One Size Fits All

Let's face it: Procrustes was a lousy host. Sure he had a nice bed, solid iron, nothing like what you would find at Bob's Discount Furniture with matching night table and love seat. But his bed was just one size, and Procrustes did what it took to make every guest fit it, even if he had to stretch out short people or chop the legs off long ones.

Courtesy flickr user tomislaymedakt (Creative Commons)

When I put diagnostic codes on patient encounter forms, I often feel like I am channeling my inner Procrustes by shoe-horning unwitting people, whether they fit or not, into the categories I have available. All too often, there are no codes available to fit what my patients have, but I have to pick one anyway. I can't bill without a diagnostic code, and I do like to get paid.

Consider Jerry, a high-school wrestling coach with scabs up and down both forearms. For several weeks, Jerry's been going quietly crazy trying to get his arms cleared up, but with no success. One doctor tried treating him for bugs, which didn't help his itching but did make Jerry feel worse about his situation and prospects. He had taken weeks off from work for fear of sharing something contagious with the kids he coaches. He knows wrestlers pick up many nasty things from each other anyway.

"Every night when I try to fall asleep, I scratch myself silly," he said. "I can't stop. At this point, I don't think I'll ever get better."

The distribution of his forearm scabs was consistent with no disease I knew of. It did, however, fit with someone picking at oneself. So I gave Jerry an optimistic outlook, an itch pill to take at bedtime, a cream to apply twice a day, and the advice to cover both forearms with gauze and a bandage when he went to bed. I told him that would keep the cream on. It would, of course, also keep his fingers off.

My actual diagnosis was: "Wrestling-coach-who-knows-that-you-can-pick-up-bacteria-viruses-funguses-and-heaven-knows-what-else-from-those-dirty-mats-and-also-from-other-wrestlers-so-now-I've-got-one-of-them-and-I'll-never-get-better-and-I'll-have-to-quit-my-work."

But of course there is no diagnostic code for that. There is a code, however, for "neurotic excoriations," also called "dermatitis factitia, 698.4." Is Jerry really neurotic? Should he see a psychiatrist about his internal conflicts? As for "factitious," that means, "manmade, artificial, counterfeit." Jerry's scratches are indeed manmade, but are they counterfeit - is Jerry looking for workers' comp? No, actually he is "nervous-about-this-one-specific-thing-because-of-ideas-he-has-in-his-head-reinforced-by-what-he's-been-told." But there's no code for that.
So "dermatitis factitia, 698.4" it is. Procrustes would be proud.

Or consider Fred. He presented with some scratched areas on his fingers and hands that also did not fit a recognizable pattern. It turns out that Fred is a truck driver who, though still employed, now finds himself, after a recent divorce, living in a shelter for homeless men.

Fred's actual diagnosis: "I-am-a-clean-upstanding-gainfully-employed-man-forced-to-live-with- unwashed-people-and-who-knows-what-they-bring-back-to-the-room-from-wherever-they-go-all-day."

I know you'll be shocked to learn there's no code for that either. So I gave him an antibiotic ointment to put on (mostly to give him something to do besides scratch) and diagnostically went with "impetigo, 683."

Every diagnosis, regardless of how "organic," is full of meaning for each individual patient: Am I falling apart? Is this the beginning of the end? Am I following my family's pattern straight to health perdition? Am I so disgusting that I'll need to withdraw from polite society? There is, of course, no room on the encounter sheet for all this meaning stuff, only for "the diagnosis."

When it comes to people like Jerry and Fred, there really is no diagnosis, just meaning. Strip that away and everything gets better (which of course it did in both their cases). But the way things work in our medical motels, you've got to move 'em in and move 'em out, and nobody leaves without a code. If you don't code it, it didn't happen.

So codes they get. One size fits all. Let's hear it for Procrustes.

Let's face it: Procrustes was a lousy host. Sure he had a nice bed, solid iron, nothing like what you would find at Bob's Discount Furniture with matching night table and love seat. But his bed was just one size, and Procrustes did what it took to make every guest fit it, even if he had to stretch out short people or chop the legs off long ones.

Courtesy flickr user tomislaymedakt (Creative Commons)

When I put diagnostic codes on patient encounter forms, I often feel like I am channeling my inner Procrustes by shoe-horning unwitting people, whether they fit or not, into the categories I have available. All too often, there are no codes available to fit what my patients have, but I have to pick one anyway. I can't bill without a diagnostic code, and I do like to get paid.

Consider Jerry, a high-school wrestling coach with scabs up and down both forearms. For several weeks, Jerry's been going quietly crazy trying to get his arms cleared up, but with no success. One doctor tried treating him for bugs, which didn't help his itching but did make Jerry feel worse about his situation and prospects. He had taken weeks off from work for fear of sharing something contagious with the kids he coaches. He knows wrestlers pick up many nasty things from each other anyway.

"Every night when I try to fall asleep, I scratch myself silly," he said. "I can't stop. At this point, I don't think I'll ever get better."

The distribution of his forearm scabs was consistent with no disease I knew of. It did, however, fit with someone picking at oneself. So I gave Jerry an optimistic outlook, an itch pill to take at bedtime, a cream to apply twice a day, and the advice to cover both forearms with gauze and a bandage when he went to bed. I told him that would keep the cream on. It would, of course, also keep his fingers off.

My actual diagnosis was: "Wrestling-coach-who-knows-that-you-can-pick-up-bacteria-viruses-funguses-and-heaven-knows-what-else-from-those-dirty-mats-and-also-from-other-wrestlers-so-now-I've-got-one-of-them-and-I'll-never-get-better-and-I'll-have-to-quit-my-work."

