falling by the wayside.

Perhaps the best lesson to learn from this applies to all areas of life: bigger, newer, and more expensive doesn’t always mean better and can sometimes mean quite the opposite.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

I’m in solo practice (yes, one of those doctors). We’re a dying breed, which is sad because I genuinely like it. It’s certainly not for everyone, but it suits me perfectly.

It’s not easy. In my first 6 months of doing this, I pretty much picked up an MBA just by experience. I’d never had to deal with payroll, withholding taxes, forms, licensing, and a million other things, and had to learn them on the fly.

But looking back, I’m glad I did it. Like many other doctors, I joined a large group right out of residency. They seemed to offer security, and it was easier than trying to hang up my own shingle. But after a few years of office politics, dealing with business people, and being forced to review graphs labeled "physician revenue per square foot of office space," I couldn’t take it anymore.

So here I am. This will be my 12th year flying solo, and I regret none of it. Nobody argues with me about my choice of computer systems, what I wear, vacation scheduling, taking call, or whether we need to hire different staff or open satellite offices (I still don’t understand why some doctors do the latter).

I could probably make more money by joining a group, but money isn’t the biggest thing to me. My life is a lot simpler here. I can control how many patients I see, how many hours I work, and what cases I take; this gives me time to see my kids.

Unfortunately, the pressures of repaying loans ASAP drive most people to join whatever group offers them the most money. As a result, most of today’s solo doctors are on their second (or third or ...) practice incarnation. They’ve gained enough experience to realize that big groups aren’t always what they’re made out to be. In solo practice, you’re at least working with someone you’ve lived with for your entire life, and you have a good idea of their strengths and weaknesses.

I have no more idea of what the future holds than you do. Every few years, there’s a prediction that solo doctors are on our way out. And maybe some day they’ll be right, and I’ll be forced to join a group again.

That will be too bad because medicine started out as a solo job, going back to the tribal medicine man, or healer. And, after all these years, I wouldn’t have it any other way.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

I’m in solo practice (yes, one of those doctors). We’re a dying breed, which is sad because I genuinely like it. It’s certainly not for everyone, but it suits me perfectly.

It’s not easy. In my first 6 months of doing this, I pretty much picked up an MBA just by experience. I’d never had to deal with payroll, withholding taxes, forms, licensing, and a million other things, and had to learn them on the fly.

But looking back, I’m glad I did it. Like many other doctors, I joined a large group right out of residency. They seemed to offer security, and it was easier than trying to hang up my own shingle. But after a few years of office politics, dealing with business people, and being forced to review graphs labeled "physician revenue per square foot of office space," I couldn’t take it anymore.

So here I am. This will be my 12th year flying solo, and I regret none of it. Nobody argues with me about my choice of computer systems, what I wear, vacation scheduling, taking call, or whether we need to hire different staff or open satellite offices (I still don’t understand why some doctors do the latter).

I could probably make more money by joining a group, but money isn’t the biggest thing to me. My life is a lot simpler here. I can control how many patients I see, how many hours I work, and what cases I take; this gives me time to see my kids.

Unfortunately, the pressures of repaying loans ASAP drive most people to join whatever group offers them the most money. As a result, most of today’s solo doctors are on their second (or third or ...) practice incarnation. They’ve gained enough experience to realize that big groups aren’t always what they’re made out to be. In solo practice, you’re at least working with someone you’ve lived with for your entire life, and you have a good idea of their strengths and weaknesses.

I have no more idea of what the future holds than you do. Every few years, there’s a prediction that solo doctors are on our way out. And maybe some day they’ll be right, and I’ll be forced to join a group again.

That will be too bad because medicine started out as a solo job, going back to the tribal medicine man, or healer. And, after all these years, I wouldn’t have it any other way.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

I’m in solo practice (yes, one of those doctors). We’re a dying breed, which is sad because I genuinely like it. It’s certainly not for everyone, but it suits me perfectly.

It’s not easy. In my first 6 months of doing this, I pretty much picked up an MBA just by experience. I’d never had to deal with payroll, withholding taxes, forms, licensing, and a million other things, and had to learn them on the fly.

But looking back, I’m glad I did it. Like many other doctors, I joined a large group right out of residency. They seemed to offer security, and it was easier than trying to hang up my own shingle. But after a few years of office politics, dealing with business people, and being forced to review graphs labeled "physician revenue per square foot of office space," I couldn’t take it anymore.

So here I am. This will be my 12th year flying solo, and I regret none of it. Nobody argues with me about my choice of computer systems, what I wear, vacation scheduling, taking call, or whether we need to hire different staff or open satellite offices (I still don’t understand why some doctors do the latter).

I could probably make more money by joining a group, but money isn’t the biggest thing to me. My life is a lot simpler here. I can control how many patients I see, how many hours I work, and what cases I take; this gives me time to see my kids.

Unfortunately, the pressures of repaying loans ASAP drive most people to join whatever group offers them the most money. As a result, most of today’s solo doctors are on their second (or third or ...) practice incarnation. They’ve gained enough experience to realize that big groups aren’t always what they’re made out to be. In solo practice, you’re at least working with someone you’ve lived with for your entire life, and you have a good idea of their strengths and weaknesses.

I have no more idea of what the future holds than you do. Every few years, there’s a prediction that solo doctors are on our way out. And maybe some day they’ll be right, and I’ll be forced to join a group again.

That will be too bad because medicine started out as a solo job, going back to the tribal medicine man, or healer. And, after all these years, I wouldn’t have it any other way.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

Recently, there was a post on Sermo.com, the online physician community, concerning a doctor taken to small claims court. A patient decided to seek a second opinion in another city and was trying to recoup travel expenses by suing him for plane fare.

