Throwaway05
22d ago
but compared to almost every other country there is still some strange probability, of maybe 20%, that you eat something that tastes perfectly average and leaves you feeling diffusely sick for the next day like someone force-fed you a liter of gutter oil.
If this is happening to you the issue is likely something along the lines of too much fat or too much salt for your digestive system.
It's relatively common in America for Americans to have that problem with salt in Americanized Chinese food for instance.
Throwaway05
26d ago
Someone probably already told you this or you put it together yourself, but just in case -
Physician notes are usually organized in the "SOAP" fashion (subjective, objective, assessment, plan) for most purposes the A/P is all that matters so you can usually scroll down to the A/P (and some EMRs will directly facilitate this). Anything materially valuable should be recapped in that spot "...given patient's reports of acute pain, profound anorexia and reported history of diverticular disease as well as supra pubic tenderness suspect episode of diverticulitis..."
Lots of EMRs will also let you filter out the copy forward /auto filler to make things easier to read and identify any S/O that actually has value.
Unfortunately the EMR help won't help if you are getting PDF print outs.
I also support the movement to reformat the notes to APSO format to shove the useless shit to the bottom. Some places do that by default.
If you are getting a complete record I hope they aren't sending you all the bullshit nursing notes.
Throwaway05
26d ago
I look at a lot of medical records for work
Hmmm, any comments on what I could be doing in my documentation but probably don't.
Throwaway05
26d ago
I mean soccer aka football.
Always useful to have something you can talk to patients about. It can distract them, calm them down, normalize you, establish empathy, whatever.
It can be hard to be a normal person in medicine.
Throwaway05
26d ago
What Dak did has always been permissible under the rules, and, again, doesn’t really seem that bad or out of the ordinary. He literally just spit on the ground in the general direction of Jalen Carter;
So same stuff happens, Carter doesn't respond, a ref catches it... you don't think Dak gets flagged this game?
I absolutely think they'd throw a flag for spitting at Carter while shit talking.
We'd probably be talking about it being an overreaction, but still.
Throwaway05
26d ago
I think their is a kernel of an interesting conversation in discussing the union of impulse control, testosterone, substances of abuse (as are likely present) and how some of this may in fact be beneficial given the sport...but I don't know where to take that so I'll toss it inside.
Instead let's consider the game and metagame of this. Given that we can't take anything either of them say at face value (I assume Big Dom's hand is shoved firmly up Carter's ass and Dak is a pro at this point).
The game - I "believe" Dak probably was trying to instigate given the shit eating grin and the fact that both teams clearly came to play and were chippy as hell. But I think a reasonable person could believe Dak was doing it on purpose, and a different reasonable person could believe it wasn't deliberate.
So the metagame then - if you throw the book at Carter and let Dak "get away with it" it's going to make players feel that being a dick on the field is incredibly useful, as long as they don't get caught. That's a complete failure of the point of emphasis.
Do I think players are going to walk away believing that? Unsure. Certainly Eagles fans and anti-Cowboys fans will mostly think that.
Sidebar-
For the Eagles haters out there, this might be better for the Eagles in the long run, since it might decrease how much of a cap hit Carter causes when his big contract rolls in.
Throwaway05
26d ago
Football is a different beast than most sports and has a shocking degree of complexity for a bunch of large men ramming into each... - don't worry you don't have to pretend to pay attention.
Although picking up the other football will likely have professional benefits for you given your practice location.
Throwaway05
26d ago
It's clear from the footage that Dak directly spat at Carter with specific intent to taunt and enrage him. Likely also with some verbal content between the two of them we can't tell from the footage. We can tell Dak knew exactly what he was doing.
In a non football context doing that could easily start a fight. That doesn't suggest that the fight is justified, or a response in kind or with escalation (spitting on instead of at) is justified.
But it's still aggressive and offensive.
If you are going to flag someone for flexing (Nolan Smith I believe?) then spitting at a player is absolutely worthy of punishment regardless of Carter overreaction.
