These are the charts our coders gave me during my 10 minute billing orientation:

So that’s good – theoretically I should be able to just consult the horoscopes augheries billing charts and see what level I can bill for based on what I had time to document in my note, right?

Except “Medical Decision Making” seems to supersede everything and is apparently totally derived from how many tests I order and how many prescriptions I give, rather than how much thought I put into NOT ordering extra tests and unnecessary drugs.

It’s outrageous, really: you could meet every criteria for a Level 5 visit on those charts, but if the auditor thinks that your Medical Decision Making was ‘uncomplicated’ (meaning either your conclusion was that the pt was at minimal / low risk of imminent death, and / or you didn’t order more than 1-2 tests or prescriptions) then they will downgrade your whole beautiful 5 page note to a Level 2 visit and ding you for overbilling.

OR you could just document as you see fit, not worry about consulting any billing charts or double checking your note, and just type the magical words “Greater than 50% of this 60 minute visit was comprised of face-to-face counseling and coordination of care” in there at the end and call it a day.

The worst part is that our outpatient EMR seems hell-bent on helping me bill to the highest level via complicated charting (radio buttons for everything! 7 extra clicks to get to the ‘free text’ option!) and it is JUST NOT WORTH IT, SIR.

I honestly didn’t ask questions about EMRs when I interviewed for jobs because I firmly believed that – as a millennial – I can learn any software and make it work. I guess I was so used to attendings complaining about Epic (which, at least at the more expensive version my fellowship hospital used, is fantastic) that I foolishly believed I could use any EMR.

But I am here to tell you folks that there are absolutely EMRs in existence where 1) it takes 4 clicks to get to physician notes, and then despite having a blank left-hand of the screen, you have to double-click on each physician note to view it 2) phone encounter notes are so cumbersome to create and ugly once created that nobody even bothers to document phone encounters – which is fine with the EMR, created for the sole purpose of billing, because you can’t bill for a phone encounter so why make it accessible, ever? and 3) orders can only be written by first selecting or creating a diagnosis, then clicking an appropriate tab, then correctly typing in the entire order, then linking the order to the diagnosis anyway.

TL;DR: Allscripts EMR is absolutely a viable reason to turn down a job.

But it’s not all complaining here in Attending Land.

Mostly there’s long hours of me not doing anything. Because I just started and I don’t have any patients.

Mostly I just kind of show up in the office from 9am – 2pm out of a general sense that I should be physically at work some of the time to justify my paycheck.

They tell me my outpatient schedule will get busier once I start taking call next month.

We’ll see…

… I was perhaps wrong.

This gradual realization reminds me of being an intern and “knowing” that I was going to be the cool intern, the intern that never questioned medical students. (see: 10 Things Med Students Should Never Do) and then discovering that indeed, many – if not all – med students were once pre-meds, and as everyone knows, pre-meds are terrible.

I think the crowning moment was last month, when I was paged – not once, but twice – by 2 different members of the same ICU team, to have the following conversation:

“Hey, we have this patient with epilepsy – he’s been on carbamazepine and just got a g-tube inserted this morning, so we need to curbside you for AED management.”

“Oh. OK. …. wait, because the g-tube isn’t safe to use yet?”

“No, because he just had a g-tube placed.”

“Okay. … I mean, that’s fine… but carbamazepine is an oral drug. Does he.. can we not use the g-tube? Is he having seizures?”

“Uh, no, no, neither of those.”

“…. Oh, so he’s been on an IV AED while waiting for the g-tube to be placed? Yeah, if it’s been over 1 week we do need to restart the carbamazepine at a lower dose, and I just need a second to look up the titration schedule -”

“No, no, he’s only ever been on carbamazepine.”

“Huh. So… he’s been on oral carbamazepine, and you’re transitioning him to.. oral carbamazepine?”

“We just need you to weigh in on the pill to liquid conversion.”

People.