That hit home. A few years ago, I ordered an MR angiogram to see if a patient had an aneurysm. His insurance covered the test, but he still had to pay about $500 as part of his deductible. He threatened to sue me for the entire amount unless I agreed to pay half.

I refused, and he tried very hard to make life miserable for me. He threatened several times to file a malpractice suit, telling me that he’d make sure my rates rose more than the $250 needed to placate him. I even reported it as a possible risk to my carrier, and they told me issues of this sort were quite common (to my surprise). I was told that they generally don’t go anywhere and are often used as a way of giving doctors ulcers.

I stood my ground, and after a few weeks he gave up and stopped calling. The experience left me quite shaken, which I suppose is what he wanted. I don’t routinely discuss tests and other costs with a patient unless asked. The variability in insurance plans makes it impossible for me to know how much of a study will come out of a patient’s pocket.

This doesn’t mean people haven’t tried. Patients do occasionally ask me to pick up part of a test’s cost, or to cover cab fare because I referred them to a tertiary care center downtown, or to pay other miscellaneous charges. I always refuse.

Obviously, there are significant differences between the two cases. My patient was following treatment recommendations, whereas the other patient sought a second opinion. But the point is similar: Should we be held liable for a patient’s ancillary expenses?

My answer is no, and I suspect I’d be hard pressed to find a doctor who disagrees. I certainly don’t expect my own internist to cover my deductible for routine tests, or to pay for time I take off work to go to his office or the cost of gas to drive there.

At the end of the day, we are only advisers. No one can force a patient to have a test or procedure, or take a medication, regardless of whether or not it’s within their financial means.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

Recently, there was a post on Sermo.com, the online physician community, concerning a doctor taken to small claims court. A patient decided to seek a second opinion in another city and was trying to recoup travel expenses by suing him for plane fare.

That hit home. A few years ago, I ordered an MR angiogram to see if a patient had an aneurysm. His insurance covered the test, but he still had to pay about $500 as part of his deductible. He threatened to sue me for the entire amount unless I agreed to pay half.

I refused, and he tried very hard to make life miserable for me. He threatened several times to file a malpractice suit, telling me that he’d make sure my rates rose more than the $250 needed to placate him. I even reported it as a possible risk to my carrier, and they told me issues of this sort were quite common (to my surprise). I was told that they generally don’t go anywhere and are often used as a way of giving doctors ulcers.

I stood my ground, and after a few weeks he gave up and stopped calling. The experience left me quite shaken, which I suppose is what he wanted. I don’t routinely discuss tests and other costs with a patient unless asked. The variability in insurance plans makes it impossible for me to know how much of a study will come out of a patient’s pocket.

This doesn’t mean people haven’t tried. Patients do occasionally ask me to pick up part of a test’s cost, or to cover cab fare because I referred them to a tertiary care center downtown, or to pay other miscellaneous charges. I always refuse.

Obviously, there are significant differences between the two cases. My patient was following treatment recommendations, whereas the other patient sought a second opinion. But the point is similar: Should we be held liable for a patient’s ancillary expenses?

My answer is no, and I suspect I’d be hard pressed to find a doctor who disagrees. I certainly don’t expect my own internist to cover my deductible for routine tests, or to pay for time I take off work to go to his office or the cost of gas to drive there.

At the end of the day, we are only advisers. No one can force a patient to have a test or procedure, or take a medication, regardless of whether or not it’s within their financial means.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

Recently, there was a post on Sermo.com, the online physician community, concerning a doctor taken to small claims court. A patient decided to seek a second opinion in another city and was trying to recoup travel expenses by suing him for plane fare.

That hit home. A few years ago, I ordered an MR angiogram to see if a patient had an aneurysm. His insurance covered the test, but he still had to pay about $500 as part of his deductible. He threatened to sue me for the entire amount unless I agreed to pay half.

I refused, and he tried very hard to make life miserable for me. He threatened several times to file a malpractice suit, telling me that he’d make sure my rates rose more than the $250 needed to placate him. I even reported it as a possible risk to my carrier, and they told me issues of this sort were quite common (to my surprise). I was told that they generally don’t go anywhere and are often used as a way of giving doctors ulcers.

I stood my ground, and after a few weeks he gave up and stopped calling. The experience left me quite shaken, which I suppose is what he wanted. I don’t routinely discuss tests and other costs with a patient unless asked. The variability in insurance plans makes it impossible for me to know how much of a study will come out of a patient’s pocket.

This doesn’t mean people haven’t tried. Patients do occasionally ask me to pick up part of a test’s cost, or to cover cab fare because I referred them to a tertiary care center downtown, or to pay other miscellaneous charges. I always refuse.

Obviously, there are significant differences between the two cases. My patient was following treatment recommendations, whereas the other patient sought a second opinion. But the point is similar: Should we be held liable for a patient’s ancillary expenses?

My answer is no, and I suspect I’d be hard pressed to find a doctor who disagrees. I certainly don’t expect my own internist to cover my deductible for routine tests, or to pay for time I take off work to go to his office or the cost of gas to drive there.

At the end of the day, we are only advisers. No one can force a patient to have a test or procedure, or take a medication, regardless of whether or not it’s within their financial means.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

Anybody ever give a patient a specific drug just because he asked for it? I do it all the time.