Throwaway05
26d ago
Dak
While one is worse than the other and they are always going to get the second guy...... you can't throw the book at Carter and let Dak get away with instigating that. It's bad looks all around.
Saints
My suspicion with them is that they do not have an NFL QB and the vet talent they've been riding on for so long will have the wheels fall off.
CMC
I think he's effectively done, he may be able to still perform at a high level but not for a full season and at the expense of post-football quality of life. Man needs to hang it up. Without him though? IDK they've worked magic before.
NFCE
Agree with you, but I also think they are in for a sophomore slump. Could easily see the Cowboys or Giants somehow winning the division, especially with the tough schedule the Eagles have. Felt more comfortable with that before the Parsons trade though. Giants will be high variance.
NFCN
I feel like the Packers and Vikings are both well positioned to be the top team in the NFC...or not. Lions have to regress, right? Bears will probably be a good team but underperform in W/L because of their schedule.
Chargers Fan
I'm so sorry.
Throwaway05
26d ago
Oooooooooh. Me teach sport. Real football. Or fake football? Ball touch foot less, maybe fake.
-The start of the season was last night and within six seconds of the game starting two black players spat at/on each other on national television. Both were some of the most important players in the game. The NFL had decided to emphasis professionalism this year. Oops.
-One of the teams (the Saints) engaged in very risky and tricky team composition management for years and now are dealing with the fallout in a catastrophic hilarious fashion. They are so so bad (at least on paper).
-One of the historically better teams in the league (49ers) seems to alternate between nearly winning it all and sucking ass on a yearly basis. It's funny.
-One of the divisions (NFCE) has had exceptionally good parity, no-one has "won the division" in back to back years in decades. Eagles won last year (and the Super Bowl). Will they break the curse?
-One of the divisions (NFCN) was comically competitive last year, with three out of the four teams being arguably some of the best teams in football. Will they take a step back?
-Chiefs. Yeah you know this one.
Throwaway05
26d ago
Football is back baby!
I wish everyone luck with #YourTeam unless they are playing #MyTeam.
Additionally - #DakSpatFirst.
That said it seems like the league will be making professionalism a point of emphasis and that has already generated some friction. Between that and the importance (or lack there of) of Dak triggering Carter, well some culture war fodder has popped out if anyone wants to go to the other thread for that.
Some things I'm looking forward to:
-Just how bad the Saints are going to be.
-Finding out if we get Good 49ers or Bad 49ers.
-Which team will win the NFCE since the Eagles are curse ineligible.
-How much of a shit show the NFCN will be.
-Will Chiefs performance have an impact on Swift's relationship.
Throwaway05
27d ago
No worries, let me message you separately.
Throwaway05
27d ago
I mean TBH I did submit my post and then go back and instantly edit it because I felt the specific question (as opposed to the context) was worth addressing. I'll come back to that.
As for your frustrations yes I don't think SMH was being particularly professional and at the same time he's young, hasn't finished training (and hasn't yet gone through the parts of training that really hammer in the professionalism) and didn't seem to bother OP so I'm not super upset about it.
And on the other hand you seem upset - that's a valid feeling and also a bit disproportionate given OP's lack of disgruntlement.
Soooooooo how do I balance gentle wagging my finger at all parties involved without furthering exasperation?
I think we should lean back on "the vast majority of people here are just living their life doing their best and being directly called out is going to create defensiveness that isn't really conducive towards helping someone acknowledge error and improve."
Lord knows I give myself some grace so I should probably to other people as well, when possible.
That said, so back to the meat of the thing (cognition is neat!!).
Yes you should be able to diagnose schizophrenia from a specific type of writing but if someone is producing some alternate theory of physics or whatever it will be hard to tell if that is representative of disordered thinking or just the weird shit being weird shit (not commenting on correctness with that). I haven't read OP's thing because the exercise holds little interest to me but I doubt it's very diagnostic, but we have had posters here (well I think only on reddit?) that I saw and was like...."oh."