I dare you to find a way to suggest that the “pill to liquid conversion” is always 1:1 without sounding judgmental. (Bonus points for receiving a 3rd page 2 hours later, during which the resident “just wanted to clarify” that it definitely didn’t matter that the medication was being given by g-tube rather than by mouth.

… I mean… the mouth connects to the- there is no significant sublingual absorption in a medication that is not sublingua- I mean it’s exactly like zofran and tylenol and any other medication ev- aw, lord, nevermind. )

But by and large, I have been able to live up to my ideals. I have driven from home to the ward at 1am to do the emergency LP that the primary team could not get. And I showed up again at 7am the next day for consult pre-rounds.

I have spent hours getting pseudoseizure patients admitted to the epilepsy monitoring unit rather than the general floor. I have, in great detail, explained to many residents how a headache cocktail works and how they can in fact learn how to order one themselves – because no one ever explained this to me before my adult neurology year, and it seemed like a useful gen peds thing to know.

I have also gotten a disturbing number of calls from outside hospitals and EDs where they have asked for my advice, received it, and then… followed it. And my attendings weren’t aware, because it was 2am and they neither needed nor wanted to be aware of anything that went well.

Man. Remember when I was posting about anatomy test anxiety? I wish I could go back in time and tell myself “Look, in the future, when you’re on-call at 2am… google will exist. You’re just gonna have to be really quick about it. It’ll be fine.”

Even though I’m still disturbed that I’m somehow now in a position where attendings actually listen to me at night (and even weirder, sometimes in a position where I get angry on the rare occasion that they don’t) – I’m mostly just glad I seem to have made it through the anxiety.

Looking back, I really can’t believe how anxious I was about antibiotic coverage.

… I actually no longer know antibiotic coverage. And at the time, I thought that would make me a terrible doctor.

Instead, I know that when a patient on phenobarb, keppra, and a versed drip starts having breakthrough seizures at 2am, I can pretty much use whatever rationale makes sense to me to decide which one of those medications to load and then increase – and the day team will just appreciate that I did something, and especially that the something I did involved some sort of logic. Regardless of whether it worked or not.

And if the ED calls me about a patient who had a weird movement that was maaaybe a seizure, maybe not, but they’re back to normal now – I can either admit the patient or recommend we see them as an outpatient (spoiler alert: either way, we should probably just see them as an outpatient), and again, the world will not end if I am wrong.

I have found this out first-hand.

Basically, if I could go back in time and shake myself out of the weird anxiety-laden hole I had dug for myself, I’d do it in a second.

And I’m only writing this in case you’re identifying with me from the past, in which case… you’ll be fine.

You’ll be fine.

Adult strokes: “Guns don’t kill people. Heparin kills people.”

1: Adults with normal potasasium.. need more potassium. In peds, we are pretty much cool with anything over 3.2, and super scared of any number that starts with 5.

So in adult medicine this year, it wasn’t until the 3rd time I got a sign-out of “His K was 3.6, so we repleted IV” and reacted incredulously and indignantly before I finally accepted the truth of the new world order of adult medicine that I now must live by: K under 4.0 is unacceptable. Cardiac arrhythmias and whatnot. Asymptomatic PVCs.

Be a man. Replete that shit.

2: Adults can sign-out AMA. My first AMA, I paged psychiatry to ask whether they thought the patient had capacity. I think the psych resident showed up more for moral support and genuine concern for me than anything else. Especially since I explained over the phone that I am from pediatrics and am scared to death to discharge a patient who needs more treatment.

They patiently explained that I am a doctor and can decide these things for myself. In turn, I patiently explained to them that I am basically dumb.

3: Adult attendings are so hands-off you don’t even have to staff all in-house consults with them. You don’t even have to staff ADMISSIONS with them. In pediatrics, we don’t even page the resident first for consults – you page the attending, and they page the pediatric resident to say “Hey, go see this consult for me and then we’ll discuss it.” And at my program, even a 4am admision is paged to the attending first.

