Friday, June 27, 2008

Fun with Drug Testing, Volume One

You know, I've been a Medical Review Officer for a little while now, and from time-to-time I begin to think that it is fairly routine. Then someone pulls a new one on me. This happened yesterday.

I wrote a couple of days ago about the cocaine-user personality type. They are usually the most violent in their protests, and therefore are usually the most fun. Marijuana users, however, are normally quite complacent and resigned, zen-like, to their fate. Now I don't claim to know which is the chicken and which is the egg in this scenario. Are laid-back, complacent people attracted, naturally, to cannabis? Are intense, aggressive personalities are already primed by nature for cocaine use? Or is it the substances themselves that impart these personality traits? As an aside, I find this fascinating. Occasionally, however, I run across someone who seems to have chosen (or been chosen by) the wrong drug.
The call is made. The donor answers. I explain the purpose of my call. I verify her identity. I note that she doesn't seem all that surprised to hear from me - never a good sign. I inform her that her drug test is positive for THC (marijuana). Then all Hell breaks loose.

She moans loudly, as if in anguish. It's almost more of a screech, really. She begins to protest.

"But I'm not a user! I don't use marijuana! That's impossible!"

"Ma'am, it is not my place or my desire to accuse you of anything. I am simply notifying you that, for whatever reason, there is marijuana residue in your urine."

"But I don't use marijuana!!!" Now it gets interesting.

She muffles the phone just enough to make it obvious that she is telling someone what is going on.
"The doctor says my drug test is positive for marijuana!"

"What? But you don't even use marijuana!"

The unexpected appearance of this new player in our little game catches me a little off guard, but is almost immediately funny to me. I instantly imagine a number of different comedic scenarios where two potheads hatch this little plan. I imagine their rehearsals - "No, you have to speak more clearly for him to hear...". Eventually, she admits to the old stand-by: second-hand exposure. Incidentally, this doesn't work, so I don't know why people still try it. This further validates the result, at least in my mind. As usual, I picture a room or a car, filled with cannabis smoke, and the innocent donor, just trying to have a good time, but passing on grass. Right.

Thursday, June 26, 2008

Country Doctors Finally Get Their Just Desserts

After decades of exploiting the inept rural masses through their subtle manipu-lation, the so-called Family Doctor has finally been positioned for eradication by American Medicine.

Until recently, among the various interests that run this multi-billion dollar industry, there had been disagreement about the best way to snuff out the last remnants of what all agree is an anachronistic, generally unnecessary barrier between these patients and the sub-sub specialists they so desperately need and want. Finally, through a combination siege of decreased reimbursements, federal regulations, paperwork, and public criticism of the lack of professionalism of these "people's doctors", it appears that at last, each medical problem can and will be cared for by a different physician.

The American Medical Association, long-time supporter of the Sub-Specialist cause, applauds the progress. In a series of steps that began with demanding board certification for Family Physicians, then failing to act while "Physician Extenders" (Nurse Practitioners and Physician Assistants) took over the role previously played by the country doctors, they virtually assured the end for Family Medicine. This victory is especially good news for the other major player in the medical industry, the insurance lobby.

With primary care services provided by nurses and medical technologists, the costs are expected to be significantly lower on the front end. Diagnosis is expensive, and by limiting the role of the primary care provider to filling medications and gathering data for the specialists, it is expected to create what is already being gleefully predicted as an "Insurance Boom".

There is an another possible unexpected benefit to this sea-change in the way medicine is practiced. By centralizing medical expertise in larger and larger medical centers, then relegating the data collection duties to physician extenders where the patients live, it should pave the way for the eventual socialization of healthcare. In fact, insurance executives and the government are already looking ahead and working together to find a solution to the next big problem - the glut of subspecialists. With advances in telemedicine, a future with one cardiologist per state seems finally within our grasp.

