Scrubs and Subpoenas
Beware Of The Anchor
The pain in his jaw is just TMJ, a stress-induced nuisance, right? But as the day goes on and night begins to fall, a misdiagnosis would leave a family shattered and a haunting question: what if the practitioner had done something different? Join Dr. Sally Miller, Fitzgerald faculty member and expert witness, for chilling patient case that will remind us all to beware of the ‘anchor’.
Transcript
00;01;20;16 – 00;01;37;10
Jannah Amiel
Hello and welcome to another episode of Scrubs and Subpoenas Tales from the Witness Stand. I’m your host, John Amiel. And joining me is our FHA faculty member and expert witness, Dr. Sally Miller. Dr. Sally Miller, how are you? I’m very well, thank you.
00;01;37;10 – 00;01;37;28
Sally Miller
And you?
00;01;38;01 – 00;01;58;08
Jannah Amiel
Very good. Thank you. Thank you. Now, for those of you that just might be tuning in for the first time, Dr. Sally Miller does serve as an expert witness. Now, we talked about this in our early episodes, kind of what an expert witness says. But can you give us a little refresher on what that means? It sounds like you’re the smartest person on the bench.
00;01;58;10 – 00;02;20;14
Sally Miller
That’s really not that high of a bar, to be honest with you. No, no, just kidding. Just kidding. From my attorney friends and peers who heard that. I would never say that. Meaning we know. So an expert witness, actually. I think there’s a continuum of things that we do. But the bottom line is that we are retained to review charts and offer an expert opinion on the standard of care.
00;02;20;14 – 00;02;30;01
Sally Miller
Typically of of of a professional who holds the same level of licensure and, you know, work experience that we do. A work setting, I guess is what I’m trying to say.
00;02;30;03 – 00;02;58;21
Jannah Amiel
Okay. Excellent. Excellent. Now we look at or kind of talk through cases that you’ve actually served as an expert witness on. And this is a really good opportunity not only to want to hear some of the I don’t want to say bad things, but when things do go wrong, things do go wrong in health care. And to dissect that together and to think about where those opportunities to maybe have made a different decision to take a different action could have been so that we can learn from that, right?
00;02;58;21 – 00;03;22;20
Jannah Amiel
We can learn from that and practice better, right? Practice this the safest level of our ability for our patients and for our health care institution as well. Right. This is not about kind of pointing the finger and saying, I can’t believe that this person did this right. We’re all health care professionals and we understand that every single person can make a mistake, including providers like us.
00;03;22;20 – 00;03;45;09
Jannah Amiel
And so how do we learn from that? Right. So when you’re ready, Dr. Miller, we’re ready to hear this next case. And listen, you know, as you guys are listening in, as audience listening in. Think about where your identify maybe those pitfalls. Maybe there was a little tweaking that we could have done to have a different outcome. So when you’re ready, I’m ready.
00;03;45;11 – 00;04;04;15
Sally Miller
I’m ready. Okay. And from time to time, you know, I will. I keep notes. Like timeline can be really important. So I do have notes and will occasionally glance at them because unfortunately, in my advanced years, I don’t always remember every detail unless it’s right in front of me. But this one actually, the events here all happen in a relatively quick timeframe.
00;04;04;15 – 00;04;28;03
Sally Miller
So in this case, this this took place in a an emergency room that had a fast track. So, you know, you have your regular emergency room where the bigger emergencies go. And then fast track is often for almost like urgent care or quick care kind of stuff. This was in this was in Vacation Town. So there were a number of, you know, people that were just there for the short haul, transients, basically.
00;04;28;03 – 00;04;52;06
Sally Miller
So the fast track, it was not unusual for them to have, you know, some injuries like sprains, strains people would come from. They were there on vacation and maybe forgot their meds for something like that kind of thing. So with that as the backdrop, Yes, what happened here was this what was reported to be an essentially healthy 49 year old man came in to the emergency room and he was triaged to the fast track.
00;04;52;11 – 00;05;22;21
Sally Miller
And he was there because he said he had really bad TMJ, no temporomandibular joint. He told the staff he had really bad TMJ pain and he was there on vacation with his wife and two small children and his TMJ really hurt and he forgot his meds. And so he came in asking for pain medication. And I believe, you know, to say asking for pain medication and a fast track usually like sparks off all sorts of like red alerts and alarms here, you know, living in the world we live in right now.
