You really continue to piss me off, so please read this!!!!

[Guest guest]

I've tried lecturing, cajoling, suggesting, and it doesn't seem to be sinking in. SO NOW I'M GOING TO TRY SHOUTING!!! I just spent a little over an hour with a new client who is a chiropractic patient. She was in a rather severe rearend mva, went to the urgent care clinic a couple of days later, they gave her some drugs and told her to go away. 30 days later, she had not been working (sent all of her child care customers to other homes, because she simply couldn't do the work), so finally (with perhaps a little help from me) she finds herself at the chiropractic clinic nearest her home--an experienced and compassionate doctor who I know and who has experience treating trauma victims. Why am I pissed??? Because I believe that while there was undoubtedly a clinically sufficient intake done, there was a totally inadequate intake interview done. Because of that, unless I personally get involved to correct the documentation problem, four months from now, this patient (who is hurt pretty bad) is going to be cut-off by an IME doctor (unless its by one of the handful of you truly objective IME docs--we all know who you are--as do you), this doctor is going to have a huge unpaid balance, and may even tell the patient that she can no longer be seen, because her insurance company is no longer paying the bill. In my opinion, it will be the doctor's own fault, not the patient's, not mine, and probably not even the insurance company's. Many clinics outsource their intake interviews to C.A.'s, especially if the patient doesn't speak English. If you don't have an extra 15 minutes to personally do an adequate intake or to sit through one that is being translated for you, then quite frankly, I don't have an extra 12-40 hours to litigate the issue of whether your treatment was reasonable, necessary, and causally related to injuries sustained on such and such a date, and I'm going to find it too inconvenient to spend time away from my family on a weekend so I can get ready for a hearing or trial, the whole purpose of which is to get your bill paid. Now in this case, we may get lucky. This patient may be completely healed within four months like a great many patients, and so the lack of documentation will not cause the doctor any pecuniary harm. It will have cost the patient, though, because she will not be compensated for all of the injuries she had, she will only be compensated for those injuries that were documented. If it ain't written down, it never existed. Initial documentation is not critical to the straight forward case. Initial documentation is critical to the problematic case and to the patient who falls within that category of soft tissue injuries that become chronic. You don't start doing a good job documenting the problematic case only after you realize that you and your patient really are in war where the defense is "liar, liar, pants of fire--70 percent of soft tissue injuries spontaneously heal in 4-6 weeks so hers did too." You start preparing for the problematic case the moment it walks into your clinic. If someone tells you that they were rearended at 50 mph and you don't follow-up to ask how much damage was done to their vehicle, only to discover it was only a scratch, then I don't want you treating my clients. Why? Because you'll not bother asking if her car was knocked forward--you won't inquire whether the actual injury producing biomechanics even occurred. If a patient tells you that they don't know if their car was knocked forward and you don't follow up with an inquiry into whether she moved her car prior to getting out and looking at the scratch, then I don't want you treating my clients. Most people have no clue if their car got knocked forward, in fact many swear it didn't because they remember the sensation of their foot slamming onto the brake even harder. However, everyone can tell you how far the bullet car was from their back bumper when they got out to look. If that information is not in your chart notes, then I don't want you treating my clients. Let me know so I can send them to someone else. If someone tells you they were in a bad wreck a month ago, went to Providence and got some pills, and haven't been to anyone else since, and a big flashing red light and siren does not go off in your head, then I don't want you treating my clients. "Tell me everything you've done to get better in the past month since Kaiser Permanente told you to go away? Advil, rest, exercises, some left over expired oxycodone from that root canal four years ago?? If that information isn't written down by you, then I don't want you treating my clients. Get the idea?? A lapse in treatment needs to be explained. It's part of the case, it might be part of the reason the patient takes longer to respond to treatment. Don't hide it!!! Use it. If there're prior injuries, don't hide them!!! Make them your best friend. If xrays show degeneration, don't ignore it, celebrate it!!!! An xray of my 95 year old grandma's neck should suggest to you that perhaps she's not going to respond in 4-6 weeks. Preexisting conditions or exasperations take a case out of the "simple" category. Am I being arrogant, presumptuous, insensitive, condescending, and pickle?? You bet. Are you going to hear me apologize anytime soon?? Only if you can honestly tell me that you read this message and it simply doesn't apply to you. Let me share with you what I do and what I ask every client in the initial interview (believe it or not, there're T.V. and radio lawyers who outsource their initial client interviews to secretaries and support staff--go figure--imagine the poor injured citizen who has the misfortune of having both a doctor and a lawyer who outsourced their initial interviews--one day their sitting in their lawyer's office learning for the first time that Farmers says their case is worth $ 1,250, the outstanding medical bills are $ 750.00, and golly, the only way to get more is to file a lawsuit, but I'll need you to come up with the $ 250.00 filing and service fee, knowing full well the poor bastard hasn't worked for 6 months and has a stack of collection notices on the kitchen counter). I'm not done!!! What pisses me off even more is when I've done interviewing the client and they've told me all sorts of clinically significant things and I say, did you tell your doctor that??? They say, "No, I didn't think it was related--I thought it was just stress, and doctor never asked me." The problem with this current client I can fix. I can always fix problems as long as I know about them in a timely fashion. Had this