To give a clear example (and you can find this kinda stuff on reddit if you know where to look):
"listen listen listen help me please PLEASE i cant get the polices to help ive called 13 times a day for the last 13 days and they keep telling me I need a doctor but I dont need a doctor I need someone to get them to stop following me I cant get rid of them even when I use the bathroom I can hear them in the next room over telling me things I need them to stop stalking me but the police won't help my family say I need to calm down but I am calm I just dont know what to do about them my doctor gave me a medicine for anxiety but I dont like how it makes me feel and what they say about it online makes me thing the doctor is working with them so I won't go back I dont know what to do help"
You see that and someone is clearly having an exceptionally bad trip or true psychosis with poor prognostic indicators.
Throwaway05
27d ago
Context
Woah nelly, okay a couple things going on here.
While I'll note that the way @self_made_human rolled in is not quite how I would go about it, I would also be lying if I hadn't done shit like that before, and I'd definitely be fucking lying if my fucking cursing and fucking casual language in my posts wasn't also considered grossly unprofessional by my colleagues (just in a different dimension). We aren't perfect.
However it also seems that OP is not particularly upset at the accusation - I try to pay careful attention to where my feelings are coming from in situations where I'm more incensed than the victim. Something to consider.
Also, even if your point has validity the way you framed it will probably result in the mods rolling in at some point.
Okay now the fun part! As a didactic matter, schizophrenia isn't quite what people think it is.
Schizophrenia is a specific mental illness with a number of symptoms, delusional thought content is one of them but not required. It is also one of a number of psychotic disorders and while it is the one people think about and doctors usually see the most (sort of) that doesn't mean it is always the problem.
Loosely, thought content exists on a spectrum of:
"Normal" -> Culturally accepted but bizarre (I may say this is woke, an atheist may say this is religion). -> Crank shit (think Terence Howard) -> Crank shit with other symptoms (Schizotypal personality disorder) -> Delusional disorder (the person has a delusion, which is a fixed, false belief and impaired reality testing with respect to this specific item, but no other problems) -> Schizophrenia/Schizoaffective, etc.
Medical illness and substance use can move people temporarily or permanent along this line. Some of the connection points have evidence they are related in a way that represents a true spectrum some don't.
Some other illnesses like intellectual disability, autism, borderline personality disorder, anorexia, and OCD can functionally put people somewhere on this line even though they are probably less a part of this spectrum.
Human cognition is strange. Some of the mega woke may be truly delusional but functionally much further left on the spectrum. Brains do what they want, sorry rambling.
In any case for schizophrenia specifically you need other symptoms. Most bizarre rambling on the internet (absent substance use) is usually schizophrenia because its most common and has significant insight impairment so they want to share the oddity in a place where people won't yell at them. Not all of it is tho.
Other things you expect to see are hallucinations (usually auditory, not visual), impairments in personal and social functioning (less obvious on the internet), and disorganized thought and speech - that's usually the clue with schizophrenic ramblings on the internet.
However the difference between "crank" (which as we know is sometimes right) and disorganized can be quite a fine distinction.
Edit: I guess I didn't answer the question? It can be clearly done in one post sometimes, which I did a few times on the old forum. It can take considerably more. Shouldn't really be done over the internet, but if someone tells me their blood pressure is 190/120 I can just diagnose them with high blood pressure. Certain kinds of weird shit (like the gang stalking subreddit) is pretty pathognomonic.
Throwaway05
28d ago
Yes exactly, I don't know of any cases where a patient has sued over a bad estimate, but I do know plenty of cases where a patient had an estimate that was labeled as such and then refused to pay the bill when the estimate was...an estimate. Puts the hospital in an awkward spot and I do know of many cases where the hospital chose to take the PR hit and sued patients to attempt to force them to pay their bill (it is possible some of those generated counter lawsuits?).