00;05;22;21 – 00;05;48;03
Sally Miller
But if I if I remember correctly, these were non-steroidal that he was using. Okay. In any event, that’s the story. So so now it’s a fast track chart and they’re not always the most hugely detailed. You know, you don’t have all this long narrative and a fast track chart. But, you know, what was recorded was that he had a medical history consistent with, quote, bad TMJ, bad in quotation marks.
00;05;48;05 – 00;06;08;11
Sally Miller
He also had a history of lumbar herniated nucleus per pulses and a remote history of a renal tumor. It didn’t say whether it was a benign tumor or a malignant tumor. It did not indicate that he had had any surgery nephrectomy and I would hope not if he was taking non-steroidal, you know, cause TMJ. So I don’t know what the renal tumor was.
00;06;08;14 – 00;06;28;23
Sally Miller
And, you know, sometimes patients don’t even know. I mean, you have a you have a scan or an X-ray or an image for some other reason, and there might be a benign cyst on the renal. So, you know, again, we’re supposing here, I guess, but what I can tell you for sure, it documented a renal tumor, but the history did not document any history of malignancy, any renal surgery.
00;06;28;27 – 00;06;51;09
Sally Miller
There was no documentation that there was that there was any any loss of renal function. So that’s that. So his chief complaint on this day when he walked in was that he was having upper back and neck TMJ pain. He also reported that he had been boogie boarding earlier in the day. It was, you know, on the water as a water vacation.
00;06;51;12 – 00;07;12;00
Sally Miller
He had been boogie boarding earlier that day and subsequently developed a neck upper back and jaw tightening. He was otherwise in no acute distress. This is what was reported. His vital signs were stable. His pulse ox was normal blood pressure consistent with an emergency room visit, in other words, a little bit elevated. But nobody seemed especially worried about it.
00;07;12;07 – 00;07;36;18
Sally Miller
So he was triaged to the fast track side where an apron assumed his care. And that was the information coming in that she had to work with. So the medical history provided to the A.P. at this encounter included basically everything. I just I just said the TMJ, the herniated nucleus proposes and the remote history of a renal tumor, the patient’s family and social history, as recorded by the NP, were benign.
00;07;36;19 – 00;08;01;08
Sally Miller
There were no apparent risk factors recorded for cardiovascular disease. The record also document that the NPS assessment and management of the patient revealed a thorough, focused examination consistent with his reported history of TMJ, and that you know that typically is a fast track, urgent care kind of thing. If somebody has a particular complaint, you you focus your evaluation based on the complaint.
00;08;01;11 – 00;08;27;17
Sally Miller
Medical history was documented, as I’ve mentioned a few times over, and the NP did document a review of systems and she documented that they’re all negative responses to questions about constitutional symptoms. So no fever, no joint pain, unplanned weight loss, fatigue, that kind of thing. A denied any respiratory, cardiovascular, GI you neurological. And she also documented musculoskeletal and intake.
00;08;27;17 – 00;08;43;25
Sally Miller
You mentary system’s a bit discordant with the back and neck pain and stuff that was here there. But that’s no unfortunately you will see that some of you have a chief complaint of X and then when you look at the review of systems, it says negative in the same system that the patient.
00;08;43;25 – 00;08;45;14
Jannah Amiel
Makes me bonkers. It makes.
00;08;45;20 – 00;09;13;05
Sally Miller
Me too. I mean, just, you know, it just has that look of a click and pick boom, boom. Anyway, then there was a physical examination recorded. The physical exam was consistent with TMJ pain. You know, there was like a palpation and drop jaw. The record contained documentation of the patient’s pain presentation, a physical examination. Constitutionally, you know, no acute distress, no delivery system, that kind of thing.
00;09;13;07 – 00;09;34;02
Sally Miller
There was a documented eye, ear, nose, throat, neck, respiratory and cardiovascular exams, all documented as within normal limits. Irrelevant body systems were not documented. And that’s not I mean, that’s consistent with the way a fast tracked sort of thing goes, because the nature of the quick care is it is quick care. You have a complaint, you come in.
