Excerpted from SEAK’s course, “How to Start, Build, and Run a Successful Physician Life Care Planning Practice”
I, again, restate state the problem. Patient status post multiple cervical bulges, has cervical radiculopathy on EMG, and I have a neurosurgical recommendation for surgery. The patient has lumbar disc herniation (inaudible 00:00:15). But we can backtrack (inaudible 00:00:18). The patient has lumbar disc herniations with a tear, with EMG positive, and recommendation for surgery. And the patient has a shoulder tear and I have orthopedic recommendation for surgery. Next.
So now we get into the pricing. And so, some of this relies on myself as experience as a physician. Other relies on doing quite a bit of research. So I’m just telling the patient see a physiatrist on a yearly basis, a neurologist for EMG. She’s going to live I think it was, like, 40 some years. Get a neck and back involvement, at least four EMGs in a lifetime. Go see an orthopedic surgeon or a neurosurgeon. I will sometimes interact those or I will put one or the other, or I will put both in and do an average. The patient who’s been told by surgery that the patient is gonna need disc surgery. But that was wishy washy, whether it’s been studied with or without fusion. So we have prices, we put pricing in with fusion, without fusion, and we put all those prices in and average those out. Keep going.
Same thing for lumbar surgery, with or without surgery, with or without fusion, and we put those prices in. What the price is of a intra articular injection for steroids. Keep going.
What a arthroscopic surgery looks like. Now, this is one of my biases. I’ve been doing chronic pain for a very long time. And as I said yesterday, I’ve seen treatments and therapies come and go. Now is if you prescribe opioids, you’re a pill-pushing doctor and you’ve got a patient who’s asking for drugs. That’s not true. But I am a believer within a certain age, as the aging process and people with these orthopedic injuries age prematurely, so I will put in that they may need to be working with a pain management doctor for sometimes opioids. The neurosurgeon indicated that the patient was a candidate for a spinal cord stimulator. So, therefore, we ended up putting in the price for the trial and for the implantation, and for replacing every six years. And then, you don’t have pain without psychological changes. So I limit it to no more than 30 visits in a lifetime, but seeing a psychiatrist and a psychologist. And again, I’ve already talked to the patient about this.
This is a patient who works basically at a computer doing pricing and does some telemarketing, as well. I think she had a bachelor’s degree, so she had a lot of positivity that would allow her to have transferable capabilities. The problem is people with necks and backs don’t sit very long and can’t stand very long so they need frequent changes in position. And this was a lady I absolutely did ask for a vocational rehabilitation, put it in the life care plan. Because as she ages or she loses jobs, she may need the help of a vocational counselor to help her look into other areas as she ages.
Next down. So as a pain doctor, I’m allowed to talk about pain. I’m allowed to talk about my doctors who are treating her in my practice with pain. So we are allowed to add certain things. So I did say that age 45 I was going to put her on a low dose of oxy codone, which is basically Percocet without the Tylenol. Because, you know, long term Tylenol kills the liver. But we basically are pushing really hard more the topicals and gabapentin, which is a medication for nerve pain. I indicated that, again, as a physiatrist, I order these medications all the time. She presently was on Prozac, but I indicated at age 45 I would feel comfortable putting her on Klonopin because her level of anxiety was climbing, actually, over the year that we saw her in the office. I’m a strong believer in GI protection, all of us as physicians are trained in doing that. And anybody who’s stressed out, we ought to protect their tummies. I indicated, again, with the aging process, at age 45 it would be appropriate to offer some type of sleeping medication, And, obviously, if we’re gonna put her on any kind of opioid medication, we would need to put her on a medication for constipation. Next.
So these are the imaging studies, cervical x-rays, an MRI, lumbar, and shoulder. And then, beginning at age 45, when they were gonna put her on the opioids, one could argue why didn’t you start her earlier, because we did talk about some of the other medications. Again, I like to be conservative, so I’m not doing labs until 45. It would be appropriate for general practitioner doctors to order some of those tests. This is a mother who has three children, I think it’s three children, and she’s having to hire…never had to hire anybody to do light housekeeping or heavy housekeeping. I will tell you I saw this patient about four months ago and I redid the life care plan, and I did take out the homemaker and housekeeper.