Additionally the hospital does all kinds of crazy nonsense to prevent theoretical lawsuits, often the staff is the victim. I do a fuckton of modules every year that likely do nothing to reduce hospital liability but they are just crossing their fingers and making staff do this shit. Also the classic cases of a heroin addict being told "don't leave, if you do you have a high chance of dying" "no thanks I'm going to get high" and then some poor resident being forced to chase them down to convince them to sign an AMA form which has no value at all.
Lastly you have malpractice lawsuits, which illustrate that you can generate multiple hundreds of millions in verdict with no particular malpractice performed, or somehow be held liable even though you were completely uninvolved. Meddit is littered with these cases.*
After that abuse it's not shocking that people in medicine are skittish as hell.
*To be clear wrong does occur on occasion but supposedly the research shows that actual wrong doing is statistically unrelated to judgements/verdicts.
Throwaway05
28d ago
Second this - I bought a new Herman Miller Embody which cost a pretty penny but was absolutely worth it (and has a killer warranty).
You can find them from an office supply store, corporate office selling or tossing its stuff, etc and get most of the benefits for a fraction of the price.
Throwaway05
29d ago
We called urgent care and could not obtain even an upper bound on how much a dx + rx would cost. Hundreds? Thousands? Who knows lol.
Note that an upper bound is an extremely difficult question.
If you worked with a realtor and said you wanted to buy a house but didn't know yet where you'd be buying and what your requirements were...the only reasonable answer to the upper bound is whatever the most expensive house ever sold is. An urgent care has some maximum limitation on available services (in comparison with an ED) but the situation is fundamentally somewhat similar. That number would be functionally useless.
"What will you most likely charge me as the cash price for a basic office visit" is something a PCP can easily do and generally do when they are allowed to do so.
However as this is America many places will prohibit providing this type of information as a matter of policy because of the risks associated with doing so (like being sued if the bill is higher than the estimated number). This is a general side effect of corporatized medicine as decisions are made by large inflexible organizations with massive legal and compliance departments and clinical and office staff with no independence and authority.
As you saw independent practitioners may still use common sense,* but they are being forced out of the market by things like increased regulatory burden.
This is what had me so incensed the first time this came up - individual requests like "provide prices" "you need an EMR" "have an HR department" have become so burdensome and accumulated in such numbers that private practice increasingly no longer makes sense and therefor flexibility is gone.
*And some types of interactions like this are strictly speaking illegal/fraud.
Throwaway05
29d ago
I had the pleasure of watching multiple BLM protests move slowly closer and closer to my home, with various things being thrown, smashed, or set on fire while the police did nothing. At night their were gunshots outside, something that hadn't happened in recent memory where I lived.
Millions of Americans shared this experience and likely have a corresponding amount of wariness.
Throwaway05
30d ago
Again don't really blame you - based off of the issues we have with insurance it often seems like the people on the other side didn't really have correct training. That actually being the case seems like the kinda thing that would be by design.
Depending on how long ago this was it could also just be process changes. As I get older I get more worried about these, times when you find out Pluto isn't a fucking planet anymore.
If you are lucky someone tells you at a reasonable time but it's all too easy to get left behind.
I apologize because this is going to be by its nature rather rude and unavoidably direct, but you didn't engage the first time + your comment got a large number of upvotes and since it's reappeared as a AAQC... I need to point out again that your comment is factually inaccurate.
I don't think this is specifically your fault, insurance companies are notorious for inappropriately denying claims (and of course see United and Luigi in the news). It seems likely that inadequate or incorrect training is the norm. Additionally major aspects of the billing process have been revised on multiple occasions.
So:
Yes it is true that medical services are typically billed via CPT in most contexts.
Yes it is true that your bill can usually get adjusted if you complain (but that isn't necessarily because you are correct, it's because "Karening" works).
But, no. No that is not how CPT codes (specifically E/M) work at all.
First and probably most importantly, that's not how "time" works.
Time spent reviewing records and documentation on the patient, time spent interacting with the patient, time spent on orders afterword, time spent on documentation, and time spent on coordination of care (which can easily be very, very long) all count as time.
