Billing

I don’t know what everyone else thinks but I have found it quite difficult to decide what to charge my patients when they come to see me. I know there are bulk-billing incentives but I always find it hard to decided what to bill my patients who don’t fall into that category.

The difficulty comes when working in a mixed billing centre and having to decide how much I need to charge them when they walk out. I know I have been taught to bill according to the timing of the consultation but sometimes when there is a consult that is difficult which has obviously warranted a Level C billing, I have to decide whether I charge them the $100+ fee that comes with it. I know they’ll get a big sum of that back but I wonder what everyone else thinks about someone having to pay that much when they leave. Do you feel uncomfortable? Do you reduce the consult to a Level B knowing that the gap will be the same? Do you bulk bill them when they’re in the Level C category? Or do you feel that over time your patients start to expect a certain standard from you which involves being charged irrespective of the presentation so as to justify that time they’ve spent with you? I’d like to think the last option is true.

I know coming from the hospital system, the idea of consultation based billing has never been a problem for me but now I find myself constantly having to decide what “the right thing to do is”. I know I don’t want to undervalue my profession or even undervalue myself but sometimes I don’t know what the right amount is to justify that time spent with a patient. Let me know your thoughts :).

Meningococcal B vaccinations

How many of you guys have prescribed the meningococcal B vaccination? It’s called Bexsero.

I had a mother come in asking for it. I didn’t know much about it but luckily I had some brochures handy and articles that I could present to her.

Here are some key points:

  • 200 – 250 cases of meningococcal occur each year. The majority of these cases are due to meningococcal B. Meningococcal C has declined since the 2003 immunisation schedule.
  • The immunisation covers 76% of strains of Meningococcal B in Australia
  • There is a cost involved (approximately $137)
  • You are required to take either 2 or 3 doses and a booster shot is also offered
  • A common side effect is post-vaccination fever

Let me know if there was anything else you’ve heard out there which also needs to be discussed with parents.

More information can be found at: http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/85A6879534C02B4DCA257B640002F38E/$File/ATAGI-advice-bexsero.pdf

Getting Exposure

Does anyone know how it is that people start reading a blog? Does the author tend to comment on other websites and hope that those people reading that website will venture over to this part of town. I know when I comment on a post I want it to be worthwhile and not just a random promotion but I know I’m at a point where I want people to see what’s written here and give me their thoughts. I think that time will come when I write a piece that I know I need to tell the world. For now I’m happy writing for myself and those few who chose to follow this blog. I hope one day I can compile a list of stories and interesting consultations from over the years.

Interesting Case of the Day
Today I was presented with a 6 year old who had 2 cystic lumps over the upper eyelid and the lower eyelid. It was initially treated as a stye and managed with antibiotics. The practice point in this presentation is that a stye needs to have an associated hair follicle in the area that’s affected. This was close but not part of a hair follicle. This was in fact a chalazion or meibomian cyst and the treatment is different. You can confirm their presence by inverting the eyelid. Once I knew what it was I advised mum to apply warm compresses on it (for 5-10 minutes approximately 3 times a day). This is the definitive treatment and baby shampoo can be used to prevent recurrence when applied over the eyelid. In the instance where it is infected, oral antibiotics may be used. If there is no improvement then of course you’ll need to make a specialist referral to remove the cyst. Sometimes we just have to look a little closer.

Offended?

So today I was faced with an unusual situation. I was due to see my next patient and went out into the waiting room to call her. It wasn’t long after 5pm so the waiting room was pretty empty. When I called her name she stood up and walked towards me and continued walking beside me for a few steps. I introduced myself and then she blurted “sorry I thought I was seeing a female doctor… you know because of my lady problems. I specifically asked reception for a lady doctor”. I stopped, turned around and walked towards reception. I acknowledged the request but was puzzled. Could I not handle this situation? Why did she wait until half way down the corridor to tell me she wanted a female doctor? I honestly don’t know. Anyway, I asked reception about the mix up and they said they’d sort it out.

I felt a little awkward. I know it’s not me but sometimes it makes you wonder what it means to be equal. Why is it that I somehow can’t handle a situation that I have been trained to tackle.

Just something different today.

Chest Pain

What are your stories of patients coming in with chest pain?

I was presented with a 60yo male last week who reported 4/10 pain in his chest, slight shortness of breath during the day and weakness in the arms. The pain felt like a lump in his chest and he is known to have a significant history of indigestion.

I trialled some mylanta and did an ECG and here I was looking at a man with what seemed to be a minor MSK chest pain reporting significant ST elevation in the posterior leads of his ECG.