00;09;34;06 – 00;09;59;19
Sally Miller
We’re not really there to establish this long relationship. So, you know, his he was evaluated and recorded in the way that I just described, how he presented with what he reported as an exacerbation of a preexisting musculoskeletal condition precipitated by muscle strain activity. He reported no medical, family or social factors, risk factors for a cardiovascular disease, the review of systems and physical exam.
00;09;59;19 – 00;10;22;15
Sally Miller
Like I said, are all essentially negative. The patient was diagnosed by the apron with an exacerbation of TMJ. He was given non-steroidal and he was discharged. So for the listening audience at home, I know you’re thinking, okay, there’s got to be something here. Why are we even talking about this case? You know, if they all have totally ever after it, would it make the podcast?
00;10;22;17 – 00;10;27;09
Jannah Amiel
You still got nervous? I got to tell you.
00;10;27;11 – 00;10;57;04
Sally Miller
I mean, I know. Well, 4 hours later, the patient was transported back to the same emergency room by ambulance. He was in cardiopulmonary arrest and dead on arrival. my God. Autopsy revealed that the cause of death was a myocardial infarction. So. Which probably now and I, you know, like the thing the thing for me that was just really hard to get around was the jaw, neck and back tightening.
00;10;57;07 – 00;11;24;06
Sally Miller
You know, those are cardinal phrases that every nurse learns in basic nursing education about jaw pain. So and so I was retained by defense counsel to ask if I could defend the nurse practitioner. And so the thing the thing that’s just so painfully, you know, when we look back here because, listen, you know, hindsight 20, 20, you know, all of those all of those catch phrases, you know, Yeah.
00;11;24;06 – 00;11;42;29
Sally Miller
About hindsight being 20, 20, Monday morning quarterbacking, it’s so easy to look back after, you know, the outcome and all of those things are true. So so and we have to separate from that like an expert witness. You can’t look at it from the lens of knowing what happened because the APRN didn’t get to look at it from the lens of knowing what happened.
00;11;43;05 – 00;12;05;20
Sally Miller
And so like every case, I mean, I went into it very open minded. But in the end, the thing that’s different here and again, I’m we are not here to judge. It’s really just for all of us to learn from so that these things don’t happen to us in our patients in the future. I can totally understand how the apron got caught in a mindset.
00;12;05;23 – 00;12;32;07
Sally Miller
I think in another case we talked about anchoring. Does that sound familiar or if not, we’ll talk about it at some point. Yeah. So anchoring, it’s a common phenomenon, common turn, you know, thrown around the health care world where we get like if there’s a diagnosis on the patient’s chart where the patient gives you a diagnosis, it’s really easy to fall into that and lose that that open minded initial broad approach.
00;12;32;07 – 00;13;01;04
Sally Miller
I mean, that the clinical reasoning process and this again, is taught to every nurse practitioner, every medical student, everybody who makes diagnoses, the clinical decision making process is supposed to be deducted. You start very broad. I come in to you and say, I’m having jaw pain, I have TMJ, but we as the providers are taught to not just go right down that road, that the first thing we do is consider all the potential causes of that symptom in that patient.
00;13;01;11 – 00;13;19;22
Sally Miller
And, you know, some people are thinking, but you’d be there forever. Not really. He’s a 49 year old man, and that does narrow things down a bit. So you do think about whether, you know, whether it’s five things or ten things. I mean, yeah, it should be it should be a broad list because that’s where we start. And then the clinical evaluation narrows things down.
00;13;19;26 – 00;13;37;12
Sally Miller
The first thing we do is we mentally think, okay, what are all the things that can cause jaw pain? And I start asking questions. The history of prison illness. Every question in a history of present illness should be designed to either support or refute that list of differentials. Right. And so you ask a lot of questions. You could get rid of most of them.
00;13;37;17 – 00;13;56;09
Sally Miller
Most of our diagnoses come from the history. You ask a few questions, you rule out a lot of that stuff, and then you’ve got a much smaller list of potential things. Then you start doing your physical examination, and sometimes the physical exam will take you to the answer, and sometimes it won’t. And then sometimes you need to do other diagnostic studies and you just move down, down, down.