But in adult neurology subspecialties, it’s more like: Neurosurgery or the ED pages me out of concern for status epilepticus, I load the patient with whatever AED I want, I admit them if I want, and as long as the first thing I do works the attending doesn’t need to hear about it until rounds in the morning.

Discovering this was… slow and painful. It involved an embarrassing number of incredulous conversations between me and an attending at 11pm.

4: Adults get lidocaine before you stab them in the back with a 22gauge needle. In pediatrics, we gave topical lidocaine, for all the good (NONE) that it did the patients. But if you turn 18 and get admitted to the adult unit – then you get SQ lidocaine and are not tortured.

… unless you happen to get a pediatric neurology resident as your LP-er. Then you get someone who has never given SQ lidocaine before and is not even aware that it is important.

5: Pediatric neurology residents are terrible people. As evidenced by the fact that there are 6 more of them in my program, and not a single one warned me of any of the above facts.

I distinctly remember the guy above me saying, and I quote: “Why are you so worried? Calm down. It’s gonna be fine.”

Listen up, Mr. PGY-4:

This post is for you.

Attending: So! Dr Action Potential, what AED would you like to initiate?

Me: Keppra.

Attending: Correct. And why?

Me: Because… because the answer is always Keppra.

Attending: Correct.

Wednesday:

Attending: So we all agree that the patient’s seizures are not well-controlled on Keppra. Dr Action Potential, what is at the top of your differential diagnosis?

Me: … not enough Keppra.

Attending: Interesting! So what would be your recommended course of action?

Me: … give more Keppra.

Attending: Correct.

Friday:

Attending: Aha! You see, in THIS patient, we find ourselves confronting a new clinical conundrum, do we not? End-stage renal failure! Dr Action Potential, why is that a problem for our team?

Me: When the patient is in renal failure, one generally tries to avoid renally-excreted AEDs.

Attending: Correct. Clinical neurology is variable and exciting. Dr Action Potential, dare I ask, what antiepileptic would you recommend for this renal-failure patient?

Me: …the type of… Keppra… which is… renally-dosed.

Med Students: …

Attending: Correct. You know, if you didn’t tell me you spent the last 2 years in Pediatrics, I never would have guessed it. You’ve got this adult neurology thing in the bag.

Me: … Thank you, sir.

Attending: It’s quite remarkable.

Me: … I try, sir.

I mean, it doesn’t hurt to be a nice person. That’s great as long as everything’s going according to plan and the patient isn’t actually sick. Your intern can be the nice person. But the most important thing I learned in residency is that when shit goes down, all anybody wants for their loved one is a genuinely serious-looking, order-giving, no-shit-taking, Doctor standing right. there.

Sure, you can be nice and also in-charge. But if you’re walking into a room for the first time, the family usually feels better seeing someone who’s in-charge and also nice. It’s a crucial distinction.

You shouldn’t be the first one to say the word “dying” to the family. But you should damned well be the first person to write “dying” in your note. It’s a strong word. Your attending has the option to cross out this note in their addendum, but odds are you’re right, and they won’t. If you really believe it and none of the other teams have had the guts to write it, but everyone’s saying it – this is a good first step when you feel powerless.

Fellows have no power if they’re wrong. Call them on it. Useless as an intern, but good to remember past a certain point in PGY-2 when you’re fully aware that they are full of shit and you are graduating.

Enjoy the seniority while you can. Because in just 9 short work days, you will be back to the bottom of the barrel.

Welcome to fellowship.

… faced with a waiting room full of “Congestion” “runny nose x 3 days” “fever of 99” “bumps on tongue” “needs stitches removed” “father wants him drug tested” and “sneezed twice and the second time green mucous came out of nose”

Sadly, this has all led me to the grim realization of why I got such good evals as a medical student: it wasn’t because I was some sort of social genius. (And yes, I really thought I might have been a social genius.) No, it was because I did not do the following things, ALL OF WHICH I HAVE SEEN WITH MY OWN EYES.