patient come to me four months from now with an IME cut-off letter in their hands, I would probably have apologized and told her that there was nothing I could do. O.K. HERE'S WHAT I DO, AND I'M NOT SAYING THIS IS THE ONLY WAY TO DO IT. "Mr. Client, I want to start at the top of your hair and go down to your toe nails and asked you some questions. I want you to answer my questions truthfully, even if you don't think the problems are related, and even if (especially if) you've had similar problems in the past. I'm not just talking about now. I want to know whether you've had any of these symptoms at any time since the event, even if they've gone away. At any time after the event have you had a headache??? Tell me about it, how long did it last, did it start in one place and move to another, have you ever had a headache at any other time in your life (if they say "no" they either didn't understand the question which should tell you that you're not truly communicating on this patient's level or the patient is lying or prone to embellishment--neither of which means the patient was not hurt, but both of which had better send sirens and lights shooting all over the office). Has it gotten any better, is it constant, intermittent, have you ever been treated by any doctor at any time in your life for a headache. If the answer is, "No" you'd better say, "Now let me tell you why I'm asking, the insurance company in this case is going to run a computer search on your name, date of birth, and social security number, and they're going to have a record of every time you ever made a claim. If it turns out that 20 years ago you went to the doctor and indicated you had a funny twitch in your left temple, they are going to use that against you and say you are lying. The answer I want to hear is something like, "Well, I remember going to the doctor once when I had the flu and it seems to me that I had a headache, but I can't remember if I told him/her about it in between my dry heaves." If I hear something like that, then I know my client is in the right frame of mind to be answering my questions. If I don't get that kind of answer, them my client is still not in the correct frame of mind and I keep hounding them until they are in the right frame of mind. I spend a lot of time with the head, because it's such a common source of pain. If they have no headaches, then I spend the same amount of time with whatever is the first body part that they identify as being painful. From the head, the rest is a breeze. I just work down the body, asking lots of follow-ups depending on the answers I get. I also always ask, "Did you tell your doctor that???" because so often the answer is no. If someone comes in to you because they have no curve in their lower back and it took them 20 minutes to get off the floor in the morning, their not going to tell you they've been dizzy, because at that moment, dizziness is not preventing them from functioning--back pain is. Next, I always ask if they've ever been hurt before, any crimes, any prior chiropractic treatment??, any workers comp claims, any prior MVA's, etc. Any dizziness, loss of balance, nauseasness, vomitting, ringing in your ears, jaw pain, numbness, tingling or pain in your arms hands or fingers at any time?? Numbness, tingling, or pain in your legs, feet, toes, buttocks, knees?? Any trouble sleeping?? How about your emotions? Have you noticed yourself crying or wanting to for no apparent reason?? Do you get angry at the cupboards?? Do you walk into the kitchen and forget why you're in there?? Do normal household sounds like your children bother you?? Is your husband getting on your nerves more?? Does having your kids climb all over you affectionately on the couch irritate you?? Then I tell my client that there's three and only three goals in a case. First, they get better. Second, they see the right doctors and we get those doctors paid. Third, and only third, there's some money at the end of the case for client and me to divide up. We're going to work on all three goals at the same time, because we can't get to goal number three if we haven't successfully accomplished goals 1 and 2. But to accomplish 1 and 2, they need to tell the doctor everything (and I mean everything) that's bothering them. If they have an appoint next Friday, sleep bad on Wednesday but sleep good on Thursday, they need to say, "Hey, Doc, I slept well last night but the night before that my back wouldn't let me sleep a wink. We are not in the business of exaggerating, making stuff up, or embellishing. However, we are in the business of telling the truth, and you are not being a whiner if you tell your doctor everything, even if you don't think it's significant. It just overjoys me to do an intake and have the patient tell me, yeah, I told my doctor all about that, in fact he/she even asked me more questions than you did. When I hear that, I know I'm going to have a smooth case, the client is going to be appropriately compensated, and I'm not going to have to work the weekend before trial, because there isn't going to be a trial, there'll be no need. If I've offended you by this email, then I'm sorry, you needed some offending (in my lay opinion). If this email was simply a long-winded waste of your time because not one thing in it was in anyway useful to you, then I do offer my apologies. I have an arrogant hunch that a couple of years from now, you'll remember the few minutes you read this email and realize that you've been handsomely paid at least $5,000 per hour for the time it took to read. FYI, the client in question had no vomitting (which the doctor did ask her), however, she had nauseasness for two weeks, dizziness without loss of balance, numbness in her right hand, absentmindedness and forgetfulness, crying spells (she thinks its just stress from not working and being broke), she struck her head on the steering wheel and actually had a bruise on her forehead that's since healed, and sounds really irritated her. She hadn't worked for a month, was taking about 1600 mg of Advil a day for the past month, taking hot baths. The intake interview with the doctor did not cover any of these topics (according to the client, that is, I'm not beyond believing that my client was being less than truthful). However, I will confirm with the client in a week that she has in fact discussed all these things with the doctor, and if not, I'll make the call myself. Have a great weekend. Best Regards, G. (I'd put my firm's name here, too, but this is coming from me personally, and I'd hate for you to take any animosity towards me for this outrage out on my colleagues.