00;13;56;13 – 00;14;13;03
Sally Miller
But we have to start broad because if we don’t, it’s the nature of that process to narrow down. Like we don’t go this way, we go this way. And if you don’t consider all the diagnoses in the beginning, chances are you’re going to narrow down. And if it wasn’t part of your initial list, you’re going to miss it.
00;14;13;05 – 00;14;31;11
Sally Miller
So we call it anchoring. When somebody has a diagnosis and we just get stuck on it and don’t, you know, don’t think about the broader picture. This kind of stuff happens all the time. Like patients will tell you, I have migraines. So we start thinking migraine or I have reflux, we start thinking reflux, and we have to be careful not to do that.
00;14;31;11 – 00;14;58;02
Sally Miller
And like I said, I know it’s easy to Monday morning quarterback and all that kind of stuff, but if we just hold on to that, you know, hold on to that basic principle of clinical deduction, start fraud, it doesn’t take long to ask a few questions and start ruling stuff out. And then then you have a smaller list and then you can work with it in this case, when a 49 year old man comes in and what he reported was a history of TMJ.
00;14;58;02 – 00;15;24;29
Sally Miller
Yes. But he also reported that he was having neck back and jaw tightening that exacerbated during physical activity. Yeah. And that’s that’s really not the nature of TMJ. Now, TMJ can cause I mean, you’ll you’ll see reports in different articles about how some people describe it as a tightening and TMJ can actually reported they cause pain that goes all the way down to the upper back and neck and stuff like that.
00;15;25;01 – 00;15;55;09
Sally Miller
And so it certainly was one differential. So when a 49 year old man comes in and says, I have really bad neck, jaw and back pain and tightening and it started up today while I was boogie boarding, I mean, you have to consider all of the potential causes of that. And since coronary artery disease is the leading cause of morbidity and mortality in the United States and jaw pain and tightening is a cardinal feature of that like you have, you just have to consider it.
00;15;55;11 – 00;16;13;03
Sally Miller
And and I mean, it’s just you have to consider it and not. And again, we all I found myself I mean I in fact one day I’ll show you the story. It wasn’t a lawsuit, but I sort of got anchored into a thing and missed something. And the patient’s appendix perforated. And, I mean, thank God he did that.
00;16;13;03 – 00;16;28;05
Sally Miller
Yeah, I will share that one with you sometimes. So I’m not judging here because we all are. We’re just in the day to day. We’re all subject to that. It’s just so easy to fall down that rabbit hole. And the point of sharing this story is that I bet everybody listening can think of a time when they did it.
00;16;28;05 – 00;16;46;10
Sally Miller
I can think of a time when I, I just, you know, was anchored in and didn’t think the big picture. And that’s why I don’t do it anymore, you know, because now I’m aware of it and aware of how it can go. So the real you know, the real concern here is that the other piece that we are all driven in school is about theory.
00;16;46;15 – 00;17;08;11
Sally Miller
And even though, like many aprons are not that into theory, you know, we were more the doers when to do procedural stuff in order, things like a theory, whatever. But theory really does drive how we practice and those like Maslow’s hierarchy, you know, that basic needs for safety first, right? If you have to choose between a couple of things, you have to go the safe route first.
00;17;08;17 – 00;17;31;26
Sally Miller
And in a situation like this, when this 49 year old man presents with these symptoms, we have to consider aid and in an emergency room department, it’s really hard to imagine not getting an EKG because it’s right there. You know, a 49 year old man comes in and says, I’m having neck back and jaw tightening. And it got worse today when I was exercising.
00;17;31;28 – 00;18;01;21
Sally Miller
You know, that’s consistent with exertional pain and that that’s like the demographic that is at greatest risk for it. So I probably DQG now again, we are we are making some suppositions here, but there are certain things based on evidence that we can assume. We can assume that since he died of cardiopulmonary arrest 4 hours later, that he was having an MRI when he came in, I mean, of course, you know, one of the defense in the defense kind of look, well, how do we know for sure it was an MRI?
00;18;01;21 – 00;18;26;13
Sally Miller
We can’t prove it was an MRI. Well, no, we can’t. I mean, he could have been coincidental he having exertional TMJ pain for hours before he died of a massive coronary artery event. But logical reasoning, logical clinical reasoning would suggest that what he was feeling 4 hours earlier was the beginning of his infarction. Any reasonable person would see it that way, and that’s part of the standard.