Patients seem to love this new, less personal style of care. Family doctors and medical schools have been trying for years to force their gentle, relationship-based, preventive-minded approach down their throats. The public has answered with a resounding silence as their methods have been discredited and the practitioners of this ancient art have been put out of business. Finally, it appears that we can say, along with the insurance lobby, the American Socialist Party, and the (for now) safe subspecialists, "Good riddance".

Wednesday, June 25, 2008

An open letter to cokeheads

Dear Friends,

You know that doctor that calls you to talk about your drug test? Well, there's no easy way to say this...I'm that guy. I'm what we in the party-pooping industry call an MRO - a certified Medical Review Officer. I know - sounds made up. Anyway, yes, I am the one who calls you and - well, I have to assume from the way that you usually sound when you answer - interrupts your good time with friends to notify you that you will not be funding your habit with a real job any time soon. This isn't the most pleasant work sometimes. Despite what you might think, I take no joy in calling. But I've noticed something you should be aware of. You guys are making this too easy for me. It's almost like you're all reading from the same playbook. Just know that if it seems a logical way to counter me, believe it or not, somebody else already thought of it and has tried it. About a thousand times. Do you have any idea how difficult it is to truly invent something unique???
Anyway, I have decided to write this letter in order to save you the trouble of embarrassing yourself in your attempts to convince me that some terrible mistake has been made. There are a few of you that are really, really good. Keep that up, folks. You are almost (almost) believable. It makes this much more entertaining for me, and believe me, the money isn't all that good so entertainment is about all I'm getting out of this. So here is a little help for you. If we are going to have to spend this time together, we might as well sort this out.

First of all, you must realize how alike you all sound. So much so, in fact, that I have decided that it is not even you talking. It is cocaine. I don't know you, it's true. But cocaine? Ah, I know cocaine very well - at least from a distance.

Cocaine is one gregarious character. You just find yourself wanting to believe cocaine. He has a zest for life that is infectious. To be sure, he usually outlasts all his friends, leaving them a miserable, tired wreck. But they love him all the more. Oh, don't try and cover for him. You'll only look silly. Cocaine does a fine job protecting himself, thank you very much.

Cocaine is also the eternal optimist. No matter how many times we've spoken, he always insists on playing our little game...I let him know I've found him in someone's urine, he vehemently denies it, cursing me, the prospective employer, etc. He is especially fond of threatening to call his attorney on me. In typical fashion, I assume that his attorney is Mark Geragos or someone high-profile. Why wouldn't it be? This is cocaine we're talking about here, right?!?

But, in the end, cocaine knows I have him dead to rights. He'll talk a good game, but he knows when he should leave the party. After all, only amateurs make principled but doomed stands. And cocaine has been around this block a time or two. At least.

So the next time you get a call right after you've gone to sleep at one-o'clock in the afternoon and you don't recognize the number - that is, if you still have your phone - just answer it, okay? I won't be a jerk. And save yourself the trouble and exhaustion of feigning outrage and bandying your threats about. I know who I'm dealing with here. And tell cocaine I said hello. I'll catch up with him later on.

Tuesday, June 24, 2008

Close the door! And put something heavy against it!

There is definitely something about the full moon. Or maybe it is some other cosmic phenomenon; I don't know. What I do know, and what just about any emergency room employee will tell you, is that there are times when it seems that the flood gates of craziness open and pour directly into your place of work. Yesterday was such a day.

I know that nuttiness is out there somewhere. You run across it from time to time so you know it exists. The law of averages would seem to suggest that you should have a homogeneous mix of craziness throughout the year - some percentage of your total - but that is not the case. They lurk, out there in the world, until the time is right. What I can't figure out is what sort of signal causes them to attack en masse.

Rather than tackle this weighty issue, which is definitely beyond me, I choose to describe these people. I am in the process of creating a sort of taxonomy system so that all of us who deal with the public can simply name them instead of wasting our precious time and energy describing their activities. No one would bother describing how a tiger took down a gazelle in detail - that's just what tigers do. I welcome your input during this process. I think a dictionary or encyclopedia of misfits might be in the pipeline. I will try to add to this list as I am reminded of other types.

