Allan M. Block, MD

“It was my wife’s walker, and I’ve never used one before. Sorry that I keep bumping into things.”

He was in his early 70s, recently widowed. He hadn’t needed a walker until yesterday, and his son had gotten it out of the garage where they’d just stowed it away. I showed him how to change the height setting on it so he didn’t have to lean so far over.

His daughter was a longstanding patient of mine, and now she and her brother were worried about their dad. He’d been so healthy for years, taking care of their mother as she declined with cancer. Now, 2 months since her death, he’d started going downhill. He’d been, understandably, depressed and had lost some weight. A few weeks ago he’d had some nonspecific upper respiratory crud, and now they were worried he wasn’t eating. He’d gotten progressively weaker in the last few days, leading to their getting out the walker.

I knew my patient for several years. She wasn’t given to panicking, and was worried about her dad. By this time, I was too. Twenty-eight years of neurology training and practice puts you on the edge for some things. The “Spidey Sense,” as I’ve always called it, was tingling.

It took a very quick neurologic exam to find what I needed. He was indeed weak, had decreased distal sensation, and was completely areflexic. It was time to take the most-dreaded outpatient neurology gamble: The direct office-to-ER admission.

I told his daughter to take him to the nearby ER and scribbled a note that said “Probable Guillain-Barré. Needs urgent workup.” They were somewhat taken aback, as they had dinner plans that night, but his daughter knew me well enough to know that I don’t pull fire alarms for fun.

As soon as they’d left I called the ER doctor and told her what was coming. My hospital days ended 2 years ago, but I wanted to do everything I could to make sure the right ball was rolling.

Then my part was over. I had other patients waiting, tests to review, phone calls to make.

This is where the anxiety began. Nobody wants to be the person who cries wolf, or admits “dumps.” I’ve been on both sides of admissions, and bashing outpatient docs for unnecessary hospital referrals is a perennial pastime of inpatient care.

I was sure of my actions, but as the hours crept by some doubt came in. What if he got to the hospital and suddenly wasn’t weak? Or it was all from a medication error he’d made at home?

No one wants to claim they saw a flare when there wasn’t one, or get the reputation of being past their game. I was worried about the patient, but also began to worry I’d screwed up and missed something else.

I finished the day and went home. After closing out my usual end-of-the-day stuff I logged into the hospital system to see what was going on.

Normal cervical spine MRI. Spinal fluid had zero cells and elevated protein.

I breathed a sigh of relief and relaxed back into my chair. I’d made the right call. The hospital neurologist had ordered IVIG. The patient would hopefully recover. No one would think I’d screwed up a potentially serious case. And, somewhere in the back of my mind, the Sherlock Holmes inside every neurologist tipped his deerstalker cap at me and gave a slight nod.

There’s the relief of having done the right thing for the patient, having made the correct diagnosis, and, at the end of the day, being reassured that (some days at least) I still know what I’m doing.

It’s those feelings that brought me here and still keep me going.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“It was my wife’s walker, and I’ve never used one before. Sorry that I keep bumping into things.”

He was in his early 70s, recently widowed. He hadn’t needed a walker until yesterday, and his son had gotten it out of the garage where they’d just stowed it away. I showed him how to change the height setting on it so he didn’t have to lean so far over.

His daughter was a longstanding patient of mine, and now she and her brother were worried about their dad. He’d been so healthy for years, taking care of their mother as she declined with cancer. Now, 2 months since her death, he’d started going downhill. He’d been, understandably, depressed and had lost some weight. A few weeks ago he’d had some nonspecific upper respiratory crud, and now they were worried he wasn’t eating. He’d gotten progressively weaker in the last few days, leading to their getting out the walker.

I knew my patient for several years. She wasn’t given to panicking, and was worried about her dad. By this time, I was too. Twenty-eight years of neurology training and practice puts you on the edge for some things. The “Spidey Sense,” as I’ve always called it, was tingling.

It took a very quick neurologic exam to find what I needed. He was indeed weak, had decreased distal sensation, and was completely areflexic. It was time to take the most-dreaded outpatient neurology gamble: The direct office-to-ER admission.

I told his daughter to take him to the nearby ER and scribbled a note that said “Probable Guillain-Barré. Needs urgent workup.” They were somewhat taken aback, as they had dinner plans that night, but his daughter knew me well enough to know that I don’t pull fire alarms for fun.

As soon as they’d left I called the ER doctor and told her what was coming. My hospital days ended 2 years ago, but I wanted to do everything I could to make sure the right ball was rolling.

Then my part was over. I had other patients waiting, tests to review, phone calls to make.

This is where the anxiety began. Nobody wants to be the person who cries wolf, or admits “dumps.” I’ve been on both sides of admissions, and bashing outpatient docs for unnecessary hospital referrals is a perennial pastime of inpatient care.

I was sure of my actions, but as the hours crept by some doubt came in. What if he got to the hospital and suddenly wasn’t weak? Or it was all from a medication error he’d made at home?

No one wants to claim they saw a flare when there wasn’t one, or get the reputation of being past their game. I was worried about the patient, but also began to worry I’d screwed up and missed something else.

I finished the day and went home. After closing out my usual end-of-the-day stuff I logged into the hospital system to see what was going on.

Normal cervical spine MRI. Spinal fluid had zero cells and elevated protein.

I breathed a sigh of relief and relaxed back into my chair. I’d made the right call. The hospital neurologist had ordered IVIG. The patient would hopefully recover. No one would think I’d screwed up a potentially serious case. And, somewhere in the back of my mind, the Sherlock Holmes inside every neurologist tipped his deerstalker cap at me and gave a slight nod.

There’s the relief of having done the right thing for the patient, having made the correct diagnosis, and, at the end of the day, being reassured that (some days at least) I still know what I’m doing.

It’s those feelings that brought me here and still keep me going.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“It was my wife’s walker, and I’ve never used one before. Sorry that I keep bumping into things.”

He was in his early 70s, recently widowed. He hadn’t needed a walker until yesterday, and his son had gotten it out of the garage where they’d just stowed it away. I showed him how to change the height setting on it so he didn’t have to lean so far over.

His daughter was a longstanding patient of mine, and now she and her brother were worried about their dad. He’d been so healthy for years, taking care of their mother as she declined with cancer. Now, 2 months since her death, he’d started going downhill. He’d been, understandably, depressed and had lost some weight. A few weeks ago he’d had some nonspecific upper respiratory crud, and now they were worried he wasn’t eating. He’d gotten progressively weaker in the last few days, leading to their getting out the walker.

I knew my patient for several years. She wasn’t given to panicking, and was worried about her dad. By this time, I was too. Twenty-eight years of neurology training and practice puts you on the edge for some things. The “Spidey Sense,” as I’ve always called it, was tingling.

It took a very quick neurologic exam to find what I needed. He was indeed weak, had decreased distal sensation, and was completely areflexic. It was time to take the most-dreaded outpatient neurology gamble: The direct office-to-ER admission.

I told his daughter to take him to the nearby ER and scribbled a note that said “Probable Guillain-Barré. Needs urgent workup.” They were somewhat taken aback, as they had dinner plans that night, but his daughter knew me well enough to know that I don’t pull fire alarms for fun.

As soon as they’d left I called the ER doctor and told her what was coming. My hospital days ended 2 years ago, but I wanted to do everything I could to make sure the right ball was rolling.

Then my part was over. I had other patients waiting, tests to review, phone calls to make.

This is where the anxiety began. Nobody wants to be the person who cries wolf, or admits “dumps.” I’ve been on both sides of admissions, and bashing outpatient docs for unnecessary hospital referrals is a perennial pastime of inpatient care.

I was sure of my actions, but as the hours crept by some doubt came in. What if he got to the hospital and suddenly wasn’t weak? Or it was all from a medication error he’d made at home?

No one wants to claim they saw a flare when there wasn’t one, or get the reputation of being past their game. I was worried about the patient, but also began to worry I’d screwed up and missed something else.

I finished the day and went home. After closing out my usual end-of-the-day stuff I logged into the hospital system to see what was going on.

Normal cervical spine MRI. Spinal fluid had zero cells and elevated protein.

I breathed a sigh of relief and relaxed back into my chair. I’d made the right call. The hospital neurologist had ordered IVIG. The patient would hopefully recover. No one would think I’d screwed up a potentially serious case. And, somewhere in the back of my mind, the Sherlock Holmes inside every neurologist tipped his deerstalker cap at me and gave a slight nod.