00;18;26;15 – 00;18;43;06
Sally Miller
And then the other assumption is that it would have been evident on a 12. It would have been I mean, that’s so and then of, you know, the defense always looking for the best way to defend their client, which is what they should do. We’d say, well, not every not every M.E. shows up on an EKG. And that’s true.
00;18;43;06 – 00;19;17;08
Sally Miller
I mean, there are exceptions, there are assignment images, there are lateral wall images. You won’t always see them. But the logical thought process is the logical evidence based approach is that the vast majority would be evident on a 12 lead. And then the other thing that we do know statistically from an evidence based perspective is that the leading cause of death in the first 24 hours after an MRI is just ramaiah and had he been admitted when he first came in, he would have been monitored and a destroyed MIA would have been identified and there would have been an intervention.
00;19;17;11 – 00;19;42;07
Sally Miller
And that’s just I mean, that is the standard. That is standard of care. We know that if he was admitted with an MRI, he would have been on monitoring and monitoring would have revealed the that the destroyed MIA and it would have been treated. So there are there are suppositions, but there are times when, based on the evidence and based on the known trajectory of a medical condition, it is reasonable to make those assumptions.
00;19;42;07 – 00;20;12;18
Sally Miller
So it’s never nothing’s 100%. I mean, listen, he could have been having his TMJ pain and then he could have just had a massive M.I. Out of the blue 4 hours later, it could have been that that EKG would have been normal. But like logical, logical trajectory of those events, it doesn’t doesn’t support that. So it is reasonable to make the inference that he was having an MI earlier, I probably would have identified it and intervention would have been available.
00;20;12;21 – 00;20;33;00
Sally Miller
And so in this particular case, I mean, after much discussion and much soul searching, I told the attorney that I that I did not feel like I could support, you know, the actions of the apron in this case. And he said he said, I know, he said I I’m not surprised. And I know that we’re going to have to make a settlement here.
00;20;33;05 – 00;20;50;29
Sally Miller
I was just hoping that you could give me some idea of how significant that that was, you know, how significant the area was and what would be the level of our contribution. And so I told him, you know, pretty much what I just told you. I told him no, told him my analysis and why. And I do know that they went on to settle the case.
00;20;50;29 – 00;20;54;13
Sally Miller
They never they’re never allowed to share how much.
00;20;54;15 – 00;20;54;28
Jannah Amiel
Dango.
00;20;54;29 – 00;21;18;03
Sally Miller
You know that. I know. I know. It’s in the terms of the settlement, they can’t share how much now it might be of public record at this point, I don’t know. I never looked back. But but I mean, he is a 49 year old man with two small children who had, you know, still a good 15, if not more, years of of productive work life ahead of them and leaving behind a wife and two small children.
00;21;18;09 – 00;21;22;18
Sally Miller
I would imagine that the settlement was appreciable.
00;21;22;20 – 00;21;44;06
Jannah Amiel
That’s rough, you know, And I’m like, I’m really trying. I’m really trying not to be Monday morning quarterback. I’m really trying. But having had worked in the E.R., it is one of the things, as you’re saying right out loud, you’re you’re saying those like Hallmark findings that quite honestly in the E.R. that I worked in and this is pediatrics, I’ll tell you, it was the same.
00;21;44;06 – 00;22;10;04
Jannah Amiel
It existed in our adult world and in our pediatric world. There were standing orders. Right. Maybe that’s a symptom of a bigger thing, of a bigger opportunity to make improvements in health care. But there were standing orders for if like this that and that appear you do this right. So for something like that, the jaw pain, the upper back pain, the neck pain automatically like we’re just doing it, we’re just checking because it could be into your point.
00;22;10;07 – 00;22;33;00
Jannah Amiel
It’s the difference between what’s actually happening to the patient. Right. Which maybe was just TMJ, but the potential of what could be happening is way greater than TMJ. And then you know what I’m thinking about Dr. Miller? TMJ. Anyway, I don’t even know what the treatment is for that. I assume it’s just pain management and then things comfort measures in that way.
