An ICD-9 Story

Medical billing and epidemiology relies on a classification of diseases maintained by the World Health Organization. On the first of October, 2015, we will transition from ICD-9 to ICD-10, a major change that increases the number of available diagnoses from some 17,000 codes up to more than 155,000. In a strange cosmic twist, that’s the same day that most retails need to install readers for credit cards with chips or be liable for bad purchases.

With that in mind, I present a short story in ICD-9, with a translation into English.

It was E900.0. That, combined with E904.1 and E904.2, not to mention V69.4, is what led to 780.2. I admit it, I have V69.0 and V69.1. I usually sleep well, but that night was different, thanks to 780.55 due to 780.92. That morning I understandably drank 969.7, leading to 785.1. During E924.2 while E013.0 I felt 780.4. Stepping out I had 368.45 before I 780.2.When I was V49.89 after my E884.9. I had a 784.0, as if I had a 305.00. I used my E011.1 to call work to say I’d be late and hoped to avoid V62.1. He greeted me with a 784.42 indicating 300.4.

Last year I V49.89. The flights are arduous, subjected to E918 or being in V01.9 with a 780.92 E979.6 at E902.0. After landing I’m 780.79 due to V69.4 and 780.55, leading to excessive 786.09.

I was in 309.29. At least, thank to the ubiquity of E849.6, I didn’t have to suffer from 292.0.

If you think this makes for 315.00 and is a 729.1 to read, just wait for ICD 10! Ever see a V91.07XA?!

It was too hot. That, combined with lack of food and water, not to mention lack of sleep, is what led to my fainting. I admit it, I don’t exercise or eat right. I usually sleep well, but that night was different, thanks to interrupted sleep from my son’s crying all night. That morning I understandably drank one too many cups of coffee, leading my heart to skip a beat. During a hot shower I felt lightheaded. Stepping out my vision narrowed before I passed out. I awakened after my fall to the floor. I had a headache, as if I had a hangover. I grabbed my cellphone to call my work to say I’d be late and hoped I wouldn’t be in trouble with the boss. He greeted me with an edge to his voice, indicating he was wasn’t completely happy.

Last year I traveled to foreign countries. The flights are arduous, subjected to being squeezed in with other passengers, or being next to a crying, germy child at altitude. After landing I’m worn out due to lack of sleep and jet lag, leading to excessive yawning.

I was in culture shock. At least, thank to the ubiquity of vendors, I didn’t have to suffer from caffeine withdrawal.

If you think reading this is difficult and is a pain in the butt to read, just wait for ICD 10. Ever see a burn due to water-skis on fire?!

Asinine Associations

As I previously wrote, when physicians place orders, they have to associate diagnoses. This is becoming even more painful as we move towards ICD-10, of which I’ll have more to say later.

I’m sure this was an attempt by the government to save money, but in the vast majority of cases the ordering physician has no secondary gain, and they order the test because they think it’s the right thing to do. I can understand it for some expensive tests or procedures, but many are just plain obvious.

I think lawmakers should have a taste of their own medicine. When they need office supplies, they should have to give a reason. Here, I’ll help them out with a few items to help them understand how it works:

StaplesTo attach separate pieces of paper.

NotepadTo write down information.

PenTo apply in conjunction with a notepad to convey information.

ChairTo help counteract gravity to prevent leg and back pain and fatigue.

Laser Printer TonerTo print out things using a laser printer.

Light BulbTo counteract darkness.

Dangers of a Transparent Medical Record

Over the years there has been a push to allow more patient access to their records. Patients in our system that have signed up for MyChart with our electronic medical record Epic, can see most of their test results shortly after they are back, even if not yet reviewed by the physician who ordered them.

To avoid patients misinterpreting or reacting badly to the results, certain tests, such as HIV and pathology, are not automatically released. Although releasing the results automatically acts as a safeguard for abnormal results that may have been missed by the physician, it also opens the possibility of patients inappropriately acting on the results.

I’ve had patients make changes in their medications after seeing their results, and without even discussing it with me until their next visit. One patient who saw that his sleep study showed he had sleep apnea, borrowed a friends extra CPAP machine, adjusted the settings based on his research on the internet, then tried it out for 2 weeks!

As the saying goes, a little knowledge can be dangerous. Patients should use the information in their charts to inform them, and help ask educated questions, but not to replace their physician. There is often a lot more to making a diagnosis and deciding on a treatment than just looking at test results.