There’s the relief of having done the right thing for the patient, having made the correct diagnosis, and, at the end of the day, being reassured that (some days at least) I still know what I’m doing.

It’s those feelings that brought me here and still keep me going.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Doctors love puzzles, they say. Especially neurologists.

The detective work on a case is part of the job’s appeal. Taking clues from the history, exam, and tests to formulate a diagnosis, then a treatment plan.

But I’m not talking about that.

As I’ve written before, I’ve tried hard to divorce myself from the news. In times where the world seems to have gone mad, I just don’t want to know what’s going on. I focus on my family, my job, and the weather forecast.

But, inevitably, I need something to do. At some point I run out of notes to type, tests to review, emails to answer, and bills to pay. I used to read the news, but now I don’t do that anymore. I even avoid my favorite satire sites, like Onion and Beaverton, because they just reflect the real news (I still read the Weekly World News, which has no relationship to reality, or pretty much anything, whatsoever).

So now, when I’m done with the day’s work, I shut down the computer (which isn’t easy after 25 years of habitual surfing) and sit down with a jigsaw puzzle. I haven’t done that since I was a resident.

It usually takes me 2-3 weeks to do one (500-1,000 pieces) in the 30 minutes or so I spend on it each evening. There’s solace in the quiet, methodical process of carefully looking for matching pieces, trying a few, the brief glee at getting a fit, and then moving to the next piece.

I know I can do this on my iPad, but it’s different with real pieces. Lifting up a piece and examining it for matching shapes and colors, sorting through the tray, wondering if I made a mistake somewhere. The cardboard doesn’t light up to let me know I got it right.

Inevitably, the mind wanders as I work on them. Sometimes back to a puzzle at the office, sometimes to my doing the same puzzle (I’ve had them for a while) at my parents’ house in my teens, sometimes to my kids away at college, or a book I once read.

But that’s the point. It’s almost a form of meditation. Focusing on each piece as my mind moves in other directions. It’s actually more relaxing than I thought, and a welcome escape from the day.

And, like other seemingly unrelated tasks (such as Leo Szilard waiting for a traffic light to change, albeit on a lesser scale), sometimes it brings me an answer I’ve been searching for. A light bulb will go on for a patient case I’ve been turning over for a few days. When that happens I grab my phone and email the thought to myself at work.

It puts my mind in neutral at the end of the day. When I finally go to bed I’m less focused on things that can keep me awake at night.

Though occasionally I do dream of puzzles.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Doctors love puzzles, they say. Especially neurologists.

The detective work on a case is part of the job’s appeal. Taking clues from the history, exam, and tests to formulate a diagnosis, then a treatment plan.

But I’m not talking about that.

As I’ve written before, I’ve tried hard to divorce myself from the news. In times where the world seems to have gone mad, I just don’t want to know what’s going on. I focus on my family, my job, and the weather forecast.

But, inevitably, I need something to do. At some point I run out of notes to type, tests to review, emails to answer, and bills to pay. I used to read the news, but now I don’t do that anymore. I even avoid my favorite satire sites, like Onion and Beaverton, because they just reflect the real news (I still read the Weekly World News, which has no relationship to reality, or pretty much anything, whatsoever).

So now, when I’m done with the day’s work, I shut down the computer (which isn’t easy after 25 years of habitual surfing) and sit down with a jigsaw puzzle. I haven’t done that since I was a resident.

It usually takes me 2-3 weeks to do one (500-1,000 pieces) in the 30 minutes or so I spend on it each evening. There’s solace in the quiet, methodical process of carefully looking for matching pieces, trying a few, the brief glee at getting a fit, and then moving to the next piece.

I know I can do this on my iPad, but it’s different with real pieces. Lifting up a piece and examining it for matching shapes and colors, sorting through the tray, wondering if I made a mistake somewhere. The cardboard doesn’t light up to let me know I got it right.

Inevitably, the mind wanders as I work on them. Sometimes back to a puzzle at the office, sometimes to my doing the same puzzle (I’ve had them for a while) at my parents’ house in my teens, sometimes to my kids away at college, or a book I once read.

But that’s the point. It’s almost a form of meditation. Focusing on each piece as my mind moves in other directions. It’s actually more relaxing than I thought, and a welcome escape from the day.

And, like other seemingly unrelated tasks (such as Leo Szilard waiting for a traffic light to change, albeit on a lesser scale), sometimes it brings me an answer I’ve been searching for. A light bulb will go on for a patient case I’ve been turning over for a few days. When that happens I grab my phone and email the thought to myself at work.

It puts my mind in neutral at the end of the day. When I finally go to bed I’m less focused on things that can keep me awake at night.

Though occasionally I do dream of puzzles.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Doctors love puzzles, they say. Especially neurologists.

The detective work on a case is part of the job’s appeal. Taking clues from the history, exam, and tests to formulate a diagnosis, then a treatment plan.

But I’m not talking about that.

As I’ve written before, I’ve tried hard to divorce myself from the news. In times where the world seems to have gone mad, I just don’t want to know what’s going on. I focus on my family, my job, and the weather forecast.

But, inevitably, I need something to do. At some point I run out of notes to type, tests to review, emails to answer, and bills to pay. I used to read the news, but now I don’t do that anymore. I even avoid my favorite satire sites, like Onion and Beaverton, because they just reflect the real news (I still read the Weekly World News, which has no relationship to reality, or pretty much anything, whatsoever).

So now, when I’m done with the day’s work, I shut down the computer (which isn’t easy after 25 years of habitual surfing) and sit down with a jigsaw puzzle. I haven’t done that since I was a resident.

It usually takes me 2-3 weeks to do one (500-1,000 pieces) in the 30 minutes or so I spend on it each evening. There’s solace in the quiet, methodical process of carefully looking for matching pieces, trying a few, the brief glee at getting a fit, and then moving to the next piece.

I know I can do this on my iPad, but it’s different with real pieces. Lifting up a piece and examining it for matching shapes and colors, sorting through the tray, wondering if I made a mistake somewhere. The cardboard doesn’t light up to let me know I got it right.

Inevitably, the mind wanders as I work on them. Sometimes back to a puzzle at the office, sometimes to my doing the same puzzle (I’ve had them for a while) at my parents’ house in my teens, sometimes to my kids away at college, or a book I once read.

But that’s the point. It’s almost a form of meditation. Focusing on each piece as my mind moves in other directions. It’s actually more relaxing than I thought, and a welcome escape from the day.

And, like other seemingly unrelated tasks (such as Leo Szilard waiting for a traffic light to change, albeit on a lesser scale), sometimes it brings me an answer I’ve been searching for. A light bulb will go on for a patient case I’ve been turning over for a few days. When that happens I grab my phone and email the thought to myself at work.

It puts my mind in neutral at the end of the day. When I finally go to bed I’m less focused on things that can keep me awake at night.

Though occasionally I do dream of puzzles.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Mrs. Smith came in for neck pain.

This isn’t a new issue, her last flare was 4 or 5 years ago. I’d done an MRI back then, which just showed reassuringly typical arthritic changes, and she did great with a few sessions of physical therapy.

She’d woke one morning a few months ago with a stiff and aching neck, similar to how this started last time. A couple weeks of rest and NSAIDs hadn’t helped. There were no radiating symptoms and her exam was the same as it’s been since I met her back in 2010.

I wrote her an order for physical therapy and found the address and phone number of the place she’d gone to for it a few years ago. She looked at my order, then set it on my desk and said “Doctor, I’d really like an MRI.”

I went back to her chart and reread my note for her last flare of neck pain. Identical symptoms, identical exam. I pulled up the previous MRI report and went over it. Then I explained to her that there really was no indication for an MRI at this point. I suggested we go ahead with physical therapy, and if that didn’t help I would then re-check the study.

She wasn’t going to budge. A friend of hers had recently needed urgent surgery for a cervical myelopathy and was in rehab. Mrs. Smith’s husband’s health was getting worse, and if her neck had something seriously wrong she wouldn’t be able to take care of him if it went unchecked.

So I backed down and ordered a cervical spine MRI, which was pretty much unchanged from the previous MRI. After it came back she was willing to do therapy.

I’m sure some out there will accuse me, the doctor, of letting the patient call the shots. To some degree you’re correct. But it’s not like the request was insanely unreasonable. Obviously, there were other factors going on, too. She was scared and needed reassurance that there wasn’t anything therapy wouldn’t help and that she would be able to keep caring for her ailing husband during his cancer treatments.