Granted, this doesn’t extend to situations where a drug is unnecessary or contraindicated, but – for example – if a migraine patient comes in and wants to try another preventive or triptan, what do you do? As with any other drug, I discuss it with the patient, and if she still wants it, and it’s not unreasonable, I’ll do it.

© Daniel Stein/istockphoto.com

Some out there will say that this makes me a pushover for direct-to-consumer advertising, since that’s where most patients hear about these things. (For the rest, the information usually comes from a friend or their own research.)

But realistically, resistance is futile. If you deny patients a reasonable request because it was their idea instead of yours, they’ll likely move on to another doctor, complain to their internist or friends about you, or both.

The argument of "your insurance doesn’t cover this" won’t hold water at first. Samples or your handwritten script are free. All it takes for them to realize they’d rather stay with their old medicine is the pharmacist’s telling them how much it will cost. So, in the end, economics will be the decider.

Generics work the same way. In most cases – the exception being epilepsy drugs – I won’t fight for brand names. Some patients think I can write magic notes to get them brand-name drugs at generic prices. It’s easier than arguing, so I write them. The cost will always make them change their mind.

After years of experience, I find that it’s a lot easier to let the patients’ pocketbooks make them realize this than to waste time trying to convince them myself.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

Anybody ever give a patient a specific drug just because he asked for it? I do it all the time.

Granted, this doesn’t extend to situations where a drug is unnecessary or contraindicated, but – for example – if a migraine patient comes in and wants to try another preventive or triptan, what do you do? As with any other drug, I discuss it with the patient, and if she still wants it, and it’s not unreasonable, I’ll do it.

© Daniel Stein/istockphoto.com

Some out there will say that this makes me a pushover for direct-to-consumer advertising, since that’s where most patients hear about these things. (For the rest, the information usually comes from a friend or their own research.)

But realistically, resistance is futile. If you deny patients a reasonable request because it was their idea instead of yours, they’ll likely move on to another doctor, complain to their internist or friends about you, or both.

The argument of "your insurance doesn’t cover this" won’t hold water at first. Samples or your handwritten script are free. All it takes for them to realize they’d rather stay with their old medicine is the pharmacist’s telling them how much it will cost. So, in the end, economics will be the decider.

Generics work the same way. In most cases – the exception being epilepsy drugs – I won’t fight for brand names. Some patients think I can write magic notes to get them brand-name drugs at generic prices. It’s easier than arguing, so I write them. The cost will always make them change their mind.

After years of experience, I find that it’s a lot easier to let the patients’ pocketbooks make them realize this than to waste time trying to convince them myself.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

Anybody ever give a patient a specific drug just because he asked for it? I do it all the time.

Granted, this doesn’t extend to situations where a drug is unnecessary or contraindicated, but – for example – if a migraine patient comes in and wants to try another preventive or triptan, what do you do? As with any other drug, I discuss it with the patient, and if she still wants it, and it’s not unreasonable, I’ll do it.

© Daniel Stein/istockphoto.com

Some out there will say that this makes me a pushover for direct-to-consumer advertising, since that’s where most patients hear about these things. (For the rest, the information usually comes from a friend or their own research.)

But realistically, resistance is futile. If you deny patients a reasonable request because it was their idea instead of yours, they’ll likely move on to another doctor, complain to their internist or friends about you, or both.

The argument of "your insurance doesn’t cover this" won’t hold water at first. Samples or your handwritten script are free. All it takes for them to realize they’d rather stay with their old medicine is the pharmacist’s telling them how much it will cost. So, in the end, economics will be the decider.

Generics work the same way. In most cases – the exception being epilepsy drugs – I won’t fight for brand names. Some patients think I can write magic notes to get them brand-name drugs at generic prices. It’s easier than arguing, so I write them. The cost will always make them change their mind.

After years of experience, I find that it’s a lot easier to let the patients’ pocketbooks make them realize this than to waste time trying to convince them myself.

Dr. Block has a solo neurology private practice in Scottsdale, Ariz. He has been a practicing neurologist since 1998 and in private practice since 2000.

How many of you out there use e-prescribing to get the Medicare bonus? Raise your hands. And how many of you with your hands up really find it’s easier than regular prescribing? I thought so.

I use it, too, although I am far from enamored with it. But, like most of you, I take Medicare, and don’t want to lose the bonus (or eventually be penalized). How do I hate thee? Let me count the ways.

My biggest gripe is controlled substances, an area where technology has clearly outstripped regulation. I can understand wanting to control some drugs, such as those on schedule II or maybe even schedule III, but my e-prescribing system won’t let me refill even minor things, like pregabalin (Lyrica) or zolpidem (Ambien). Here in Arizona, it also won’t let me fill carisoprodol (Soma) or Fioricet (acetaminophen, butalbital, and caffeine).

©Brian Jackson/iStockphoto.com

But it still sends e-refill requests on these drugs, when it knows I can’t refill them! You’d think it would have some way of filtering requests for controlled and noncontrolled substances, and sending the former by fax. It’s legal to send the refill request by fax, but one wonders: How much more secure is a fax to my office than the Internet?

So when an approval for a refill request for a controlled drug comes up online, I have this choice: I can ignore it and hope they’ll eventually fax me something, or I can try to approve it online.

When I do the latter it says, "This is prohibited. Click on the ‘contact me’ button to have the requesting pharmacy contact you by another method."

Sounds like a good idea, right? But when I do that, I’ve learned that all it does is tell the pharmacy that I denied it, which isn’t even close to the truth. So they tell the patient I denied it, and the patient gets angry and yells at my office.