00;22;33;07 – 00;22;49;01
Jannah Amiel
But if someone walked into the E.R. and was like, Hey, I’m just on vacation, I’ve got TMJ, I’m out of pain meds, even if we weren’t giving them a controlled substance or anything like that. And, you know, you had those symptoms. It’s one of those things that’s like, well, this is not an E.R. visit. Are you sure? You know what I mean?
00;22;49;01 – 00;23;12;23
Jannah Amiel
Like this. I don’t just we don’t get out pain prescriptions for TMJ without having really checked to make sure everything is okay. And and even, you know, even I’m and then I now I’m just adding to it even that like this isn’t something more sketchy, right? Like a patient comes in and says they got TMJ in any pain meds and you’re like, Do you really do you really have TM J You know, is that really what’s going on?
00;23;12;25 – 00;23;31;14
Jannah Amiel
So that that is really it is hard. I will say as a, you know, as a nurse to think about having missed it and that at that just sucks because somebody lost their life, a wife lost their husband and children lost a father. And that really is that really is rough. Wow.
00;23;31;17 – 00;23;50;19
Sally Miller
It it is. And it’s the big takeaways for all of us. Again, the takeaways for me, like, I feel so privileged to have had the opportunities to review all the things because it’s made me better, not only a better documenter but better at what I do. I mean, I’m I’m very, very serious about this kind of thing now about not falling right down.
00;23;50;23 – 00;24;07;12
Sally Miller
Know how often I like as in the outpatient setting, whether it’s family practice or psych or even in the inpatient setting as an acute care nurse practitioner. It’s just so easy to take the record that the patient comes to you with, look at their history and think, it’s that I mean, I listen, I see it all the time now.
00;24;07;18 – 00;24;28;25
Sally Miller
I have a history of bipolar, a history of this, a history of that. And it would be so easy to just keep it up and contribute, but continue to manage those things. But, you know, the one takeaway here is don’t is don’t fall into anchoring. And of course, you know, there will be someone who says, but my goodness, we make do work up every new thing every time somebody comes in.
00;24;28;27 – 00;24;58;07
Sally Miller
Well, in a situation like this, yeah, when it’s a new patient to you, it’s really it’s really a challenge when they tell you a diagnosis. Because remember, you know, now in the in the days of Google and everybody’s Googling stuff and, you know, people will all the time tell you what they have. And then we find out it’s because doctor Google supported that diagnosis And and sometimes they got it right.
00;24;58;07 – 00;25;14;16
Sally Miller
I mean, I’ve learned things from patients who were very bright and knew how to research it and came in with good info. But we just we always have to have an open mind and just be skeptical about that. We just can’t can accept any of it at face value. And again, it doesn’t mean you have to spend 5 hours just just to step back and go, okay, well, hold on.
00;25;14;16 – 00;25;41;29
Sally Miller
You know, putting on your email, you know, do all this. Let’s just let’s just think about about this for a moment. And so, I mean, that’s one takeaway. And then and then the other one, of course, is safety. You know, if if there is the remotest possibility that something could be more seriously wrong. But we do balance it because also in apron programs now there’s a real emphasis on not shotgunning, not ordering everything ever in the whole world.
00;25;41;29 – 00;26;04;26
Sally Miller
You know, 30 years ago you did somebody walked in, you just ordered a bunch of stuff, all these large EKG, all this kind of stuff. And we’ve gotten so far away from that. And now that’s not the appropriate way. And that evaluation should be targeted. They should be appropriate to the complaint. And that’s all very true. But it’s our job to find that balance and not be so narrowed that we don’t do the things that are necessary.
00;26;04;26 – 00;26;30;07
Sally Miller
So when push comes to shove, it’s just really hard to, you know, in retrospect, it’s really hard to see how a male because that’s the higher risk gender of this age, which is high risk with that classic description of symptoms that occurred during exertional activity is right there in an era where 12 leads are available everywhere. It’s just really hard not to, you know, to not do that.
00;26;30;07 – 00;26;40;26
Sally Miller
And then it is it is a reasonable assumption that it would have identified I identified the problem. So I think those are the those are the takeaways for us.
00;26;40;28 – 00;27;08;24
Jannah Amiel
And you brought up a really good point, too, that like not shotgunning, right? Because I wonder, I don’t know, like I’m not an advanced provider in this way, but if there is like a real hesitation and maybe it’s like, I know what’s the right word for that, like an administrative thing, right? That if you’re just not quite sure what’s going on with the patient in front of you, and there’s a couple of things you’re considering, but those couple of things are going to require a couple of different diagnostics or laboratories.