Chiropractic Care

I have a confession. Last year I went to a chiropractor for the first time. I had been having some neck and sacroiliac pain. I went to a massage therapist a few times. Although it felt good, especially for the neck, it didn’t seem to last more than a few weeks at most. Anti-inflammatory medications only gave temporary relief. Thus I was interested in trying something else, particularly when I started having some acute left sacroiliac pain that made it difficult to move around at times. I also had intermittent low back pain, left trochanteric bursitis, knee pain and plantar fasciitis. In Timothy Ferriss’s interesting book, The 4-Hour Body, he recommended active release techniques and a Functional Movement Screen (FMS), which I was curious about and thought might help. When I looked into it more, I found that these were pretty much only offered by chiropractors.

Physicians are trained to be scientific, and tend to dismiss what is called alternative, complementary, or allopathic medicine, including homeopathy, naturopathy, chiropractic, and traditional Chinese medicine. I wanted some relief from my symptoms, and I was also curious about what chiropractors do, so I decided to go there, rather that to physical therapy. Patients often ask me what I think about going to a chiropractor, but I had no personal experience. I justified to myself that it would be like a journalistic endeavor, which it sort of is, now that I’m blogging about it.

I purposely chose a clinic about 12 miles from my office. As I pulled into the parking lot I had second thoughts. I felt like I was breaking a taboo. Even though I figured it was unlikely I would be seen by a patient or anyone else I knew, I looked around before getting out of the car. That evening I told my wife not to tell anyone that I had gone to see a chiropractor.

Fifteen minutes after my scheduled appointment time the chiropractor came out to the waiting room, addressed me by my first name, and said she would be out shortly after reviewing my chart. She was young and attractive and had graduated about two years earlier. She came back and said, “I guess I should be calling you Dr. Ginsberg”. We went back to an exam room and she took a thorough history of the various pains I had. She asked about duration, severity, onset, exacerbating factors and prior injuries. She asked if I’d ever been to a chiropractor before and I said no. She said I was her first also (physician patient)! She asked me about my practice. When I complained about the paperwork, she pointed to her desk and said she has the same problem. Like a lot of doctors fresh out of school, she also had a lot of debt.

Next she did a very thorough musculoskeletal and neurological exam, other than checking cranial nerves and cerebellar function. Her range of motion and testing of strength and sensation reminded me of what I used to do as a medical student and intern, but now often shortcut. She discussed active release techniques then did some, including the Graston Technique. She asked if I was willing to have adjustments and I expressed some hesitation, particularly having it done to the neck. She said had no I had no red flags and that she did did this maybe 20 times a day. I initially agreed to let her adjust my back. After twisting me like a pretzel and throwing on her weight, causing a not unpleasant popping sensation in my back, she told me, “You just had your first adjustment.”

She then did more active release technique on my back, using a special table that moved,  making my back flex and extend. Then she did an adjustment on my mid and perhaps upper back.  She asked if I wanted to have my neck done, and reminded me of the decreased range of motion I had on one side. I thought about my patients who refused medications for their cholesterol or diabetes for fear of side effects, despite my recommendations, so I reluctantly agreed to trust her expertise. I was a bit nervous and she had to tell me me to relax. It was not especially uncomfortable when she twisted my head suddenly, but I had visions of a farmer breaking a chicken’s neck and I hoped I would not becoming a quadriplegic. Thankfully that did not come to pass.

We talked a little about the traditional distrust physicians have of chiropractors. She said some people just need a quick adjustment, but admitted that 75% of people come in with problems that are due to underlying muscle weakness or imbalance, and that they won’t fix the problem without addressing the issue. She said unfortunately some chiropractors don’t deal with this and only do adjustments. She knew one who had the same patient penciled in for every Friday at the same time for a year.

She said to return, preferably within 3 to 5 days, though I made it a little later due to my schedule, to have another treatment and a Functional Movements Systems evaluation.

I couldn’t really tell a difference after the first session. She warned me I might be sore at first, but I was not. Although massage may help various body aches and pains, I suspect many people like it for the therapeutic touch. I was surprised that chiropractic was similar, and I suspect that’s part of the reason for its popularity.

I later returned for another appointment. I underwent their own functional performance exam with one of the trainers. They said it was more thorough then the Functional Movement Screen. I later found out that FMS is a widely marketed system, for which chiropractors and others pay a lot to get certified, but that’s a different story.  In any case, the trainer said that I did pretty well, but was particularly weak in my medial glutes, which surprised me.  He recommended at least setting up an appointment to set me up with a home exercise program as I said coming in for regular treatments would be difficult.

Next I had another session with the chiropractor. She again did Active Release Techniques and adjustments. She was unable to adjust my neck as I involuntarily tensed up. I asked her why insurance companies require referrals for physical therapy but not chiropractic. She said it’s because chiropractors can make diagnoses.

I returned one more time to work on various exercises. Although I’ve exercised at the gym for decades, I started incorporating some of the exercises the trainer taught me, and I’ve had very little sacroiliac pain since then.