There are doctors out there with a more paternalistic view of patient care than mine. They’re probably thinking I should have taken a hardball approach of “you don’t need an MRI. You can do therapy, or you can find another doctor.” But that’s not me. I can’t do that to a nice older lady, especially one who’s been coming to me for various ailments over the last 12 years.

Not only that, but such an approach seemed doomed to fail in this case. It might have gotten her to go to therapy, but I suspect she wouldn’t have gotten better. Her fears about a serious neck issue would increase over time, until she (or the therapist) finally called, said she wasn’t getting better, and could I order an MRI now?

In that way, maybe the MRI helped guarantee that she’d have a good response to therapy.

Medicine is never easy. We learn a lot of rules and guidelines in the name of providing good, economically viable, patient care, but still have to recognize that there isn’t a one-size-fits-all approach.

I can’t say that what I did was the right thing. But it was right for Mrs. Smith.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Mrs. Smith came in for neck pain.

This isn’t a new issue, her last flare was 4 or 5 years ago. I’d done an MRI back then, which just showed reassuringly typical arthritic changes, and she did great with a few sessions of physical therapy.

She’d woke one morning a few months ago with a stiff and aching neck, similar to how this started last time. A couple weeks of rest and NSAIDs hadn’t helped. There were no radiating symptoms and her exam was the same as it’s been since I met her back in 2010.

I wrote her an order for physical therapy and found the address and phone number of the place she’d gone to for it a few years ago. She looked at my order, then set it on my desk and said “Doctor, I’d really like an MRI.”

I went back to her chart and reread my note for her last flare of neck pain. Identical symptoms, identical exam. I pulled up the previous MRI report and went over it. Then I explained to her that there really was no indication for an MRI at this point. I suggested we go ahead with physical therapy, and if that didn’t help I would then re-check the study.

She wasn’t going to budge. A friend of hers had recently needed urgent surgery for a cervical myelopathy and was in rehab. Mrs. Smith’s husband’s health was getting worse, and if her neck had something seriously wrong she wouldn’t be able to take care of him if it went unchecked.

So I backed down and ordered a cervical spine MRI, which was pretty much unchanged from the previous MRI. After it came back she was willing to do therapy.

I’m sure some out there will accuse me, the doctor, of letting the patient call the shots. To some degree you’re correct. But it’s not like the request was insanely unreasonable. Obviously, there were other factors going on, too. She was scared and needed reassurance that there wasn’t anything therapy wouldn’t help and that she would be able to keep caring for her ailing husband during his cancer treatments.

There are doctors out there with a more paternalistic view of patient care than mine. They’re probably thinking I should have taken a hardball approach of “you don’t need an MRI. You can do therapy, or you can find another doctor.” But that’s not me. I can’t do that to a nice older lady, especially one who’s been coming to me for various ailments over the last 12 years.

Not only that, but such an approach seemed doomed to fail in this case. It might have gotten her to go to therapy, but I suspect she wouldn’t have gotten better. Her fears about a serious neck issue would increase over time, until she (or the therapist) finally called, said she wasn’t getting better, and could I order an MRI now?

In that way, maybe the MRI helped guarantee that she’d have a good response to therapy.

Medicine is never easy. We learn a lot of rules and guidelines in the name of providing good, economically viable, patient care, but still have to recognize that there isn’t a one-size-fits-all approach.

I can’t say that what I did was the right thing. But it was right for Mrs. Smith.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Mrs. Smith came in for neck pain.

This isn’t a new issue, her last flare was 4 or 5 years ago. I’d done an MRI back then, which just showed reassuringly typical arthritic changes, and she did great with a few sessions of physical therapy.

She’d woke one morning a few months ago with a stiff and aching neck, similar to how this started last time. A couple weeks of rest and NSAIDs hadn’t helped. There were no radiating symptoms and her exam was the same as it’s been since I met her back in 2010.

I wrote her an order for physical therapy and found the address and phone number of the place she’d gone to for it a few years ago. She looked at my order, then set it on my desk and said “Doctor, I’d really like an MRI.”

I went back to her chart and reread my note for her last flare of neck pain. Identical symptoms, identical exam. I pulled up the previous MRI report and went over it. Then I explained to her that there really was no indication for an MRI at this point. I suggested we go ahead with physical therapy, and if that didn’t help I would then re-check the study.

She wasn’t going to budge. A friend of hers had recently needed urgent surgery for a cervical myelopathy and was in rehab. Mrs. Smith’s husband’s health was getting worse, and if her neck had something seriously wrong she wouldn’t be able to take care of him if it went unchecked.

So I backed down and ordered a cervical spine MRI, which was pretty much unchanged from the previous MRI. After it came back she was willing to do therapy.

I’m sure some out there will accuse me, the doctor, of letting the patient call the shots. To some degree you’re correct. But it’s not like the request was insanely unreasonable. Obviously, there were other factors going on, too. She was scared and needed reassurance that there wasn’t anything therapy wouldn’t help and that she would be able to keep caring for her ailing husband during his cancer treatments.

There are doctors out there with a more paternalistic view of patient care than mine. They’re probably thinking I should have taken a hardball approach of “you don’t need an MRI. You can do therapy, or you can find another doctor.” But that’s not me. I can’t do that to a nice older lady, especially one who’s been coming to me for various ailments over the last 12 years.

Not only that, but such an approach seemed doomed to fail in this case. It might have gotten her to go to therapy, but I suspect she wouldn’t have gotten better. Her fears about a serious neck issue would increase over time, until she (or the therapist) finally called, said she wasn’t getting better, and could I order an MRI now?

In that way, maybe the MRI helped guarantee that she’d have a good response to therapy.

Medicine is never easy. We learn a lot of rules and guidelines in the name of providing good, economically viable, patient care, but still have to recognize that there isn’t a one-size-fits-all approach.

I can’t say that what I did was the right thing. But it was right for Mrs. Smith.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The medical news is full of articles about the coming epidemic of dementia. How many people will have it in 10 years, 20 years, etc. It’s a very legitimate concern, and I am not going to make light of it, or disagree with the predictions.

In my everyday practice, though, I find there’s an epidemic of overdiagnosed dementia, in those who aren’t even close.

This occurs in a few ways:

Aricept is pretty inexpensive these days. Long off patent, insurance companies don’t bother to question its use anymore. So anyone older than 60 who complains of losing their car keys gets put on it. Why? Because patients want their doctors to DO SOMETHING. Even if the doctor knows that there’s really nothing of alarm going on, sometimes it’s easier to go with the placebo effect than argue. I think we’ve all done that before.

There are also a lot of nonneurologists in practice who still, after almost 30 years on the market, think Aricept improves memory, when in fact that’s far from the truth. The best it can claim to do is slow down the rate at which patients get worse, but nobody wants to hear that.

I’ve also seen Aricept used for pseudodementia due to depression. Actually, I’ve seen it used for depression, too. Sometimes it’s used to counteract the side effects dof drugs that can impair cognition, such as Topamax, even in patients who aren’t even remotely demented.

None of the above are a major issue on their own. Where the trouble really happens, as with so many other things, is when they collide with an EMR, or someone too rushed to take a history, or both.

Let’s say Mrs. Jones is on Aricept because she went into a room, then forgot why she did.

Then she gets admitted to the hospital for pneumonia. Or she changes doctors and, like many practices these days, her medications are put in the computer by an MA or secretary.

A lot of times just the mention of Aricept will automatically bring the assumption that the person is demented, so that gets punched in as a diagnosis and the patient is now believed to be unable to provide a reliable history. Or the person entering the info looks up its indication and enters “Alzheimer’s disease.”

Even worse is that I’ve seen EMRs where, in an effort to save time, the computer automatically enters diagnoses as you type medications in, and it’s up to the doctor to review them for accuracy. How that saves time I have no idea. But, as above, in these cases it’s going to lead to an entry of dementia where there isn’t any.

That, in particular, is pretty scary. As I wrote here in January of this year, what happens in the EMR stays in the EMR (kind of like Las Vegas).

I’m not knocking off-label use of medications. I don’t know a doctor who doesn’t use some that way, including myself.

But when doing so leads to the wrong assumptions and diagnoses it creates a lot of problems.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The medical news is full of articles about the coming epidemic of dementia. How many people will have it in 10 years, 20 years, etc. It’s a very legitimate concern, and I am not going to make light of it, or disagree with the predictions.

In my everyday practice, though, I find there’s an epidemic of overdiagnosed dementia, in those who aren’t even close.