I’ve verified this sad tale with different patients and local pharmacists. Because of getting burned like this, I now just ignore online controlled drug requests and wait until the patient or pharmacy contacts me. How efficient is that?

Another issue I have with our e-prescribing system is writing mega-pill amounts. It won’t allow greater than 999 pills per refill. I have no idea why.

For most scripts this isn’t an issue. But it occasionally crops up, usually with 90-day supplies of carbidopa-levodopa (Sinemet) or gabapentin (Neurontin). When that occurs, I’m pretty much stuck ordering the 999 or mailing the patient a paper script.

I don’t think e-prescribing is a time saver, either. The script I could write by hand in less than 1 minute often takes 3-5 minutes to send online if it’s a new script, or a new patient, or both.

Friends of mine who work in pharmacies tell me it hasn’t cut back on medication errors, either. And a quick search of the Internet finds similar complaints from both sides, so apparently I’m not alone.

I have nothing against progress, or technology, or even saving paper. Yet, requiring a technology to be used before it’s ready for prime time only replaces one set of problems with another – to the detriment of the patient.

How many of you out there use e-prescribing to get the Medicare bonus? Raise your hands. And how many of you with your hands up really find it’s easier than regular prescribing? I thought so.

I use it, too, although I am far from enamored with it. But, like most of you, I take Medicare, and don’t want to lose the bonus (or eventually be penalized). How do I hate thee? Let me count the ways.

My biggest gripe is controlled substances, an area where technology has clearly outstripped regulation. I can understand wanting to control some drugs, such as those on schedule II or maybe even schedule III, but my e-prescribing system won’t let me refill even minor things, like pregabalin (Lyrica) or zolpidem (Ambien). Here in Arizona, it also won’t let me fill carisoprodol (Soma) or Fioricet (acetaminophen, butalbital, and caffeine).

©Brian Jackson/iStockphoto.com

But it still sends e-refill requests on these drugs, when it knows I can’t refill them! You’d think it would have some way of filtering requests for controlled and noncontrolled substances, and sending the former by fax. It’s legal to send the refill request by fax, but one wonders: How much more secure is a fax to my office than the Internet?

So when an approval for a refill request for a controlled drug comes up online, I have this choice: I can ignore it and hope they’ll eventually fax me something, or I can try to approve it online.

When I do the latter it says, "This is prohibited. Click on the ‘contact me’ button to have the requesting pharmacy contact you by another method."

Sounds like a good idea, right? But when I do that, I’ve learned that all it does is tell the pharmacy that I denied it, which isn’t even close to the truth. So they tell the patient I denied it, and the patient gets angry and yells at my office.

I’ve verified this sad tale with different patients and local pharmacists. Because of getting burned like this, I now just ignore online controlled drug requests and wait until the patient or pharmacy contacts me. How efficient is that?

Another issue I have with our e-prescribing system is writing mega-pill amounts. It won’t allow greater than 999 pills per refill. I have no idea why.

For most scripts this isn’t an issue. But it occasionally crops up, usually with 90-day supplies of carbidopa-levodopa (Sinemet) or gabapentin (Neurontin). When that occurs, I’m pretty much stuck ordering the 999 or mailing the patient a paper script.

I don’t think e-prescribing is a time saver, either. The script I could write by hand in less than 1 minute often takes 3-5 minutes to send online if it’s a new script, or a new patient, or both.

Friends of mine who work in pharmacies tell me it hasn’t cut back on medication errors, either. And a quick search of the Internet finds similar complaints from both sides, so apparently I’m not alone.

I have nothing against progress, or technology, or even saving paper. Yet, requiring a technology to be used before it’s ready for prime time only replaces one set of problems with another – to the detriment of the patient.

How many of you out there use e-prescribing to get the Medicare bonus? Raise your hands. And how many of you with your hands up really find it’s easier than regular prescribing? I thought so.

I use it, too, although I am far from enamored with it. But, like most of you, I take Medicare, and don’t want to lose the bonus (or eventually be penalized). How do I hate thee? Let me count the ways.

My biggest gripe is controlled substances, an area where technology has clearly outstripped regulation. I can understand wanting to control some drugs, such as those on schedule II or maybe even schedule III, but my e-prescribing system won’t let me refill even minor things, like pregabalin (Lyrica) or zolpidem (Ambien). Here in Arizona, it also won’t let me fill carisoprodol (Soma) or Fioricet (acetaminophen, butalbital, and caffeine).

©Brian Jackson/iStockphoto.com

But it still sends e-refill requests on these drugs, when it knows I can’t refill them! You’d think it would have some way of filtering requests for controlled and noncontrolled substances, and sending the former by fax. It’s legal to send the refill request by fax, but one wonders: How much more secure is a fax to my office than the Internet?

So when an approval for a refill request for a controlled drug comes up online, I have this choice: I can ignore it and hope they’ll eventually fax me something, or I can try to approve it online.

When I do the latter it says, "This is prohibited. Click on the ‘contact me’ button to have the requesting pharmacy contact you by another method."

Sounds like a good idea, right? But when I do that, I’ve learned that all it does is tell the pharmacy that I denied it, which isn’t even close to the truth. So they tell the patient I denied it, and the patient gets angry and yells at my office.

I’ve verified this sad tale with different patients and local pharmacists. Because of getting burned like this, I now just ignore online controlled drug requests and wait until the patient or pharmacy contacts me. How efficient is that?

Another issue I have with our e-prescribing system is writing mega-pill amounts. It won’t allow greater than 999 pills per refill. I have no idea why.