Class One - "The squeaky wheel":

These nuts have discovered that they can raise the stakes in a conversation or interaction to a place where no sane person would dare follow. They have become masters of manipulation - using our own common sense against us. They bait us into interaction, usually by appealing to our genuine desire to help others - only to bring the axe down when we are within their grasp. They have discovered the secret of social blackmail - that if they are the most irritating person in the room, they often get served first and best in order to avoid a scene.

Class Two - "The Mr. Wilson":

A little advice - just because you are advancing in years does not give you the right to be a grumpy, uncompromising jerk. I know, I know. I'm not doing my job the way you would. I'm sure I'm not doing it the way doctors used to. And I'm sure that you, like me, disapprove of the majority of what you see going on in the world these days. None of that, however, is the fault of me or my staff. So lay off, dude.

Class Three - "The Over-Protector":

I actually had one of these yesterday, too. It is usually a husband, but may also be a parent. Whether for desire for some sort of secondary personal gain or because they are maniacally self-centered, believing that no one can care for the object of their affection the way they can, this type is disposed to violent outbursts that take on the appearance of legitimate concern. The problem is, their nuttiness drives a wedge between the patient and the person who has the ability to help them. My feeling is, if you could do this yourself, then why are you here right now? Back off and let me do my job. Please.

Class Four - "The Shape-Shifter":

This is one of my personal favorites. This looks somewhat like what we doctors have termed Borderline Personality Disorder. You start out as "the best doctor in the world", then slowly become the Adolf Hitler of modern American Medicine as you consistently fail to live up to the ridiculous expectations and demands of the patient. These people are exhausting, especially if you make the common rookie mistake of trying to reason with them and prove that you really are not the evil anti-Christ they accuse you of being. Listen to the voice of experience, people.

This is so much fun, I really hate to stop. I'll try to add some more later. Thanks for your patience.

Monday, June 23, 2008


I suppose everyone has to start somewhere. I have always loved to write, and I have missed it very much. It is remarkable how blogging has given a forum to all of us amateurs. So far, it seems to be pretty straight-forward. Maybe my technophobia won't show too badly.

I'm not entirely sure what this will become. I have thought about trying to create a forum for medical questions and/or complaints...kind of an "ask the doctor" deal. But I've also had a great desire to write about some of the political and economic issues that face American Medicine - and that have been so front-page lately. Perhaps it can be a little of both. I guess some introductions are in order so you can know your author a little better.

I am a Texan. Worse still, I am a Texan of the most obnoxious variety, as I do not currently reside in Texas. A dear college friend of mine from California was convinced that the brainwashing of Texas schoolchildren occurred in about 4th grade, as it seemed to her that for anyone over the age of about 10 it was already too late. I guess there's some truth in that. It's not easy being number one.

I first left home at seventeen after enlisting in the U.S. Marine Corps. I spent 4 years mostly "State-side", and was honorably discharged to pursue my education. I attended Panola College for a year, then transferred to Baylor University. I graduated with a Bachelor of Science degree in Biology, and just a couple of credits short of minoring in religion, classics, and chemistry. I was accepted into the University of Texas Medical School at San Antonio, and graduated in 2003. I completed a rotating internship in family and community medicine with heavy obstetrics experience in Conroe, Texas. I moved to Alabama and began practicing as a general practitioner in 2004.

If required to sum up my feeling about my practice of medicine in one word, I fear it would probably be - well, disappointed. It would be an oversimplification to blame that disappointment all on the changing economics, or the interference of third parties in the doctor-patient relationship, or the lack of respect afforded family physicians in the specialist-driven marketplace, or even to blame it all on the many external factors, as I am confident my own weaknesses have contributed mightily to this situation as well. I do feel strongly, however, that the world has changed, and has left the Family Physician, critical to the success of the system, behind.

I look forward to posting and I hope that you will all find it interesting, entertaining, thought-provoking, or at least an amusing glimpse into the madness and silliness that is my life.