This occurs in a few ways:

Aricept is pretty inexpensive these days. Long off patent, insurance companies don’t bother to question its use anymore. So anyone older than 60 who complains of losing their car keys gets put on it. Why? Because patients want their doctors to DO SOMETHING. Even if the doctor knows that there’s really nothing of alarm going on, sometimes it’s easier to go with the placebo effect than argue. I think we’ve all done that before.

There are also a lot of nonneurologists in practice who still, after almost 30 years on the market, think Aricept improves memory, when in fact that’s far from the truth. The best it can claim to do is slow down the rate at which patients get worse, but nobody wants to hear that.

I’ve also seen Aricept used for pseudodementia due to depression. Actually, I’ve seen it used for depression, too. Sometimes it’s used to counteract the side effects dof drugs that can impair cognition, such as Topamax, even in patients who aren’t even remotely demented.

None of the above are a major issue on their own. Where the trouble really happens, as with so many other things, is when they collide with an EMR, or someone too rushed to take a history, or both.

Let’s say Mrs. Jones is on Aricept because she went into a room, then forgot why she did.

Then she gets admitted to the hospital for pneumonia. Or she changes doctors and, like many practices these days, her medications are put in the computer by an MA or secretary.

A lot of times just the mention of Aricept will automatically bring the assumption that the person is demented, so that gets punched in as a diagnosis and the patient is now believed to be unable to provide a reliable history. Or the person entering the info looks up its indication and enters “Alzheimer’s disease.”

Even worse is that I’ve seen EMRs where, in an effort to save time, the computer automatically enters diagnoses as you type medications in, and it’s up to the doctor to review them for accuracy. How that saves time I have no idea. But, as above, in these cases it’s going to lead to an entry of dementia where there isn’t any.

That, in particular, is pretty scary. As I wrote here in January of this year, what happens in the EMR stays in the EMR (kind of like Las Vegas).

I’m not knocking off-label use of medications. I don’t know a doctor who doesn’t use some that way, including myself.

But when doing so leads to the wrong assumptions and diagnoses it creates a lot of problems.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The medical news is full of articles about the coming epidemic of dementia. How many people will have it in 10 years, 20 years, etc. It’s a very legitimate concern, and I am not going to make light of it, or disagree with the predictions.

In my everyday practice, though, I find there’s an epidemic of overdiagnosed dementia, in those who aren’t even close.

This occurs in a few ways:

Aricept is pretty inexpensive these days. Long off patent, insurance companies don’t bother to question its use anymore. So anyone older than 60 who complains of losing their car keys gets put on it. Why? Because patients want their doctors to DO SOMETHING. Even if the doctor knows that there’s really nothing of alarm going on, sometimes it’s easier to go with the placebo effect than argue. I think we’ve all done that before.

There are also a lot of nonneurologists in practice who still, after almost 30 years on the market, think Aricept improves memory, when in fact that’s far from the truth. The best it can claim to do is slow down the rate at which patients get worse, but nobody wants to hear that.

I’ve also seen Aricept used for pseudodementia due to depression. Actually, I’ve seen it used for depression, too. Sometimes it’s used to counteract the side effects dof drugs that can impair cognition, such as Topamax, even in patients who aren’t even remotely demented.

None of the above are a major issue on their own. Where the trouble really happens, as with so many other things, is when they collide with an EMR, or someone too rushed to take a history, or both.

Let’s say Mrs. Jones is on Aricept because she went into a room, then forgot why she did.

Then she gets admitted to the hospital for pneumonia. Or she changes doctors and, like many practices these days, her medications are put in the computer by an MA or secretary.

A lot of times just the mention of Aricept will automatically bring the assumption that the person is demented, so that gets punched in as a diagnosis and the patient is now believed to be unable to provide a reliable history. Or the person entering the info looks up its indication and enters “Alzheimer’s disease.”

Even worse is that I’ve seen EMRs where, in an effort to save time, the computer automatically enters diagnoses as you type medications in, and it’s up to the doctor to review them for accuracy. How that saves time I have no idea. But, as above, in these cases it’s going to lead to an entry of dementia where there isn’t any.

That, in particular, is pretty scary. As I wrote here in January of this year, what happens in the EMR stays in the EMR (kind of like Las Vegas).

I’m not knocking off-label use of medications. I don’t know a doctor who doesn’t use some that way, including myself.

But when doing so leads to the wrong assumptions and diagnoses it creates a lot of problems.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

March 30 was National Doctor’s Day, which resulted in my getting all kinds of generic emails from pharmaceutical reps, market research places, insurance companies, and the two hospitals I’m on staff at.

They all had similar meaningless platitudes thanking me for what I do, reassuring me that I’m appreciated, that I make the world a better place, yadda yadda yadda. The hospital even said I could swing by the medical staff office and pick up an “appreciation bag,” which I’m told contained a T-shirt, bottle of hand sanitizer, and a few other trinkets.

Spare me.

I’m not looking for any of that. In fact, I really don’t care.

Wishing me a “Happy Doctors Day” after spending the other 364 days denying my claims, refusing to cover tests or medications for my patients who need them (I don’t order these things for the hell of it, you know), telling me that I’m bringing down your Press Ganey scores, complaining about the copay that I have no control over, yelling at my staff for doing their jobs ... is pretty damn hollow.

It’s kind of like Mother’s Day: If you’re a jackass to your mom most of the year, sending her flowers on a Sunday in May doesn’t make it all right.

People also seem to forget that, in a small practice, my awesome staff is an extension of myself. Mistreating them, then wishing me a “Happy Doctor’s Day,” is also worthless.

I still like what I do. All the hassles from insurance companies, various administrators, the occasional angry patient … after all these years, they put a dent in it, but I still have no regrets about the course I’ve chosen. They can’t take away the happiness I get from helping those who need me.

It’s a job I love that’s allowed me to support my family and work with two wonderful staff members I’d never have met otherwise. After 23 years the only gratitude that means anything to me is the occasional heartfelt “thank you” from a patient.

And that’s all I need.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

March 30 was National Doctor’s Day, which resulted in my getting all kinds of generic emails from pharmaceutical reps, market research places, insurance companies, and the two hospitals I’m on staff at.

They all had similar meaningless platitudes thanking me for what I do, reassuring me that I’m appreciated, that I make the world a better place, yadda yadda yadda. The hospital even said I could swing by the medical staff office and pick up an “appreciation bag,” which I’m told contained a T-shirt, bottle of hand sanitizer, and a few other trinkets.

Spare me.

I’m not looking for any of that. In fact, I really don’t care.

Wishing me a “Happy Doctors Day” after spending the other 364 days denying my claims, refusing to cover tests or medications for my patients who need them (I don’t order these things for the hell of it, you know), telling me that I’m bringing down your Press Ganey scores, complaining about the copay that I have no control over, yelling at my staff for doing their jobs ... is pretty damn hollow.

It’s kind of like Mother’s Day: If you’re a jackass to your mom most of the year, sending her flowers on a Sunday in May doesn’t make it all right.

People also seem to forget that, in a small practice, my awesome staff is an extension of myself. Mistreating them, then wishing me a “Happy Doctor’s Day,” is also worthless.

I still like what I do. All the hassles from insurance companies, various administrators, the occasional angry patient … after all these years, they put a dent in it, but I still have no regrets about the course I’ve chosen. They can’t take away the happiness I get from helping those who need me.

It’s a job I love that’s allowed me to support my family and work with two wonderful staff members I’d never have met otherwise. After 23 years the only gratitude that means anything to me is the occasional heartfelt “thank you” from a patient.

And that’s all I need.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

March 30 was National Doctor’s Day, which resulted in my getting all kinds of generic emails from pharmaceutical reps, market research places, insurance companies, and the two hospitals I’m on staff at.

They all had similar meaningless platitudes thanking me for what I do, reassuring me that I’m appreciated, that I make the world a better place, yadda yadda yadda. The hospital even said I could swing by the medical staff office and pick up an “appreciation bag,” which I’m told contained a T-shirt, bottle of hand sanitizer, and a few other trinkets.

Spare me.

I’m not looking for any of that. In fact, I really don’t care.

Wishing me a “Happy Doctors Day” after spending the other 364 days denying my claims, refusing to cover tests or medications for my patients who need them (I don’t order these things for the hell of it, you know), telling me that I’m bringing down your Press Ganey scores, complaining about the copay that I have no control over, yelling at my staff for doing their jobs ... is pretty damn hollow.