Scientific data showing the benefit of chiropractic care for back pain is sparse. Recently an article showed benefit in chiropractic care for neck pain, but another showed potential risk.

So what do I tell patients now about chiropractors? For neck and back pain I still preferentially refer patients for physical therapy. If patients ask about getting chiropractic treatment, I  am now less likely to object, assuming they don’t have a medical condition that would make it riskier, but I caution them about getting neck adjustments.  Just like physicians, not all chiropractors are equally skilled. A good chiropractor probably does a better job evaluating back pain than most primary care physicians, but watch out for those who over treat. Most importantly don’t take the lazy approach of just getting, “adjustments,” but do the work to correcting muscle weaknesses that often cause the problem.

Cruise Health

As I wrote about last time, I attended the ACP Internal Medicine 2012 meeting in New Orleans. Afterwards my wife and I took a cruise on the Carnival Conquest ship that left from New Orleans and stopped at the ports of Cozumel, Jamaica and Grand Caymen.

On the first day of the cruise there is a mandatory safety briefing on deck where they discuss such things as how to board the lifeboats in the event of an emergency. The announcer appropriately discussed the importance of washing hands, but incorrectly said, “the hotter the better.” When it comes to washing your hands, cold water works as well as hot water, except that if it’s cold, people won’t wash their hands as long because it’s uncomfortable. The same is true if the water is too hot. Thus warm water is recommended.

We took an excursion to see the Mayan ruins of Tulum near Cozumel, Mexico. Before leaving the ship we were warned not drink the local water. Near the ruins in a tourist shopping center I was tempted to eat at a Häagen-Dazs ice cream stand. I figured the ice cream was safe, but I worried about the water used to clean the scoops. It was probably safe, but I didn’t want to take a chance.

Obesity is a common problem in the United States and elsewhere, and is particularly a problem in the South. This was reflected in the passengers having embarked in New Orleans. Although people understandably eat excessively on a cruise, to which I’ll take the 5th Amendment, there are opportunities to do some healthy things on a cruise. I took advantage of their gym and exercised every day, though few did. Most of the time half the people exercising were crew members.

While looking for something else, I happened to walk by an ongoing talk on Secrets To A Flatter Stomach. I sat down and listened. The speaker was a personal trainer, certified by the Australian Institute of Fitness. He was buff, which automatically makes one feel he knows what he’s talking about. In fact his advice on exercise and nutrition was sound, and he did a great job explaining things. He then talked about detox and the need to get rid of toxic water trapped around fat. They invited people to sign up for a 1 hour personal analysis and consultation at a 2 for 1 special of $35. I spoke with the speaker’s colleague, a man from Scotland, and also buff. I asked if they would be repeating the lecture as I thought my wife would enjoy hearing it. He said he would cover the same material at the consultation, and more, and do an analysis with equipment not available in the United States (this model is available in the US and seems close to the 310e V8.0 they used). I was skeptical about the detox, but the cost was pretty low so I signed up.

At our meeting he first had us fill out questionnaires about our health, including what medications we were taking and why. I purposely didn’t answer the question about occupation, but admitted I was a physician when he later asked. He then went on to tell me he had a BSC degree in Sports Science from the University of West of Scotland, which he said was about equivalent to a physician in the United States. It’s not. He ran a bio-electrical impedance test attaching an electrode to the ankle and wrist. Running a very low voltage and current, that you cannot feel, through the body, it calculates body fat, lean body weight, body water and metabolic rate. The calculations require the body weight, which he asked about, but did not measure (towards the end of a cruise the actual weight is likely to be significantly higher than the stated weight!). Although the equipment he used may not be available in the US, it’s similar to the Tanita bathroom scale I have at home. My device calculates body fat, though you have to do your own calculations to derive the other numbers, and the results he obtained were very similar to my results at home.

He said I needed to lose 6.1 lbs of fat, and admitted I was among the healthiest he had tested on the cruise, but that I also had  12.5 lbs of toxic water to remove. According to his handout, that put me in the level of, “High levels of accumulative toxic waste circulating the cells of the body. Damage to Liver and Kidneys apparent. Weight gain is inevitable. Degeneration of joints and muscle tissue. High Blood Pressure / High cholesterol.” He recommended a 3 month detox program for $300. Most people, “needed” a 6 month program, which consisted of two 3 month cycles, and some needed a year’s worth. They would then do a 3 month cycle every few years or so depending, less often if following a healthy diet. My credit card would be charged that day, and the product shipped the next, so we could get started on it as soon as we returned home. The products are supposed to cleans the digestive tract, kidneys and liver. They contain various herbal products, algae, plantain seeds for fiber, and a low dose thyroid product of some sort, and one is also supposed to eat alkaline forming foods. I was naturally skeptical. He claimed that his analysis showed that I needed detoxification because I had problems with my cholesterol. He said that with his device he didn’t need to do blood tests. How did he know about my cholesterol problem? Because I told him! Actually it’s not that much of a problem, but I try to be proactive.