While it varies depending on the complexity of the patient and the specialty, it is not uncommon for a 5 to 15 minute encounter (time spent in the room with the patient) to generate a 45 to 60 minute or more encounter (time spent working on the patient).
Your surgeon may walk into the room, talk to you briefly, and leave - but they spent 20 minutes on the phone with radiology and another 20 minutes reviewing your records. ID and Psych are notorious for writing up notes that can be pages and pages and take up a related amount of time.
For a simple yearly family medicine appointment they manage to be pretty close but for specialists...no.
The other billing option is to do so by complexity, which involves extremely complicated rules and expert level knowledge to effectively audit.
It is therefore functionally impossible for a patient to evaluate the accuracy of an E/M code, even if they had the complete chart and the expert level knowledge of that specific specialty, the physician may have used time based billing and ended up on the phone with the pharmacy for 25 minutes, therefore justifying the code.
Again sorry to just "you are wrong" but in addition to the "help help someone is wrong on the internet" urge, your information also has a reasonably decent chance of generating some cringe moments where people using it are making a huge ass out of themselves by arguing and not realizing they are incorrect.
I want to again emphasize that while upcoding is a real thing it is a very serious battle between regulators, insurance, and health systems all trying to keep each other honest. Hospitals have a strong incentive to exactly follow the letter of the law because medicare can come in six months later, audit, and remove hundreds of thousands to millions or more of billing if things aren't exactly correct.
In addition the federal government loves to sniff out fraud and will send you to federal pound me in the ass prison.
Insurance companies engage in malfeasance because errors on their end don't kill the hospital or result in jail time.
Example source: https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
From the AMA guidelines:
Physician or other qualified health care professional time includes the following activities, when performed:
■ preparing to see the patient (eg, review of tests)
■ obtaining and/or reviewing separately obtained history
■ performing a medically appropriate examination and/or evaluation
■ counseling and educating the patient/family/caregiver
■ ordering medications, tests, or procedures
■ referring and communicating with other health care professionals (when not separately reported)
■ documenting clinical information in the electronic or other health record
■ independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
■ care coordination (not separately reported)
Throwaway05
30d ago
Unfounded accusations of racial prejudice seem roughly as bad as calling someone an asshole
TBH I think it's a quite a bit worse - for many of us we live in a situation where being called racist in real life would be a profound existential threat, and in the overall blue milieu it is pretty much the worst thing you can call people.
I know I have an involuntary autonomic reaction to it even if I know I'm safe through anonymity or whatever.
Yeah I love Triple-Q but hadn't heard that one before...maybe it's time to go through everything again.
Throwaway05
1mo ago
I want to call this out to OP. We don't know what happened, we don't know if you did anything wrong - but you report a lot of problems like this and adjacent to this so it is worth being careful, much more careful.
Maybe it's something about the way you look or talk and it's total SJW nonsense. Maybe you use words that should be fine but freaks girls out. Who knows, but you have had a few problems and you'll be much safer if you try and be a bit more careful.
Sorry but you should try and protect yourself.
Throwaway05
1mo ago
Yeah old heads will tell you the new shit is dangerous - which it is, permanent psychosis induced by marijuana is much more on the table now and while it's hard to assess is starting to seem "common."
Now that's in the under 3% of the population range for the more serious cases which is deleterious when we are talking deranged homeless people but not 100% something people will notice. What gets iffier is the "failure to launch" type problem you frequently see. I gotta imagine black Americans would do a lot better if you made all the weed disappear for instance.
Haven't seen any update yet, but given the political situation they'll probably keep coding him for a long time before giving up and declaring him dead, but from a practical perspective he was dead with the shot (in the sense that repairing the damage would be nearly impossible).
His vascular structures looked torched from the video, supposedly it was a rifle round.
I have no idea how fast the response was/how close he was to a trauma center though, if the wagon had a shit ton of blood and they had advanced trauma options available it's maybe possible he makes it with severe deficits, but that's the kind of wound I wouldn't want to treat if the person was shot in the theater with Anesthesia and like fucking ECMO already standing by.
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