It’s kind of like Mother’s Day: If you’re a jackass to your mom most of the year, sending her flowers on a Sunday in May doesn’t make it all right.

People also seem to forget that, in a small practice, my awesome staff is an extension of myself. Mistreating them, then wishing me a “Happy Doctor’s Day,” is also worthless.

I still like what I do. All the hassles from insurance companies, various administrators, the occasional angry patient … after all these years, they put a dent in it, but I still have no regrets about the course I’ve chosen. They can’t take away the happiness I get from helping those who need me.

It’s a job I love that’s allowed me to support my family and work with two wonderful staff members I’d never have met otherwise. After 23 years the only gratitude that means anything to me is the occasional heartfelt “thank you” from a patient.

And that’s all I need.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Earlier this month one of our dogs needed surgery. Early one morning I dropped her off at the veterinarian’s office.

About 10 minutes after leaving, they called and asked me to come back and get her. The vet had called in sick, so all her surgeries for the day had to be rescheduled.

It’s a pain in the rear, but what can you do? It happens to the best of us. My staff has had their share of times where they had to frantically call and reschedule patients when I was too sick to work.

So I drove back and waited in line. Most people were understanding, but some less so. The lady in front of me was demanding her dog’s surgery (which hadn’t happened yet) be free due to her being inconvenienced. A staff member at another desk was dealing with an angry man who was demanding the veterinarian’s home phone number.

When I got up to the front I picked up my dog and rescheduled the surgery for 2 weeks later. The young lady at the desk handed me a reminder card and said “Thank you for not yelling at me.”

How sad is that? Is this what our society has come to, where people feel obliged to thank you for not being an ass?

Common courtesy should be the rule rather than the exception, right? What’s wrong with politeness?

Yeah, going back to have to get my dog and reschedule her surgery is an inconvenience, but that’s about it. Certainly not something to get worked up over, or to scream at another person who’s just doing their job. Getting sick is part of life. It’s happened to me, it’s happened to you, and on this day it happened to our veterinarian.

Our supposedly polite society seems to have gone in reverse during the pandemic, though the change had probably started before then. Although we all went through it together, for some it’s removed the thin veneer of civilization, leaving them angry, bitter, and hostile over things that are beyond the control of mortals.

Whatever happened to the Golden Rule? It takes less effort to be nice than nasty, and it’s definitely better for your blood pressure.

I really don’t understand this. What’s to be gained by going through the world angry at things you can’t control? Especially when they’re so minor, like having to reschedule a veterinarian’s appointment.

It just ain’t worth it to be like that. For you, or the innocent person you’re abusing.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Earlier this month one of our dogs needed surgery. Early one morning I dropped her off at the veterinarian’s office.

About 10 minutes after leaving, they called and asked me to come back and get her. The vet had called in sick, so all her surgeries for the day had to be rescheduled.

It’s a pain in the rear, but what can you do? It happens to the best of us. My staff has had their share of times where they had to frantically call and reschedule patients when I was too sick to work.

So I drove back and waited in line. Most people were understanding, but some less so. The lady in front of me was demanding her dog’s surgery (which hadn’t happened yet) be free due to her being inconvenienced. A staff member at another desk was dealing with an angry man who was demanding the veterinarian’s home phone number.

When I got up to the front I picked up my dog and rescheduled the surgery for 2 weeks later. The young lady at the desk handed me a reminder card and said “Thank you for not yelling at me.”

How sad is that? Is this what our society has come to, where people feel obliged to thank you for not being an ass?

Common courtesy should be the rule rather than the exception, right? What’s wrong with politeness?

Yeah, going back to have to get my dog and reschedule her surgery is an inconvenience, but that’s about it. Certainly not something to get worked up over, or to scream at another person who’s just doing their job. Getting sick is part of life. It’s happened to me, it’s happened to you, and on this day it happened to our veterinarian.

Our supposedly polite society seems to have gone in reverse during the pandemic, though the change had probably started before then. Although we all went through it together, for some it’s removed the thin veneer of civilization, leaving them angry, bitter, and hostile over things that are beyond the control of mortals.

Whatever happened to the Golden Rule? It takes less effort to be nice than nasty, and it’s definitely better for your blood pressure.

I really don’t understand this. What’s to be gained by going through the world angry at things you can’t control? Especially when they’re so minor, like having to reschedule a veterinarian’s appointment.

It just ain’t worth it to be like that. For you, or the innocent person you’re abusing.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Earlier this month one of our dogs needed surgery. Early one morning I dropped her off at the veterinarian’s office.

About 10 minutes after leaving, they called and asked me to come back and get her. The vet had called in sick, so all her surgeries for the day had to be rescheduled.

It’s a pain in the rear, but what can you do? It happens to the best of us. My staff has had their share of times where they had to frantically call and reschedule patients when I was too sick to work.

So I drove back and waited in line. Most people were understanding, but some less so. The lady in front of me was demanding her dog’s surgery (which hadn’t happened yet) be free due to her being inconvenienced. A staff member at another desk was dealing with an angry man who was demanding the veterinarian’s home phone number.

When I got up to the front I picked up my dog and rescheduled the surgery for 2 weeks later. The young lady at the desk handed me a reminder card and said “Thank you for not yelling at me.”

How sad is that? Is this what our society has come to, where people feel obliged to thank you for not being an ass?

Common courtesy should be the rule rather than the exception, right? What’s wrong with politeness?

Yeah, going back to have to get my dog and reschedule her surgery is an inconvenience, but that’s about it. Certainly not something to get worked up over, or to scream at another person who’s just doing their job. Getting sick is part of life. It’s happened to me, it’s happened to you, and on this day it happened to our veterinarian.

Our supposedly polite society seems to have gone in reverse during the pandemic, though the change had probably started before then. Although we all went through it together, for some it’s removed the thin veneer of civilization, leaving them angry, bitter, and hostile over things that are beyond the control of mortals.

Whatever happened to the Golden Rule? It takes less effort to be nice than nasty, and it’s definitely better for your blood pressure.

I really don’t understand this. What’s to be gained by going through the world angry at things you can’t control? Especially when they’re so minor, like having to reschedule a veterinarian’s appointment.

It just ain’t worth it to be like that. For you, or the innocent person you’re abusing.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I don’t have a patient portal. Probably never will.

This isn’t an attempt at “information blocking,” or intentional noncompliance, or a rebellious streak against the CURES act.

It’s practical: I can’t afford it.

I’m a small one-doc practice. My overhead is high, my profit margin is razor thin. In the sudden spike of COVID-19– and war-related inflation, my gas and office supply costs have gone up, but I’m in a field where I can’t raise my own prices to compensate. The restaurants and grocery stores near me can, but I can’t because of the way insurance works.

With that background, I don’t have the money to set up a patient portal for people to be able to get their notes, test results, anything.

This isn’t to say that I withhold things from patients. If they want a copy of my note, or their MRI report, or whatever, they’re welcome to it. I’m happy to fax it to them, or put it in the mail, or have them come by and pick it up.

I have no desire to keep information from patients. I actually try to stay on top of it, calling them with test results within 24 hours of receiving them and arranging follow-ups quickly when needed.

That’s one of the pluses of my dinky practice – I generally know my patients and can make decisions quickly on the next step once results come in. They don’t get tossed in a box to be reviewed in a few days. I take pride in staying on top of things – isn’t that how we all want to be treated when we’re on the other side of the desk?

Politicians like to say how much America depends on small businesses and how important we are to the economy. They love to do photo ops at a newly opened ice cream place or small barbecue joint. But if you’re a doctor in a small practice, you often get treated the same way the Mega-Med Group (“287 doctors! 19 specialties! 37 offices! No waiting!”) is treated. They can afford to have a digital portal, so why can’t you?

Just because I don’t have a patient portal, though, doesn’t mean I’m hiding things from patients.

Or not doing my best to care for them.

Like Avis, I may not be No. 1, but I sure try harder.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I don’t have a patient portal. Probably never will.

This isn’t an attempt at “information blocking,” or intentional noncompliance, or a rebellious streak against the CURES act.

It’s practical: I can’t afford it.

I’m a small one-doc practice. My overhead is high, my profit margin is razor thin. In the sudden spike of COVID-19– and war-related inflation, my gas and office supply costs have gone up, but I’m in a field where I can’t raise my own prices to compensate. The restaurants and grocery stores near me can, but I can’t because of the way insurance works.

With that background, I don’t have the money to set up a patient portal for people to be able to get their notes, test results, anything.