For most scripts this isn’t an issue. But it occasionally crops up, usually with 90-day supplies of carbidopa-levodopa (Sinemet) or gabapentin (Neurontin). When that occurs, I’m pretty much stuck ordering the 999 or mailing the patient a paper script.

I don’t think e-prescribing is a time saver, either. The script I could write by hand in less than 1 minute often takes 3-5 minutes to send online if it’s a new script, or a new patient, or both.

Friends of mine who work in pharmacies tell me it hasn’t cut back on medication errors, either. And a quick search of the Internet finds similar complaints from both sides, so apparently I’m not alone.

I have nothing against progress, or technology, or even saving paper. Yet, requiring a technology to be used before it’s ready for prime time only replaces one set of problems with another – to the detriment of the patient.

Like any neurologist, I see patients with all kinds of weight-related issues: lumbar pain, type 2 diabetic neuropathy, stroke and cerebrovascular disease, and many more. So, in addition to being a neuro doc, I hand out a lot of general medicine advice: lose weight, eat better, exercise more, and take your statins and other pills.

The funny thing in all this is that I am myself about 60 pounds overweight. And, from what I see on hospital rounds, I’m not the only doctor who falls in the overweight category. My tall frame helps me hide it, but the scale and body mass index charts don’t lie.

Photo (c) travellinglight/iStockphoto.com

While I preach a healthy lifestyle, I don’t live one. Granted, I don’t smoke, and I take my simvastatin and niacin, but otherwise I make far from the best eating choices.

I think there could be a whole support group for physicians with poor eating and exercise habits. An ironic part of this job is that while we lecture patients on exercise, our schedules don’t allow many of us the time to do it ourselves. My average workday is about 14 hours, and when you try to get about 5-6 hours of sleep at night, help your kids with homework, and do other stuff at home and with your spouse, you pretty much find your exercise time limited to the hospital staircase on rounds.

I don’t know how medicine became this way. Certainly, I didn’t pick it for the lifestyle, but it’s sad that a field centered around the health of others often limits that of its practitioners.

Like any neurologist, I see patients with all kinds of weight-related issues: lumbar pain, type 2 diabetic neuropathy, stroke and cerebrovascular disease, and many more. So, in addition to being a neuro doc, I hand out a lot of general medicine advice: lose weight, eat better, exercise more, and take your statins and other pills.

The funny thing in all this is that I am myself about 60 pounds overweight. And, from what I see on hospital rounds, I’m not the only doctor who falls in the overweight category. My tall frame helps me hide it, but the scale and body mass index charts don’t lie.

Photo (c) travellinglight/iStockphoto.com

While I preach a healthy lifestyle, I don’t live one. Granted, I don’t smoke, and I take my simvastatin and niacin, but otherwise I make far from the best eating choices.

I think there could be a whole support group for physicians with poor eating and exercise habits. An ironic part of this job is that while we lecture patients on exercise, our schedules don’t allow many of us the time to do it ourselves. My average workday is about 14 hours, and when you try to get about 5-6 hours of sleep at night, help your kids with homework, and do other stuff at home and with your spouse, you pretty much find your exercise time limited to the hospital staircase on rounds.

I don’t know how medicine became this way. Certainly, I didn’t pick it for the lifestyle, but it’s sad that a field centered around the health of others often limits that of its practitioners.

Like any neurologist, I see patients with all kinds of weight-related issues: lumbar pain, type 2 diabetic neuropathy, stroke and cerebrovascular disease, and many more. So, in addition to being a neuro doc, I hand out a lot of general medicine advice: lose weight, eat better, exercise more, and take your statins and other pills.

The funny thing in all this is that I am myself about 60 pounds overweight. And, from what I see on hospital rounds, I’m not the only doctor who falls in the overweight category. My tall frame helps me hide it, but the scale and body mass index charts don’t lie.

Photo (c) travellinglight/iStockphoto.com

While I preach a healthy lifestyle, I don’t live one. Granted, I don’t smoke, and I take my simvastatin and niacin, but otherwise I make far from the best eating choices.

I think there could be a whole support group for physicians with poor eating and exercise habits. An ironic part of this job is that while we lecture patients on exercise, our schedules don’t allow many of us the time to do it ourselves. My average workday is about 14 hours, and when you try to get about 5-6 hours of sleep at night, help your kids with homework, and do other stuff at home and with your spouse, you pretty much find your exercise time limited to the hospital staircase on rounds.

I don’t know how medicine became this way. Certainly, I didn’t pick it for the lifestyle, but it’s sad that a field centered around the health of others often limits that of its practitioners.

I’ll admit it. I’ve been sued for malpractice.

I’m not going to go into the details of the case, but I’ll tell you this: It is absolutely the worst feeling you will ever have as a doctor.

Like most doctors, I try very hard to do my best for patients. I believe in "do no harm." I believe that my patient care decisions are guided by my belief in what’s best for them. Not what’s more convenient, or more financially lucrative, for me. Yet, I still got sued.

What’s amazing to me is how many doctors still believe it can’t happen to them, or that only the truly incompetent (whatever that means) get sued.

It hurts more than you could ever believe. It puts your life on hold. It adds a whole new burden to the huge weight you normally carry from day to day.

It even affects your family. You lie awake at night. Your hairs get grayer, or jump off entirely. You have many sleepless nights, trying to find a way to go on for your family and the patients who still need you.

You worry about rumors you’ve heard. That they can take your house, cars, and all belongings. That they can come to your house and pick out whatever items (including pets) they want. You realize why medical professionals have the highest rate of suicide, drug abuse, and alcoholism.