Seriously, if you don’t do these things, don’t worry. You will be fine. Your residents will love you.

• Do not claim to be late to rounds because you had a “Cat medical emergency last night.” Unless your cat is dead. But even then…. maybe don’t use the phrase “cat medical emergency”.
• Certainly do not voluntarily (and eagerly!) disclose that your “Cat medical emergency” consisted of “I thought my cat was constipated but he wasn’t.”

• DEFINITELY do not follow that up with “So the vet prescribed him kitty prozac. And I couldn’t sleep because I was so worried about the side-effects of the kitty prozac, so I was late.” Believe you me, I would rather you had just overslept.

No judgement for ‘kitty death’. Lots of judgement for ‘r/o kitty constipation.’

• Do not respond to the attending’s hopeful query “So, are you interested in [our specialty]?” with “Eeeeehhhhhh…
• If a 4 month old is mildly tachycardic, do not suggest obtaining orthostatic vitals.
• When a patient is admitted with, say, an asthma exacerbation – and you have happened to read in a past note that they are undergoing long-term therapy for PTSD- it is probably unnecessary and ill-thought out to open with “Hi! I’m a med student! So… it sounds like you were raped? Like, last year I think the chart says? How is that going?”

• If I go through your patient presentation with you twice before rounds, in the most open, non-judgemental of ways, asking you repeatedly ‘Any other questions?’ – it is in the foolishly earnest hope that in front of the attending the words “So.. they were born at 38 weeks… is that preterm? Sorry, haha, I don’t know what preterm is” will NOT come out of your mouth.

• I will point out to you that the healthy teenager with the urine output of “0.3 cc/kg/hr” is likely not saving their urine. This is a gift. I do this to HELP you. I do NOT do this so that you can present the patient to the attending as “Initially, we were worried about kidney failure. After a lot of thinking about it, we  discovered that the patient was not saving their urine. Doing this led us to rule-out kidney failure, which we were initially very worried about, as I said.” (WHO IS WE. I DON’T EVEN KNOW YOU.)
• Do not demonstrate “Suprapubic tenderness” by helpfully palpating my uterus.
• Seriously, just… hands off your senior resident’s uterus.

“and oftentimes I am awoken at three in the morning by screams in the attic I’ll run upstairs, wrench the door open call out a warning (and try not to sound panicked) but my hammering heart hears the voices of spirits that tempt us, the scorn that they’ve spoken I’ll remember the sad frightened noises of an old friend who dreamt once of storms on the ocean

and black eyes looking up from below”

Anyway, so that was fine. I have clinical skills. First things first – I carefully considered the most likely causes of C based on my extensive education in pathophysiology and instinctively deduced AHAHAHAHAHA aaaaah, haha nope.

sorry, can’t take myself seriously there.

Yeah, no, first things first – I looked up the most recent H&P in the EMR for reasons of borderline intellectual plagiarism.

As one does.

And do you know what I found, dear readers?

I found the following H&P, written by one of our illustrious fellows:

An H&P for this patient has been completed within the last 30 days. It has been reviewed and the patient has been examined with the following changes to the patient’s condition and exam: There are no changes in the patient’s condition or exam.

– Fellow McFellowton, MD

Followed by.. nothing. That was it.

That was the H&P.

Absolute shoddiness. That fellow should be ashamed of himself.

(… small side-note: also, why can’t we do that? I DEMAND THE RIGHT TO BE SHODDY.

NO ONE EVER TOLD ME SHODDINESS WAS AN OPTION IN <30 DAY BOUNCE BACKS.)

No. This will not stand. So I’m just gonna write

“An H&P has been completed for this patient within the last 30 days. It has been reviewed and the patient has been examined. There are no changes with the exception that this time the chief complaint is diarrhea, but otherwise, you know, samesies.

– Action Potential, MD”

I predict it will go… well.