He said that evening there would be a nutrition class, but only for those who signed up. He encouraged me to sign up for the detox, but said he wasn’t worried because they get 60 people per week to sign up. While we were talking he was interrupted by someone asking if a person could be signed up for a consultation, even though his schedule was full.  He said he would let us think about it while he took care of something. The class was later held in the gym in a glass walled off section. I counted 19 attendees. To show the legitimacy of the program, he said his company contracts with Carnival and other cruise lines to offer the program, and has been in business for years. I asked for clinical study references to support detoxification. He said he could give it to me, but not until after I signed up. I declined.

If you take a cruise, try to get in some exercise, if nothing more than some extra walking. I advise you to save your money and not spend it on a detox program, and don’t forget your sunscreen.

American College of Physicians Internal Medicine 2012

I recently attended the American College of Physicians (ACP) Internal Medicine 2012 annual meeting, held this year in New Orleans. It’s a very large meeting with thousands of physicians attending. At any one time there are dozens of courses one can attend. I try to balance learning about subjects I have a particular interest in, with those that I’m less interested, and consequently have more to learn.

Among the talks I attended was a talk on genetics issues in internal medicine by Matthew Taylor, MD, PhD.  He discussed an interesting case of a 19-year-old woman who had been in good health who had lifted weights, used a hot tub then went swimming in a lap pool and was found unresponsive in 4 feet of water in 1998. She was resuscitated but died in the hospital 12 days later. An EKG done during the hospitalization was mildly abnormal with a prolonged QT interval. This was dismissed by most cardiologists as probably or not significant when asked to review the EKG. A subsequent genetic analysis of autopsy material revealed a genetic condition associated with a prolonged QT interval, which itself increases the risk of sudden death due to an arrhythmia. Further testing showed her sister, mother and maternal grandfather were found to have the same genetic condition. Most physicians would not even consider a genetic condition as the cause of a drowning, yet making the diagnosis may prevent family members from dying due to an arrhythmia with appropriate treatment.

I attended a talk by Holly Holmes, MD on discontinuing medications. It’s much easier to start a medicine than to stop one, yet medications carry financial costs and may cause side effects. She went over some cases and discussed strategies to decrease medication use. Amusingly she pointed out that not only did she not have any financial disclosures that might cause a conflict of interest, but that no pharmaceutical company would want to pay her to recommend stopping medications!

Besides the vast number of courses, there were also hundreds of vendors from pharmaceutical companies discussing new medications, companies selling books, equipment, massage chairs and gluten free products, and many just providing free information. There were recruiters looking for doctors, and more.

There was also the opportunity to interact with colleagues from around the world. I spoke with some physicians in Canada, and one from Saudi Arabia. I usually attend the ACP national meetings every few years and always come away having learning things that will help my patients, and feeling more invigorated about my profession.

Migraine or Sinus Disease?

A fractal suggestive of visual changes associated with migraines.

One of the more common reasons patients come to see me is because they think they have a sinus infection. Often they say they have pain in the sinus below their eye, nasal congestion, and may have drainage. They  tell me that they’ve had it before, and antibiotics help.

Careful questioning often reveals that they are really have a migraine headache. Typically they start as a teenager or young adult, and tend to decrease in frequency and severity in the 40’s to 50’s. They may occur on one or both sides of the head, and are often associated with nausea, sensitivity to light and sound, and sometimes people get blurred vision or see white spots or zigzag lines. Going to sleep helps. Migraines are more frequent in females and tend to run in families. If patients are unaware of a family history of headaches, I tell them to ask their mother, sister or daughter because they may just not have mentioned it.

Patients think antibiotics help because their headaches get better a few days after they start the medicine. But migraines generally only last 4 hours to 3 days if you don’t take anything. So the antibiotics get the credit, when none is due.

Sometimes the pain from a migraine goes into the neck, or it’s only felt there, and patients think they have a neck problem. They may go to a chiropractor or massage therapist before they see me.

Migraines are also confused for sinusitis because nerves from the brain that are activated with migraines can stimulate the nose to cause congestion. ‘Sinus Headaches’ was invented by Madison Avenue (or at least some advertising agency) to sell pills. Outside the United States, you won’t find such pills being advertized or sold. Some people truly have headaches from sinus infections, but many headaches thought to be sinusitis, are really migraines.

There are lots of ways to treat migraines, which I won’t discuss in this article, but first you have to get the diagnosis right.

If you have headaches or neck pain, be careful about telling your doctor that you think you have a sinus infection or neck arthritis. You may just convince them you’re right, when maybe you’re having a migraine.