letters

Documenting away a malpractice suit

Dr. Edward Zurad did a fine job of describing how to protect oneself from malpractice claims in his article "Don't Be a Target for a Malpractice Suit" [June 2006]. I enjoyed reading it.

As a medical director for a large insurance company, I read more progress notes and letters from physicians about medical necessity than most practicing physicians will see in a lifetime. I am dumbfounded at the lack of documentation and the attorney-esque hyperbole that I see every day. Vital signs are more often omitted from the physical exam than recorded; right versus left is commonly omitted when discussing bilateral body parts; medical history is usually garbled; medications are not noted; and so it goes. It's downright embarrassing sometimes.

So, expanding somewhat on Dr. Zurad's points, these are my hints for avoiding malpractice risk:

G. Dan Mingea, MD, FAAP
Wylie, Texas

The collections treadmill

I read "Getting Off the Collections Treadmill" [June 2006] by Dr. Kristen Dillon with interest. I've been using the approach outlined in the article for more than a decade.

I have a few additional tips to offer: If you decide to discharge a patient from your panel, be sure to notify his or her managed care plan, as notification is required in most contracts. When notifying patients that their account will be sent to collections, I send one letter requesting the U.S. Postal Service's return receipt and I send a copy in a plain white envelope that is addressed and stamped by hand. If only the return receipt letter comes back, you can bet someone got the other letter. A wise collections expert once told me, "The people you send to collections are old pros at the collection game. They know the letter they have to sign for at the post office isn't from Ed McMahon notifying them that they have won the sweepstakes."

I am unapologetic about my policies. Too many patients think that all doctors are "rich and greedy." We have to pay bills just like they do. I find it especially easy to dismiss patients who smoke and then say they "can't afford" to pay me. They rarely see the irony of sitting in my office with a pack of cigarettes in their pocket when they say such things.

Janet Beck Jakupcak, MD
Marseilles, Ill.

Prescribing decisions should consider cost

Thank you for publishing "New Drugs: How to Decide Which Ones to Prescribe" [June 2006] by Dr. Philip Mohler. I wish more physicians would give credence to the issues of cost and efficacy. Too many people don't realize that they're prescribing drugs incorrectly. Why are there so many prescriptions for bid dosing of Toprol XL? Isn't the point of "XL" (aside from extra large windfall for the drug company) once a day administration?

In the ambulatory surgery center where I am the chief nurse anesthetist and responsible for ordering and maintaining the drug inventory, I know that at least one physician doesn't believe that generic metoprolol works and insists that his patients take Toprol XL bid. Furthermore, he doesn't believe Toprol XL tablets should be split despite the fact that they're scored. The contract cost at my health care facility for 100 25 mg Toprol XL tablets is equivalent to 100 50 mg tablets, which is $74 to $78 at wholesale cost. Generic metoprolol is even cheaper than pill splitting. One hundred tablets cost $3. This is significant for someone without prescription coverage who must shoulder the entire cost.

It is useless to prescribe drugs that patients can't afford. Doing so fails to keep the best interest of the patient in mind. Thank you, Dr. Mohler, for addressing a concern that is all too obvious to many of us as providers and health care recipients.

Robert B. Morgan, BSN, MA, CRNA
Elburn, Ill.

Dress like professionals

Dr. Bobby Newbell's article "Dressed to Ill" [June 2006] sounded like an effort to justify the lazy actions of doctors who are willing to sacrifice professionalism for comfort. He writes, "Dressing somewhat formally once conveyed maturity, professionalism and success." It still does! Nonverbal communication comes in many forms, and professional appearance is not the least of these. I respect my patients, and that's why I make the effort to show them professionalism at all levels, including through my attire. Until studies prove otherwise, we must do our best to appear professional and advance what we have left of our professional status.

Wm. Jackson Epperson, MD, MBA, FAAFP
Murrells Inlet, S.C.

Diagnosis du jour

I realize that Dr. Zachary Flake had humorous intent in writing his essay, "Diagnosis Du Jour" [July/August 2006], but it seems to me that a frivolous attitude toward accurate diagnosis is inconsistent with high-quality patient care. Telling worried seniors with ordinary aches and pains that they may have polymyalgia rheumatica will send some of them to the Internet for information. There they can read that this disease can lead to blindness or a stroke, it may be associated with the condition giant cell arteritis that "damages the arteries" and "there is no known cure" (http://www.clevelandclinic.org). The result may be inappropriate anxiety, a needless and unproductive consultation with a rheumatologist and possibly a fruitless course of corticosteroid treatment.

Sloppy diagnosis may "simplify life" for doctors, but it can impede high-quality patient care. A common example of this is diagnosing sinusitis when the real problem is allergic rhinitis. This may lead one to prescribe useless antibiotic treatment and to fail to educate the patient about common-sense allergen avoidance.

Robert D. Gillette, MD
Poland, Ohio

I thoroughly enjoyed Dr. Zachary Flake's article about how a diagnosis can slowly become an epidemic in your practice. I can relate, as I have seen this happen to myself over the years. Recently I've noticed how drug companies are taking advantage of this phenomenon. It starts with free CME or a monograph on a new diagnosis. Then maybe an article shows up in a journal. Soon a drug rep wants to discuss the diagnosis and gives me patient handouts or even a patient questionnaire to help me screen for it. Then ads appear during my favorite TV show telling people to go see their doctor if they have the symptoms. The diagnosis seems to take on epidemic proportions; everyone is suffering from it. Finally, a new, expensive drug is released that treats this diagnosis. It's advertised in journals, newspapers and television. Patients begin calling and requesting it. Since I have been using the diagnosis for several months at this point, everyone already believes they have it and the cure is just a pill away. I begin to feel used, manipulated and even angry - until the next new diagnosis distracts me and the cycle starts again. Please excuse me while I get back to my articles on the prevalence of chronic idiopathic constipation and erectile dysfunction.

Kevin T. Seufert, MD
Vista, Calif.

Explaining the benefits of vaccinations

I applaud Dr. Linwood Watson for his creativity in encouraging his patients to get a pneumococcal vaccination [Practice Pearls, "Explain the benefits of pneumonia immunization," September 2006]. His metaphor of buying 23 things with a dollar is simple and convincing, and it is an excellent way of promoting this important immunization. We should follow Dr. Watson's example and come up with similar metaphors for other vaccinations as well. I believe that the better arguments we can find to promote vaccinations, the greater immunization coverage we can achieve among patients of all literacy levels. This would bring us closer to our goal to protect the general public from serious infectious diseases.

Christian T. K.-H. Stadtländer, PhD, MPH, MBA
St. Paul, Minn.

Clarification

Alvin Lin, MD, author of "The Top PDA Resources for Family Physicians" [July/August 2006], has disclosed that he has on occasion received free software from Epocrates for acting as a beta tester. Epocrates offers one of the programs listed in Dr. Lin's article.