00;27;08;26 – 00;27;31;00
Jannah Amiel
You know, I always wonder like you will have a lot standing on your shoulders, right? Like, you got a lot sitting on your shoulders. If there’s ever a hesitation of like, I really can’t order all these things, even if I’m not sure, I think, like, these are the ones that I want to do, but I can’t do this because insurance is not going to pay for it or it’s going to get kicked back in this way or this, that and the other.
00;27;31;00 – 00;27;53;01
Jannah Amiel
And does that ever play a factor just as a provider of like, I want to do these things, I think that these things are necessary based off of me trying to figure out what’s going on. But I know in the back end, like I’m going to get dinged for some of this stuff like that ever occur. Is that is that like a reality for providers like yourself?
00;27;53;03 – 00;28;11;06
Sally Miller
Sure. Sure. I mean, it definitely occurs to me. I mean, it’s true. And then and then you then you have to spend time. I mean, if you really want something and the insurer won’t cover it, but you really, really think it’s necessary, it is an enormous amount of time to try to get stuff approved. And sometimes, depending on the insurer, you just can.
00;28;11;08 – 00;28;24;28
Sally Miller
And, you know, the practical day to day is that not we just don’t always have that kind of time to invest. So sometimes we wind up settling for a lesser study. And I know that there will be those listening who will think, not me. You know, I won’t settle for something less or I’m going to do what I need to do.
00;28;25;05 – 00;28;48;11
Sally Miller
And I mean, I genuinely I envy the person that practices in that kind of setting. I’m sure there are people that practice with populations where resources are not a concern, and if insurance won’t pay for it, the patient will just pay for it themselves. And I mean, that’s awesome, but that’s not the majority of the population. The majority of the population is beholden to their insurer or to, you know, a government provided insurer.
00;28;48;19 – 00;28;53;22
Sally Miller
And believe me, when they dig in their heels and they’re not going to pay for something, they’re just not going to pay for it.
00;28;53;24 – 00;29;12;17
Jannah Amiel
They’re not doing it. They’re not doing it. Wow. This is really interesting. You know, I want to say one thing that I that that I really found interesting. Every time we have an episode together, I leave with like something I thought I knew then I undo in my brain. But, you know, it was really ringing in my my head a lot.
00;29;12;20 – 00;29;42;26
Jannah Amiel
Was the pain, right? You talked about TMJ and I. I promise in my head I learned that that was a hallmark sign for women, like specifically women. And so having really hear that this is a true thing that has occurred, like a real symptom that was present in a man, this was the first time and I know it sounds silly, but it was the first time that I’ve heard it presented in a man because I remember learning and women and women and women and women.
00;29;42;26 – 00;30;04;16
Jannah Amiel
And that’s an important thing. This was an important takeaway for me that these like typical hallmark symptoms that we think are so specific to like a certain type of person are not always. They’re not always. And if it is a symptom of a problem, like check it on any single person, right. Like check it just to be safe.
00;30;04;18 – 00;30;20;16
Sally Miller
absolutely. Jaw pain and chin pain. I’ve seen that was a presentation. One one man just his chin kept hurting. And like you went to the dentist, he thought it was like a weird thing and just his chin in his chin. That was the thing he was complaining about. And it turned out to be angina.
00;30;20;18 – 00;30;35;02
Jannah Amiel
Wow. Wow. That is really incredible. Thank you, Dr. Miller, for sharing this story. This was an unfortunate ending for sure, but a lot a lot to be learned here. I really appreciate you sharing this story.
00;30;35;05 – 00;30;36;25
Sally Miller
And always a pleasure.
00;30;36;27 – 00;30;57;17
Jannah Amiel
Absolutely. And thank you all for tuning in and listening. We hope that you found this story educational. Right. And that you enjoyed hearing this and hopefully have some takeaways that you can also, you know, start to employing your own practice. And if you liked what you heard and you want to hear some more podcasts that we have going on, check out our other offerings on FHA dot com.
00;30;57;20 – 00;30;58;15
Jannah Amiel
Goodbye for now.