This isn’t to say that I withhold things from patients. If they want a copy of my note, or their MRI report, or whatever, they’re welcome to it. I’m happy to fax it to them, or put it in the mail, or have them come by and pick it up.

I have no desire to keep information from patients. I actually try to stay on top of it, calling them with test results within 24 hours of receiving them and arranging follow-ups quickly when needed.

That’s one of the pluses of my dinky practice – I generally know my patients and can make decisions quickly on the next step once results come in. They don’t get tossed in a box to be reviewed in a few days. I take pride in staying on top of things – isn’t that how we all want to be treated when we’re on the other side of the desk?

Politicians like to say how much America depends on small businesses and how important we are to the economy. They love to do photo ops at a newly opened ice cream place or small barbecue joint. But if you’re a doctor in a small practice, you often get treated the same way the Mega-Med Group (“287 doctors! 19 specialties! 37 offices! No waiting!”) is treated. They can afford to have a digital portal, so why can’t you?

Just because I don’t have a patient portal, though, doesn’t mean I’m hiding things from patients.

Or not doing my best to care for them.

Like Avis, I may not be No. 1, but I sure try harder.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I don’t have a patient portal. Probably never will.

This isn’t an attempt at “information blocking,” or intentional noncompliance, or a rebellious streak against the CURES act.

It’s practical: I can’t afford it.

I’m a small one-doc practice. My overhead is high, my profit margin is razor thin. In the sudden spike of COVID-19– and war-related inflation, my gas and office supply costs have gone up, but I’m in a field where I can’t raise my own prices to compensate. The restaurants and grocery stores near me can, but I can’t because of the way insurance works.

With that background, I don’t have the money to set up a patient portal for people to be able to get their notes, test results, anything.

This isn’t to say that I withhold things from patients. If they want a copy of my note, or their MRI report, or whatever, they’re welcome to it. I’m happy to fax it to them, or put it in the mail, or have them come by and pick it up.

I have no desire to keep information from patients. I actually try to stay on top of it, calling them with test results within 24 hours of receiving them and arranging follow-ups quickly when needed.

That’s one of the pluses of my dinky practice – I generally know my patients and can make decisions quickly on the next step once results come in. They don’t get tossed in a box to be reviewed in a few days. I take pride in staying on top of things – isn’t that how we all want to be treated when we’re on the other side of the desk?

Politicians like to say how much America depends on small businesses and how important we are to the economy. They love to do photo ops at a newly opened ice cream place or small barbecue joint. But if you’re a doctor in a small practice, you often get treated the same way the Mega-Med Group (“287 doctors! 19 specialties! 37 offices! No waiting!”) is treated. They can afford to have a digital portal, so why can’t you?

Just because I don’t have a patient portal, though, doesn’t mean I’m hiding things from patients.

Or not doing my best to care for them.

Like Avis, I may not be No. 1, but I sure try harder.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“It’s in the computer.”

How many times a week do you hear that?

The advent of the modern EMR has created a new belief in many patients: That all medical office computers are connected, and information from one can be obtained from any of them. So when I ask patients if they had labs, or an MRI, or what their medications are, that’s what I sometimes hear back.

“It’s in the computer.”

True, but not MY computer.

Then they get perplexed, and irritated. Didn’t someone at the other office, or their friends, or something they read online, tell them I’d have access to it? Isn’t all medical info in a giant online database, somewhere, and all doctors can get into it?

Admittedly, I’m probably in better shape than other solo-practice docs. I have access codes to two local radiology places, two large labs, and the largest health care system in my corner of Phoenix. So although I’m not technically a part of them, I can still pull records when I need them for patient care. But if the patient is in my office right then, it takes a minute. My office wifi isn’t the fastest, I have to enter passwords, then do two-factor authentication.

I understand – very much – the importance of the added layers of security, but it adds time to the visit.

Some people, with perhaps more faith in technology than is justified, still don’t understand this. Another doctor sent them to see me, so why don’t I have the results of previous tests and labs? If they tell us what tests they had, and where, and when they make the appointment I can often be prepared for them. But this isn’t consistent.

On the surface some sort of large-scale medical database for everyone sounds good. It would be nice to not have to scramble to get past test results when people come in, and would probably save a lot of money on duplicated labs. But there are legitimate concerns about security and privacy, too.

Not only that, but “it’s in the computer” is also only as good as the people working them. Recently I got a call from an office in a local health care system asking for my notes on a patient. I’d sent them, but they insisted they hadn’t received them. From my desk I logged into their system and found my notes, neatly scanned in and labeled with my name and specialty. When I picked up the phone and told the young lady where to look, she was nice enough to apologize.

I get that. I often overlook things under my own nose, too. But no amount of technology will fix that issue for me or anyone else.

Unfortunately, this misplaced faith in technology doesn’t seem to be going away. People will still keep believing that it works much better than it really does.

That’s human nature, too.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“It’s in the computer.”

How many times a week do you hear that?

The advent of the modern EMR has created a new belief in many patients: That all medical office computers are connected, and information from one can be obtained from any of them. So when I ask patients if they had labs, or an MRI, or what their medications are, that’s what I sometimes hear back.

“It’s in the computer.”

True, but not MY computer.

Then they get perplexed, and irritated. Didn’t someone at the other office, or their friends, or something they read online, tell them I’d have access to it? Isn’t all medical info in a giant online database, somewhere, and all doctors can get into it?

Admittedly, I’m probably in better shape than other solo-practice docs. I have access codes to two local radiology places, two large labs, and the largest health care system in my corner of Phoenix. So although I’m not technically a part of them, I can still pull records when I need them for patient care. But if the patient is in my office right then, it takes a minute. My office wifi isn’t the fastest, I have to enter passwords, then do two-factor authentication.

I understand – very much – the importance of the added layers of security, but it adds time to the visit.

Some people, with perhaps more faith in technology than is justified, still don’t understand this. Another doctor sent them to see me, so why don’t I have the results of previous tests and labs? If they tell us what tests they had, and where, and when they make the appointment I can often be prepared for them. But this isn’t consistent.

On the surface some sort of large-scale medical database for everyone sounds good. It would be nice to not have to scramble to get past test results when people come in, and would probably save a lot of money on duplicated labs. But there are legitimate concerns about security and privacy, too.

Not only that, but “it’s in the computer” is also only as good as the people working them. Recently I got a call from an office in a local health care system asking for my notes on a patient. I’d sent them, but they insisted they hadn’t received them. From my desk I logged into their system and found my notes, neatly scanned in and labeled with my name and specialty. When I picked up the phone and told the young lady where to look, she was nice enough to apologize.

I get that. I often overlook things under my own nose, too. But no amount of technology will fix that issue for me or anyone else.

Unfortunately, this misplaced faith in technology doesn’t seem to be going away. People will still keep believing that it works much better than it really does.

That’s human nature, too.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“It’s in the computer.”

How many times a week do you hear that?

The advent of the modern EMR has created a new belief in many patients: That all medical office computers are connected, and information from one can be obtained from any of them. So when I ask patients if they had labs, or an MRI, or what their medications are, that’s what I sometimes hear back.

“It’s in the computer.”

True, but not MY computer.

Then they get perplexed, and irritated. Didn’t someone at the other office, or their friends, or something they read online, tell them I’d have access to it? Isn’t all medical info in a giant online database, somewhere, and all doctors can get into it?

Admittedly, I’m probably in better shape than other solo-practice docs. I have access codes to two local radiology places, two large labs, and the largest health care system in my corner of Phoenix. So although I’m not technically a part of them, I can still pull records when I need them for patient care. But if the patient is in my office right then, it takes a minute. My office wifi isn’t the fastest, I have to enter passwords, then do two-factor authentication.

I understand – very much – the importance of the added layers of security, but it adds time to the visit.

Some people, with perhaps more faith in technology than is justified, still don’t understand this. Another doctor sent them to see me, so why don’t I have the results of previous tests and labs? If they tell us what tests they had, and where, and when they make the appointment I can often be prepared for them. But this isn’t consistent.

On the surface some sort of large-scale medical database for everyone sounds good. It would be nice to not have to scramble to get past test results when people come in, and would probably save a lot of money on duplicated labs. But there are legitimate concerns about security and privacy, too.

Not only that, but “it’s in the computer” is also only as good as the people working them. Recently I got a call from an office in a local health care system asking for my notes on a patient. I’d sent them, but they insisted they hadn’t received them. From my desk I logged into their system and found my notes, neatly scanned in and labeled with my name and specialty. When I picked up the phone and told the young lady where to look, she was nice enough to apologize.

