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Diagnostic injections: Patients vary greatly in their pain threshold.  Sometimes the most important thing that a diagnostic injection can tell you is what that patient’s pain threshold is.  Always try to record the patient’s degree of pain relief five or ten minutes after the injection, as they will often return to clinic several weeks later telling you it did “absolutely nothing.” In fact it may have been very effective for a short while but they are confused by the fact that they actually felt worse several hours after the injection.  

An unstable fracture”: This term is frequently used but poorly defined. It often denotes fractures that must be treated operatively but sometimes is used to recognize those fractures which are difficult to stabilize even operatively. A clue – most “unstable fractures” occurred under axial load and the bone is no longer capable of maintaining its own length (withstanding compression). Thus casts or plates which maintain “alignment” well, but do not maintain length well, fail -- leading to the conclusion that the fracture is “unstable.”

Casting learn to apply your plaster rapidly so that you have plenty of time to rub. around bony prominences) make indentations inside the cast over the bony prominences so that they do not rub.  Poorly laid down “tucks” made during rapid cast application are readily obliterated by compulsive rubbing and molding.  

Casting -- Pinky fingers and toes: Patients occasionally complain about an ugly cast, but they will always complain if their small finger or pinky toe is trapped and painful in the cast. Be certain to trim each cast to provide room for the little finger and small toe.  Upper limb casts should be trimmed to expose the small finger MP joint, while lower limb casts should be trimmed to expose the entire small toe.

Clinic billing: When you are starting out, you often feel like you are charging too much for the service you provide.  In addition patients complain that “I had to pay $75 to see the doctor for 10 minutes?!” Please remember that the bill submitted doesn’t just pay for the service you provide, but pays for: a) the secretary’s time scheduling the appointment, b) the secretary’s time signing the patient in to clinic, c) the nurse’s time putting the patient in the room, d) any disposable sheets, gowns or shorts the patient wears in the room, e) any gloves, dressings, and other supplies used during the visit for which the patient is not charged, f) the secretary’s time signing them out and scheduling new appointments, g) the billing office’s time for submitting and collecting the bill, h) rental of the space in which the patient is seen, i) the preparation of a medical record clinic note ($.10/line, average note 25 lines = $2.50/note), j) any letters written to employers-lawyers-insurance companies, k) malpractice insurance, l) the cost of treating patients who cannot pay, and finally what’s left over (not as much as you might think) goes to, m) paying the doctor’s salary.

“I don’t know”: You don’t always have to answer weird questions (i.e. “Why do my toenails hurt?”). The patient won’t lose respect for you and, in fact, often respects you more for your forthright honesty (certainly more than they do for a bunch of wrong answers--consider alternative practitioners and some of their nonscientific diagnoses such as “spinal alignment” problems).  


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