But of course there is no diagnostic code for that. There is a code, however, for "neurotic excoriations," also called "dermatitis factitia, 698.4." Is Jerry really neurotic? Should he see a psychiatrist about his internal conflicts? As for "factitious," that means, "manmade, artificial, counterfeit." Jerry's scratches are indeed manmade, but are they counterfeit - is Jerry looking for workers' comp? No, actually he is "nervous-about-this-one-specific-thing-because-of-ideas-he-has-in-his-head-reinforced-by-what-he's-been-told." But there's no code for that.
So "dermatitis factitia, 698.4" it is. Procrustes would be proud.

Or consider Fred. He presented with some scratched areas on his fingers and hands that also did not fit a recognizable pattern. It turns out that Fred is a truck driver who, though still employed, now finds himself, after a recent divorce, living in a shelter for homeless men.

Fred's actual diagnosis: "I-am-a-clean-upstanding-gainfully-employed-man-forced-to-live-with- unwashed-people-and-who-knows-what-they-bring-back-to-the-room-from-wherever-they-go-all-day."

I know you'll be shocked to learn there's no code for that either. So I gave him an antibiotic ointment to put on (mostly to give him something to do besides scratch) and diagnostically went with "impetigo, 683."

Every diagnosis, regardless of how "organic," is full of meaning for each individual patient: Am I falling apart? Is this the beginning of the end? Am I following my family's pattern straight to health perdition? Am I so disgusting that I'll need to withdraw from polite society? There is, of course, no room on the encounter sheet for all this meaning stuff, only for "the diagnosis."

When it comes to people like Jerry and Fred, there really is no diagnosis, just meaning. Strip that away and everything gets better (which of course it did in both their cases). But the way things work in our medical motels, you've got to move 'em in and move 'em out, and nobody leaves without a code. If you don't code it, it didn't happen.

So codes they get. One size fits all. Let's hear it for Procrustes.

Let's face it: Procrustes was a lousy host. Sure he had a nice bed, solid iron, nothing like what you would find at Bob's Discount Furniture with matching night table and love seat. But his bed was just one size, and Procrustes did what it took to make every guest fit it, even if he had to stretch out short people or chop the legs off long ones.

Courtesy flickr user tomislaymedakt (Creative Commons)

When I put diagnostic codes on patient encounter forms, I often feel like I am channeling my inner Procrustes by shoe-horning unwitting people, whether they fit or not, into the categories I have available. All too often, there are no codes available to fit what my patients have, but I have to pick one anyway. I can't bill without a diagnostic code, and I do like to get paid.

Consider Jerry, a high-school wrestling coach with scabs up and down both forearms. For several weeks, Jerry's been going quietly crazy trying to get his arms cleared up, but with no success. One doctor tried treating him for bugs, which didn't help his itching but did make Jerry feel worse about his situation and prospects. He had taken weeks off from work for fear of sharing something contagious with the kids he coaches. He knows wrestlers pick up many nasty things from each other anyway.

"Every night when I try to fall asleep, I scratch myself silly," he said. "I can't stop. At this point, I don't think I'll ever get better."

The distribution of his forearm scabs was consistent with no disease I knew of. It did, however, fit with someone picking at oneself. So I gave Jerry an optimistic outlook, an itch pill to take at bedtime, a cream to apply twice a day, and the advice to cover both forearms with gauze and a bandage when he went to bed. I told him that would keep the cream on. It would, of course, also keep his fingers off.

My actual diagnosis was: "Wrestling-coach-who-knows-that-you-can-pick-up-bacteria-viruses-funguses-and-heaven-knows-what-else-from-those-dirty-mats-and-also-from-other-wrestlers-so-now-I've-got-one-of-them-and-I'll-never-get-better-and-I'll-have-to-quit-my-work."

But of course there is no diagnostic code for that. There is a code, however, for "neurotic excoriations," also called "dermatitis factitia, 698.4." Is Jerry really neurotic? Should he see a psychiatrist about his internal conflicts? As for "factitious," that means, "manmade, artificial, counterfeit." Jerry's scratches are indeed manmade, but are they counterfeit - is Jerry looking for workers' comp? No, actually he is "nervous-about-this-one-specific-thing-because-of-ideas-he-has-in-his-head-reinforced-by-what-he's-been-told." But there's no code for that.
So "dermatitis factitia, 698.4" it is. Procrustes would be proud.

Or consider Fred. He presented with some scratched areas on his fingers and hands that also did not fit a recognizable pattern. It turns out that Fred is a truck driver who, though still employed, now finds himself, after a recent divorce, living in a shelter for homeless men.

Fred's actual diagnosis: "I-am-a-clean-upstanding-gainfully-employed-man-forced-to-live-with- unwashed-people-and-who-knows-what-they-bring-back-to-the-room-from-wherever-they-go-all-day."

I know you'll be shocked to learn there's no code for that either. So I gave him an antibiotic ointment to put on (mostly to give him something to do besides scratch) and diagnostically went with "impetigo, 683."

Every diagnosis, regardless of how "organic," is full of meaning for each individual patient: Am I falling apart? Is this the beginning of the end? Am I following my family's pattern straight to health perdition? Am I so disgusting that I'll need to withdraw from polite society? There is, of course, no room on the encounter sheet for all this meaning stuff, only for "the diagnosis."

When it comes to people like Jerry and Fred, there really is no diagnosis, just meaning. Strip that away and everything gets better (which of course it did in both their cases). But the way things work in our medical motels, you've got to move 'em in and move 'em out, and nobody leaves without a code. If you don't code it, it didn't happen.

So codes they get. One size fits all. Let's hear it for Procrustes.