I had no idea how this was managed in the GP setting but I did everything I needed to do whilst the ambulance was being called. What a rush! Oxygen on despite normal sats. GTN spray and aspirin given. IV cannula in and morphine pushed through. When the ambulance arrived there was still some ST elevation and we sent him on his way to the cath lab.

The next day after the weekend I found out he had 2 stents put in and is awaiting bypass surgery. What do you know. A life saved. Sometimes it’s better to go with your gut and look because more things are missed by not looking than not knowing.

This is the first time I had to transfer anyone to hospital but boy was it a rush. Let me know if you have any misleading presentations of chest pain yourselves.

A fortnight of stories

I’ve officially completed 2 weeks and I must say I absolutely love it! At the end of each day I felt like I had achieved something. There was purpose and meaning behind every decision I made and I felt like I was completely autonomous. I had help when I needed it but ultimately I was given the challenge of deciding if what I was doing would help this person or not. That’s a great feeling to have. Over the 2 weeks I have also been able to see patients come back to see me.

I must admit there are some days where I just wasn’t sure and I would call them up a few days later and see how they were doing. Sometimes I was happy to hear things were improving but other times I felt glad calling the patients because I could give them some more advice about the situation.

What have I learnt? What interesting cases have I seen. Here are just a few…

1. The use of duromine in a patient needing weight loss assistance who was completely motivated and had tried everything else. She was seen a week later and well she felt amazing.

2. The peri-menopausal lady with palpitations. A little scary when I had no idea if she was in AF or not but reassured with a Holter monitor and her improvement in symptoms with some simple day to day advice.

3. The girl with a cold sore where I just didn’t know if I should treat it or not. I just didn’t know if she’d be better or not by the weekend when she’d be taking photos for a wedding.

4. The pregnant lady and what to tell her regarding starting a new pregnancy and everything she will have in front of her.

5. The guy with a fractured hand with minimal swelling… and the kid with no fracture and a huge swelling.

6. The bipolar patient and managing their symptoms when they come in with a Manic episode having not taken their Paroxetine and Sodium Valproate for a few weeks.

7. The guy with a wart on his toe and the many options we can offer! Cryotherapy was quite fun!

8. The guy with a huge cutting to his forehead needing stitches.

9. The women who comes in after her husband was in an affair asking for help! First patient of the day but boy was I unprepared for such an encounter.

10. The red eye!! Trying to exclude all the fancy pancy things it could be.

As you can see these are just a small subset of patients I was able to see during my first two weeks. I love the variety and the uncertainty of being presented with a patient who just happens to be there in front of you asking for your advice. I can’t wait to collect a wealth of experience so when those patients come in I just get a feeling that something is right or wrong. At the moment I’m always double checking and always asking questions but that’s all I can do. I owe a lot to my patients and endeavour to do everything I can to offer the best care I can.

Until next time… It has been a fun couple of weeks.

P/s: I’m more than happy for anyone to just tell me their experiences with any of the above or stories they wanted to share on this page. I don’t mind it being used as a forum for discussion but I also feel it’ll be a nice page for me to see my transition through the program and see how well I mature as a person and a GP.

The First Day

It was like I was starting my first day of school. I had my notebook in my hand, a pen and a keen mind to absorb everything that was said and told.

I have to admit I was quite nervous. As soon as my day started I was presented with a range of geriatric presentations which took up most of the morning. Having come from a predominantly paediatric background, this was a bit daunting. The main things I saw were dizziness/vertigo, infant rashes, mental health care plans, a few fractures and a few pains. I was surprised that I didn’t see any hypertension or diabetes whatsoever. This was just my first day but I expected to at least someone with those fundamental conditions. I was also suprised to see noone with a cough or cold! I was happy with how the day progressed but unfortunately Medical Director (the computer program we use) will take some getting used to. Apparently we can set up templates and things to make it easier.

It was a great first day at school 🙂

Quote

“Everyone is born with music, but they may never discover what their music might be. There can be no greater tragedy in life, than for people to take their music to the grave” ~ Anonymous

Read, Steady… Go!!

So with just 2 weeks left before I start working, I just want to say how excited I am to be working on the front line of medicine.

I’m curious to know whether people have any useful tips or tricks for those first few days!! It’s definitely going to be a fun ride.

A New Start

Hi guys!

I’m hoping to update you all on the days I have in GP land and all the other things associated with being me. It’s the new year so I’m planning on making some new years resolutions! Fortunately excercising more was one of them and I’ve been able to spend 2 of the last 4 days going to the gym.

I’m hoping to look into some interesting fun facts or questions that I feel may warrant discussion and post them up soon. Just a month to go.

Until then stay cool. It’s hot!