I get that. I often overlook things under my own nose, too. But no amount of technology will fix that issue for me or anyone else.

Unfortunately, this misplaced faith in technology doesn’t seem to be going away. People will still keep believing that it works much better than it really does.

That’s human nature, too.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Mr. Jones has had multiple sclerosis (MS) since 2008. Initially it was pretty active, though I was able to bring it under control with drug A. He didn’t like the side effects, or the shots, but at that time options for MS treatment were kind of limited.

When the oral agents came out he switched to drug B. He still had some side effects on it, which he didn’t like, but his insurance didn’t cover the other oral agent that was available. So he soldiered on.

Then, in late 2019, he had an episode of optic neuritis, and a repeat MRI showed that in the last 2 years he’d had an uptick in demyelinating plaques. So, in early 2020, he switched to drug C.

Drug C has, to date, been pretty good. He’s had no side effects or relapses, and a recent brain MRI was stable.

Of course, drug C ain’t cheap. Its price isn’t even listed on ePocrates or GoodRx. So my staff and I have to do all kinds of paperwork and hoop-jumping to get it covered each year.

So in late 2021 we started the annual process, which doesn’t happen overnight. We finally received notice he’d been approved – until March 1, 2022. Only 3 months.

Given the alacrity with which these companies seem to work, we began the new authorization paperwork almost as soon as we got the last one in mid-January. This time we didn’t hear back, and every time we called they told us the application was “under review.” In the meantime, Mr. Jones’ supply of pills, which are pretty critical to his health and well-being, was gradually decreasing.

Recently, out of the blue, a 1-month supply of drug C showed up in his mailbox, along with a bill for $3,000. Mr. Jones is a career waiter at a local restaurant, and had no way to pay for this. So my staff went to work on the phones, and after a few hours got it in writing that it was being covered as a bridging supply under the manufacturer’s assistance program. Okay. That crises was averted. (I have no idea if the insurance really pays $3,000/month. Like buying a car, there can be a big difference between a drug’s asking price and what’s really paid for it).

The next morning, however, we got a note from his insurance company saying the medical reviewer had decided he didn’t need drug C, and wanted him to go back to drug B. After all, it was cheaper. I called the reviewer and argued with him. I told him he’d clinically worsened on drug B, not to mention the side effects. The reviewer said I should have mentioned that in my notes. I pointed out that it was in my notes, which had been sent along with the forms I’d filled out. He didn’t answer that, just said he’d have them fax me an appeal form.

The appeal form showed up about an hour later, so I took some time out of my weekend to fill it out. Then I faxed it back, along with (as they requested) chart notes and MRI reports dating back to 2008. Which was a lot.

So now we’ll see what happens.

Do other countries have this sort of thing? Or is this a product of the bizarre patchwork that makes up the American health care system? Different insurance companies, different subplans, and regional sub-subplans, and so on, each with a different set of rules, forms, and obstacle courses to navigate.

For all their glitzy TV commercials showing smiling, happy, multigenerational families, all looking to be in glowing health from the medical care they’re receiving, they seem to be pretty determined to keep Mr. Jones from receiving a drug that’s allowing him to continue working as a waiter 50-60 hours per week. Without it, he’d likely be unable to work and, at some point, would have to file for disability. Probably would eventually need increasingly high-cost items, going to a cane, then a walker, then a wheelchair, then a power wheelchair. ER visits, things that. In the long run, those would cost a helluva lot more than drug C.

Of course, that may be part of their game, too. Maybe they figure he’ll end up dropping off their insurance as he worsens, and then their shareholders don’t have to pay for his bad luck. I hope I’m wrong in thinking that, but such is the nature of business. And health insurance is a HUGE business.

So now I’ve faxed in the appeal forms, and can move on, for the time being, to the needs of other patients (not to mention spending time with my family). But Mr. Jones’ pill supply will run out on April 1, 2022, and I still have no idea what will happen then.

Neither does he. And for him, that’s pretty scary.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Mr. Jones has had multiple sclerosis (MS) since 2008. Initially it was pretty active, though I was able to bring it under control with drug A. He didn’t like the side effects, or the shots, but at that time options for MS treatment were kind of limited.

When the oral agents came out he switched to drug B. He still had some side effects on it, which he didn’t like, but his insurance didn’t cover the other oral agent that was available. So he soldiered on.

Then, in late 2019, he had an episode of optic neuritis, and a repeat MRI showed that in the last 2 years he’d had an uptick in demyelinating plaques. So, in early 2020, he switched to drug C.

Drug C has, to date, been pretty good. He’s had no side effects or relapses, and a recent brain MRI was stable.

Of course, drug C ain’t cheap. Its price isn’t even listed on ePocrates or GoodRx. So my staff and I have to do all kinds of paperwork and hoop-jumping to get it covered each year.

So in late 2021 we started the annual process, which doesn’t happen overnight. We finally received notice he’d been approved – until March 1, 2022. Only 3 months.

Given the alacrity with which these companies seem to work, we began the new authorization paperwork almost as soon as we got the last one in mid-January. This time we didn’t hear back, and every time we called they told us the application was “under review.” In the meantime, Mr. Jones’ supply of pills, which are pretty critical to his health and well-being, was gradually decreasing.

Recently, out of the blue, a 1-month supply of drug C showed up in his mailbox, along with a bill for $3,000. Mr. Jones is a career waiter at a local restaurant, and had no way to pay for this. So my staff went to work on the phones, and after a few hours got it in writing that it was being covered as a bridging supply under the manufacturer’s assistance program. Okay. That crises was averted. (I have no idea if the insurance really pays $3,000/month. Like buying a car, there can be a big difference between a drug’s asking price and what’s really paid for it).

The next morning, however, we got a note from his insurance company saying the medical reviewer had decided he didn’t need drug C, and wanted him to go back to drug B. After all, it was cheaper. I called the reviewer and argued with him. I told him he’d clinically worsened on drug B, not to mention the side effects. The reviewer said I should have mentioned that in my notes. I pointed out that it was in my notes, which had been sent along with the forms I’d filled out. He didn’t answer that, just said he’d have them fax me an appeal form.

The appeal form showed up about an hour later, so I took some time out of my weekend to fill it out. Then I faxed it back, along with (as they requested) chart notes and MRI reports dating back to 2008. Which was a lot.

So now we’ll see what happens.

Do other countries have this sort of thing? Or is this a product of the bizarre patchwork that makes up the American health care system? Different insurance companies, different subplans, and regional sub-subplans, and so on, each with a different set of rules, forms, and obstacle courses to navigate.

For all their glitzy TV commercials showing smiling, happy, multigenerational families, all looking to be in glowing health from the medical care they’re receiving, they seem to be pretty determined to keep Mr. Jones from receiving a drug that’s allowing him to continue working as a waiter 50-60 hours per week. Without it, he’d likely be unable to work and, at some point, would have to file for disability. Probably would eventually need increasingly high-cost items, going to a cane, then a walker, then a wheelchair, then a power wheelchair. ER visits, things that. In the long run, those would cost a helluva lot more than drug C.

Of course, that may be part of their game, too. Maybe they figure he’ll end up dropping off their insurance as he worsens, and then their shareholders don’t have to pay for his bad luck. I hope I’m wrong in thinking that, but such is the nature of business. And health insurance is a HUGE business.

So now I’ve faxed in the appeal forms, and can move on, for the time being, to the needs of other patients (not to mention spending time with my family). But Mr. Jones’ pill supply will run out on April 1, 2022, and I still have no idea what will happen then.

Neither does he. And for him, that’s pretty scary.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Mr. Jones has had multiple sclerosis (MS) since 2008. Initially it was pretty active, though I was able to bring it under control with drug A. He didn’t like the side effects, or the shots, but at that time options for MS treatment were kind of limited.

When the oral agents came out he switched to drug B. He still had some side effects on it, which he didn’t like, but his insurance didn’t cover the other oral agent that was available. So he soldiered on.

Then, in late 2019, he had an episode of optic neuritis, and a repeat MRI showed that in the last 2 years he’d had an uptick in demyelinating plaques. So, in early 2020, he switched to drug C.

Drug C has, to date, been pretty good. He’s had no side effects or relapses, and a recent brain MRI was stable.

Of course, drug C ain’t cheap. Its price isn’t even listed on ePocrates or GoodRx. So my staff and I have to do all kinds of paperwork and hoop-jumping to get it covered each year.