You question your own skills. Now, every patient you see needs a big-time work-up. Every patient with carpal tunnel syndrome needs a brain and cervical spine MRI "just to cover the bases."

Whether you win or lose, it devastates you as a person, and can kill the person deep inside who once celebrated getting a medical school admission letter.

I’ll admit it. I’ve been sued for malpractice.

I’m not going to go into the details of the case, but I’ll tell you this: It is absolutely the worst feeling you will ever have as a doctor.

Like most doctors, I try very hard to do my best for patients. I believe in "do no harm." I believe that my patient care decisions are guided by my belief in what’s best for them. Not what’s more convenient, or more financially lucrative, for me. Yet, I still got sued.

What’s amazing to me is how many doctors still believe it can’t happen to them, or that only the truly incompetent (whatever that means) get sued.

It hurts more than you could ever believe. It puts your life on hold. It adds a whole new burden to the huge weight you normally carry from day to day.

It even affects your family. You lie awake at night. Your hairs get grayer, or jump off entirely. You have many sleepless nights, trying to find a way to go on for your family and the patients who still need you.

You worry about rumors you’ve heard. That they can take your house, cars, and all belongings. That they can come to your house and pick out whatever items (including pets) they want. You realize why medical professionals have the highest rate of suicide, drug abuse, and alcoholism.

You question your own skills. Now, every patient you see needs a big-time work-up. Every patient with carpal tunnel syndrome needs a brain and cervical spine MRI "just to cover the bases."

Whether you win or lose, it devastates you as a person, and can kill the person deep inside who once celebrated getting a medical school admission letter.

I’ll admit it. I’ve been sued for malpractice.

I’m not going to go into the details of the case, but I’ll tell you this: It is absolutely the worst feeling you will ever have as a doctor.

Like most doctors, I try very hard to do my best for patients. I believe in "do no harm." I believe that my patient care decisions are guided by my belief in what’s best for them. Not what’s more convenient, or more financially lucrative, for me. Yet, I still got sued.

What’s amazing to me is how many doctors still believe it can’t happen to them, or that only the truly incompetent (whatever that means) get sued.

It hurts more than you could ever believe. It puts your life on hold. It adds a whole new burden to the huge weight you normally carry from day to day.

It even affects your family. You lie awake at night. Your hairs get grayer, or jump off entirely. You have many sleepless nights, trying to find a way to go on for your family and the patients who still need you.

You worry about rumors you’ve heard. That they can take your house, cars, and all belongings. That they can come to your house and pick out whatever items (including pets) they want. You realize why medical professionals have the highest rate of suicide, drug abuse, and alcoholism.

You question your own skills. Now, every patient you see needs a big-time work-up. Every patient with carpal tunnel syndrome needs a brain and cervical spine MRI "just to cover the bases."

Whether you win or lose, it devastates you as a person, and can kill the person deep inside who once celebrated getting a medical school admission letter.

Late last year, a study suggested that patients in the emergency department with a transient ischemic attack could be more cost-effectively treated by being sent to a neurology clinic for urgent evaluation, rather than being hospitalized for the 48 hours it takes for an average inpatient work-up (Neurology 2011;77:2082-8).

I entirely agree with this. The trouble is that these studies are always done at an academic institution and don’t take into account the nature of "trench warfare" neurology as it happens in private practice. I’ll point out some practical considerations.

©Tyler Olson/Fotolia.com

How do you plan on getting a patient seen on the same day (or even the next day) after they went to the ED? Most neurologists are booked up at least 1-2 weeks in advance. I personally start seeing patients at 8 o’clock each morning (sometimes 7 o’clock) and don’t break for lunch. I work straight through. So where am I (or anyone else) going to put them in? I suppose some people might say, "Just send them over and I’ll squeeze them in," but (in my opinion) that doesn’t work very well. You just end up trying to see them AND the rest of the patients in a rush and do a half-assed job on all of them. Quantity of care is NEVER equal to quality of care, no matter how hard you try to make them the same.

The idea of doing the work-up as an outpatient is compelling but brings up its own issues that the article didn’t consider:

• Insurance. In the hospital, whatever you order gets done. But as an outpatient, you may have to go through several layers of authorization to get an MRI and MRA. This could include having to make a doctor-to- doctor authorization phone call and can take 1-2 weeks depending on the insurance. A lot more can go wrong in 2 weeks than in a 48-hour hospital stay.

• Convenience. You need an MRI, echocardiogram, and labs? Maybe an EEG in some cases? In the hospital, they all get done THERE. But for an outpatient, you need three to four different facilities. This will likely increase the time of the work-up and make it harder for the patient. The tests will have to be done on different days, and some people will have trouble arranging transportation.

• Compliance. Let’s face it – a hospital patient is a captive audience. Aside from watching daytime TV and eating, there’s not much else to do but go have tests done. But if you spread the tests out over 1-2 weeks, the compliance factor may drop dramatically. A patient may start to think in terms of "I feel fine today, so why do I need this?" or cancel the test to attend a grandson’s birthday party and then never bother to reschedule it.

Lastly, there are the legal issues. How many of you neurologists out there want it documented in the chart that you personally told the emergency medicine doctor to discharge a TIA patient for outpatient follow-up? How many of you can envision an ED doctor wanting to take the legal risks of writing that order? And, perhaps most important, how many of you can easily see yourself being cross-examined by Marty Malpractice, J.D., about why you ordered a TIA patient sent home who then suffered a massive stroke that night? All the literature supporting your position may not make you look good in those circumstances.

The only way I actually see this working out is with a national set of solid guidelines telling us to do this and tort reform to help protect the doctors who follow them. And let’s face it, neither is likely to happen in my lifetime.

Late last year, a study suggested that patients in the emergency department with a transient ischemic attack could be more cost-effectively treated by being sent to a neurology clinic for urgent evaluation, rather than being hospitalized for the 48 hours it takes for an average inpatient work-up (Neurology 2011;77:2082-8).

I entirely agree with this. The trouble is that these studies are always done at an academic institution and don’t take into account the nature of "trench warfare" neurology as it happens in private practice. I’ll point out some practical considerations.

©Tyler Olson/Fotolia.com

How do you plan on getting a patient seen on the same day (or even the next day) after they went to the ED? Most neurologists are booked up at least 1-2 weeks in advance. I personally start seeing patients at 8 o’clock each morning (sometimes 7 o’clock) and don’t break for lunch. I work straight through. So where am I (or anyone else) going to put them in? I suppose some people might say, "Just send them over and I’ll squeeze them in," but (in my opinion) that doesn’t work very well. You just end up trying to see them AND the rest of the patients in a rush and do a half-assed job on all of them. Quantity of care is NEVER equal to quality of care, no matter how hard you try to make them the same.

The idea of doing the work-up as an outpatient is compelling but brings up its own issues that the article didn’t consider:

• Insurance. In the hospital, whatever you order gets done. But as an outpatient, you may have to go through several layers of authorization to get an MRI and MRA. This could include having to make a doctor-to- doctor authorization phone call and can take 1-2 weeks depending on the insurance. A lot more can go wrong in 2 weeks than in a 48-hour hospital stay.

• Convenience. You need an MRI, echocardiogram, and labs? Maybe an EEG in some cases? In the hospital, they all get done THERE. But for an outpatient, you need three to four different facilities. This will likely increase the time of the work-up and make it harder for the patient. The tests will have to be done on different days, and some people will have trouble arranging transportation.

• Compliance. Let’s face it – a hospital patient is a captive audience. Aside from watching daytime TV and eating, there’s not much else to do but go have tests done. But if you spread the tests out over 1-2 weeks, the compliance factor may drop dramatically. A patient may start to think in terms of "I feel fine today, so why do I need this?" or cancel the test to attend a grandson’s birthday party and then never bother to reschedule it.

Lastly, there are the legal issues. How many of you neurologists out there want it documented in the chart that you personally told the emergency medicine doctor to discharge a TIA patient for outpatient follow-up? How many of you can envision an ED doctor wanting to take the legal risks of writing that order? And, perhaps most important, how many of you can easily see yourself being cross-examined by Marty Malpractice, J.D., about why you ordered a TIA patient sent home who then suffered a massive stroke that night? All the literature supporting your position may not make you look good in those circumstances.

The only way I actually see this working out is with a national set of solid guidelines telling us to do this and tort reform to help protect the doctors who follow them. And let’s face it, neither is likely to happen in my lifetime.

Late last year, a study suggested that patients in the emergency department with a transient ischemic attack could be more cost-effectively treated by being sent to a neurology clinic for urgent evaluation, rather than being hospitalized for the 48 hours it takes for an average inpatient work-up (Neurology 2011;77:2082-8).

I entirely agree with this. The trouble is that these studies are always done at an academic institution and don’t take into account the nature of "trench warfare" neurology as it happens in private practice. I’ll point out some practical considerations.

©Tyler Olson/Fotolia.com

How do you plan on getting a patient seen on the same day (or even the next day) after they went to the ED? Most neurologists are booked up at least 1-2 weeks in advance. I personally start seeing patients at 8 o’clock each morning (sometimes 7 o’clock) and don’t break for lunch. I work straight through. So where am I (or anyone else) going to put them in? I suppose some people might say, "Just send them over and I’ll squeeze them in," but (in my opinion) that doesn’t work very well. You just end up trying to see them AND the rest of the patients in a rush and do a half-assed job on all of them. Quantity of care is NEVER equal to quality of care, no matter how hard you try to make them the same.

The idea of doing the work-up as an outpatient is compelling but brings up its own issues that the article didn’t consider:

• Insurance. In the hospital, whatever you order gets done. But as an outpatient, you may have to go through several layers of authorization to get an MRI and MRA. This could include having to make a doctor-to- doctor authorization phone call and can take 1-2 weeks depending on the insurance. A lot more can go wrong in 2 weeks than in a 48-hour hospital stay.

• Convenience. You need an MRI, echocardiogram, and labs? Maybe an EEG in some cases? In the hospital, they all get done THERE. But for an outpatient, you need three to four different facilities. This will likely increase the time of the work-up and make it harder for the patient. The tests will have to be done on different days, and some people will have trouble arranging transportation.

• Compliance. Let’s face it – a hospital patient is a captive audience. Aside from watching daytime TV and eating, there’s not much else to do but go have tests done. But if you spread the tests out over 1-2 weeks, the compliance factor may drop dramatically. A patient may start to think in terms of "I feel fine today, so why do I need this?" or cancel the test to attend a grandson’s birthday party and then never bother to reschedule it.

Lastly, there are the legal issues. How many of you neurologists out there want it documented in the chart that you personally told the emergency medicine doctor to discharge a TIA patient for outpatient follow-up? How many of you can envision an ED doctor wanting to take the legal risks of writing that order? And, perhaps most important, how many of you can easily see yourself being cross-examined by Marty Malpractice, J.D., about why you ordered a TIA patient sent home who then suffered a massive stroke that night? All the literature supporting your position may not make you look good in those circumstances.