So in late 2021 we started the annual process, which doesn’t happen overnight. We finally received notice he’d been approved – until March 1, 2022. Only 3 months.

Given the alacrity with which these companies seem to work, we began the new authorization paperwork almost as soon as we got the last one in mid-January. This time we didn’t hear back, and every time we called they told us the application was “under review.” In the meantime, Mr. Jones’ supply of pills, which are pretty critical to his health and well-being, was gradually decreasing.

Recently, out of the blue, a 1-month supply of drug C showed up in his mailbox, along with a bill for $3,000. Mr. Jones is a career waiter at a local restaurant, and had no way to pay for this. So my staff went to work on the phones, and after a few hours got it in writing that it was being covered as a bridging supply under the manufacturer’s assistance program. Okay. That crises was averted. (I have no idea if the insurance really pays $3,000/month. Like buying a car, there can be a big difference between a drug’s asking price and what’s really paid for it).

The next morning, however, we got a note from his insurance company saying the medical reviewer had decided he didn’t need drug C, and wanted him to go back to drug B. After all, it was cheaper. I called the reviewer and argued with him. I told him he’d clinically worsened on drug B, not to mention the side effects. The reviewer said I should have mentioned that in my notes. I pointed out that it was in my notes, which had been sent along with the forms I’d filled out. He didn’t answer that, just said he’d have them fax me an appeal form.

The appeal form showed up about an hour later, so I took some time out of my weekend to fill it out. Then I faxed it back, along with (as they requested) chart notes and MRI reports dating back to 2008. Which was a lot.

So now we’ll see what happens.

Do other countries have this sort of thing? Or is this a product of the bizarre patchwork that makes up the American health care system? Different insurance companies, different subplans, and regional sub-subplans, and so on, each with a different set of rules, forms, and obstacle courses to navigate.

For all their glitzy TV commercials showing smiling, happy, multigenerational families, all looking to be in glowing health from the medical care they’re receiving, they seem to be pretty determined to keep Mr. Jones from receiving a drug that’s allowing him to continue working as a waiter 50-60 hours per week. Without it, he’d likely be unable to work and, at some point, would have to file for disability. Probably would eventually need increasingly high-cost items, going to a cane, then a walker, then a wheelchair, then a power wheelchair. ER visits, things that. In the long run, those would cost a helluva lot more than drug C.

Of course, that may be part of their game, too. Maybe they figure he’ll end up dropping off their insurance as he worsens, and then their shareholders don’t have to pay for his bad luck. I hope I’m wrong in thinking that, but such is the nature of business. And health insurance is a HUGE business.

So now I’ve faxed in the appeal forms, and can move on, for the time being, to the needs of other patients (not to mention spending time with my family). But Mr. Jones’ pill supply will run out on April 1, 2022, and I still have no idea what will happen then.

Neither does he. And for him, that’s pretty scary.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

My office was open on Presidents Day this year. Granted, I’ve never closed for it.

We’re also open on Veteran’s Day, Columbus Day, and Martin Luther King Jr. Day.

Occasionally (usually MLK or Veteran’s days) we get a call from someone unhappy we’re open that day. Banks, government offices, and schools are closed, and they feel that, by not following suit, I’m insulting the memory of veterans and those who fought for civil rights.

Nothing could be farther from the truth. In fact, I don’t know any doctors’ offices that AREN’T open on those days.

Part of this is patient centered. When people need to see a doctor, they don’t want to wait too long. The emergency room isn’t where the majority of things should be handled. Besides, they’re already swamped with nonemergent cases.

Most practices work 8-5 on weekdays, and are booked out. Every additional weekday you’re closed only adds to the wait. So I try to be there enough days to care for people, but not enough so that I lose my sanity or family.

In my area, a fair number of my patients are schoolteachers, who work the same hours I do. So many of them come in on those days, and appreciate that I’m open when they’re off.

Another part is practical. In a small practice, cash flow is critical, and there are just so many days in a given year you can be closed without hurting your financial picture. So most practices are closed for the Big 6 (Memorial Day, Independence Day, Labor Day, Thanksgiving, Christmas, and New Years). Usually this also includes Black Friday and Christmas Eve. So a total of 8 days per year (in addition to vacations).

Unlike other businesses (such as stores and restaurants) most medical offices aren’t open on weekends and nights, so our entire revenue stream is dependent on weekdays from 8 to 5. In this day and age, with most practices running on razor-thin margins, every day off adds to the red line. I can’t take care of anyone if I can’t pay my rent and staff.

I mean no disrespect to anyone. Like other doctors I work hard to provide quality care to all. But the nature of medicine is such that we give up our own time to help others. So I try to be there for them as much as I can, without going overboard and at the same time keeping my small practice afloat.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

My office was open on Presidents Day this year. Granted, I’ve never closed for it.

We’re also open on Veteran’s Day, Columbus Day, and Martin Luther King Jr. Day.

Occasionally (usually MLK or Veteran’s days) we get a call from someone unhappy we’re open that day. Banks, government offices, and schools are closed, and they feel that, by not following suit, I’m insulting the memory of veterans and those who fought for civil rights.

Nothing could be farther from the truth. In fact, I don’t know any doctors’ offices that AREN’T open on those days.

Part of this is patient centered. When people need to see a doctor, they don’t want to wait too long. The emergency room isn’t where the majority of things should be handled. Besides, they’re already swamped with nonemergent cases.

Most practices work 8-5 on weekdays, and are booked out. Every additional weekday you’re closed only adds to the wait. So I try to be there enough days to care for people, but not enough so that I lose my sanity or family.

In my area, a fair number of my patients are schoolteachers, who work the same hours I do. So many of them come in on those days, and appreciate that I’m open when they’re off.

Another part is practical. In a small practice, cash flow is critical, and there are just so many days in a given year you can be closed without hurting your financial picture. So most practices are closed for the Big 6 (Memorial Day, Independence Day, Labor Day, Thanksgiving, Christmas, and New Years). Usually this also includes Black Friday and Christmas Eve. So a total of 8 days per year (in addition to vacations).

Unlike other businesses (such as stores and restaurants) most medical offices aren’t open on weekends and nights, so our entire revenue stream is dependent on weekdays from 8 to 5. In this day and age, with most practices running on razor-thin margins, every day off adds to the red line. I can’t take care of anyone if I can’t pay my rent and staff.

I mean no disrespect to anyone. Like other doctors I work hard to provide quality care to all. But the nature of medicine is such that we give up our own time to help others. So I try to be there for them as much as I can, without going overboard and at the same time keeping my small practice afloat.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

My office was open on Presidents Day this year. Granted, I’ve never closed for it.

We’re also open on Veteran’s Day, Columbus Day, and Martin Luther King Jr. Day.

Occasionally (usually MLK or Veteran’s days) we get a call from someone unhappy we’re open that day. Banks, government offices, and schools are closed, and they feel that, by not following suit, I’m insulting the memory of veterans and those who fought for civil rights.

Nothing could be farther from the truth. In fact, I don’t know any doctors’ offices that AREN’T open on those days.

Part of this is patient centered. When people need to see a doctor, they don’t want to wait too long. The emergency room isn’t where the majority of things should be handled. Besides, they’re already swamped with nonemergent cases.

Most practices work 8-5 on weekdays, and are booked out. Every additional weekday you’re closed only adds to the wait. So I try to be there enough days to care for people, but not enough so that I lose my sanity or family.

In my area, a fair number of my patients are schoolteachers, who work the same hours I do. So many of them come in on those days, and appreciate that I’m open when they’re off.

Another part is practical. In a small practice, cash flow is critical, and there are just so many days in a given year you can be closed without hurting your financial picture. So most practices are closed for the Big 6 (Memorial Day, Independence Day, Labor Day, Thanksgiving, Christmas, and New Years). Usually this also includes Black Friday and Christmas Eve. So a total of 8 days per year (in addition to vacations).

Unlike other businesses (such as stores and restaurants) most medical offices aren’t open on weekends and nights, so our entire revenue stream is dependent on weekdays from 8 to 5. In this day and age, with most practices running on razor-thin margins, every day off adds to the red line. I can’t take care of anyone if I can’t pay my rent and staff.

I mean no disrespect to anyone. Like other doctors I work hard to provide quality care to all. But the nature of medicine is such that we give up our own time to help others. So I try to be there for them as much as I can, without going overboard and at the same time keeping my small practice afloat.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.