The only way I actually see this working out is with a national set of solid guidelines telling us to do this and tort reform to help protect the doctors who follow them. And let’s face it, neither is likely to happen in my lifetime.

I’ve never been a stickler for dress codes. In fact, I’ve never really understood them.

My colleagues down the street at the Mayo Clinic Scottsdale show up for work each day in the traditional uniform of our profession – a nice business suit, with tie. They look very fashionable.

That’s not me.

My choice of clothing has evolved over the years. In residency it was a shirt, tie, and slacks, sometimes with a white coat. Eventually, I ditched the white coat when I decided it was easier just to carry my neurology toys in a black bag.

When I became an attending physician in 1998, I continued this outfit for about 6 months, then dropped the tie and switched to more comfortable short-sleeve shirts. I did this until June 15, 2006 – a day that will live forever in fashion infamy.

Courtesy Wikimedia Commons/Vera & Jean-Christophe/Creative Commons License

I was getting dressed that morning. It was supposed to be around 114° F, and I suddenly had an epiphany. I realized that dressing like that every damn day was insane. So I decided to go with a decent pair of shorts. But business shirts and shoes don’t go with shorts, so I pulled on a Hawaiian shirt and sneakers.

Nobody complained, so I continued. Because of the weather here I can do this year-round, too.

As I’ve learned, the vast majority of patients don’t care. Granted, there are exceptions, as this post about me on the doctor review site vitals.com notes: "HOW CAN YOU TRUST A DOC THAT ... SHOWS UP IN HAWAIAN SHORTS AND KHAKIS? REALLY?" (Caps and misspellings are sic.)

Another person on the site criticized me for wearing jeans to work. This is a LIE! I’ve never worn jeans to work. Only shorts since 2006.

In 6 years, I’ve had four patients fire me over my appearance. And I don’t care. If a nice outfit makes you feel I’m a better doctor, there are plenty of others you can see.

If I have to spend my day at a high-stress job, I might as well be comfortable. And I am.

I’ve never been a stickler for dress codes. In fact, I’ve never really understood them.

My colleagues down the street at the Mayo Clinic Scottsdale show up for work each day in the traditional uniform of our profession – a nice business suit, with tie. They look very fashionable.

That’s not me.

My choice of clothing has evolved over the years. In residency it was a shirt, tie, and slacks, sometimes with a white coat. Eventually, I ditched the white coat when I decided it was easier just to carry my neurology toys in a black bag.

When I became an attending physician in 1998, I continued this outfit for about 6 months, then dropped the tie and switched to more comfortable short-sleeve shirts. I did this until June 15, 2006 – a day that will live forever in fashion infamy.

Courtesy Wikimedia Commons/Vera & Jean-Christophe/Creative Commons License

I was getting dressed that morning. It was supposed to be around 114° F, and I suddenly had an epiphany. I realized that dressing like that every damn day was insane. So I decided to go with a decent pair of shorts. But business shirts and shoes don’t go with shorts, so I pulled on a Hawaiian shirt and sneakers.

Nobody complained, so I continued. Because of the weather here I can do this year-round, too.

As I’ve learned, the vast majority of patients don’t care. Granted, there are exceptions, as this post about me on the doctor review site vitals.com notes: "HOW CAN YOU TRUST A DOC THAT ... SHOWS UP IN HAWAIAN SHORTS AND KHAKIS? REALLY?" (Caps and misspellings are sic.)

Another person on the site criticized me for wearing jeans to work. This is a LIE! I’ve never worn jeans to work. Only shorts since 2006.

In 6 years, I’ve had four patients fire me over my appearance. And I don’t care. If a nice outfit makes you feel I’m a better doctor, there are plenty of others you can see.

If I have to spend my day at a high-stress job, I might as well be comfortable. And I am.

I’ve never been a stickler for dress codes. In fact, I’ve never really understood them.

My colleagues down the street at the Mayo Clinic Scottsdale show up for work each day in the traditional uniform of our profession – a nice business suit, with tie. They look very fashionable.

That’s not me.

My choice of clothing has evolved over the years. In residency it was a shirt, tie, and slacks, sometimes with a white coat. Eventually, I ditched the white coat when I decided it was easier just to carry my neurology toys in a black bag.

When I became an attending physician in 1998, I continued this outfit for about 6 months, then dropped the tie and switched to more comfortable short-sleeve shirts. I did this until June 15, 2006 – a day that will live forever in fashion infamy.

Courtesy Wikimedia Commons/Vera & Jean-Christophe/Creative Commons License

I was getting dressed that morning. It was supposed to be around 114° F, and I suddenly had an epiphany. I realized that dressing like that every damn day was insane. So I decided to go with a decent pair of shorts. But business shirts and shoes don’t go with shorts, so I pulled on a Hawaiian shirt and sneakers.

Nobody complained, so I continued. Because of the weather here I can do this year-round, too.

As I’ve learned, the vast majority of patients don’t care. Granted, there are exceptions, as this post about me on the doctor review site vitals.com notes: "HOW CAN YOU TRUST A DOC THAT ... SHOWS UP IN HAWAIAN SHORTS AND KHAKIS? REALLY?" (Caps and misspellings are sic.)

Another person on the site criticized me for wearing jeans to work. This is a LIE! I’ve never worn jeans to work. Only shorts since 2006.

In 6 years, I’ve had four patients fire me over my appearance. And I don’t care. If a nice outfit makes you feel I’m a better doctor, there are plenty of others you can see.

If I have to spend my day at a high-stress job, I might as well be comfortable. And I am.