Health care?

[EppyGA]

Wonder how long before the government steps in and tries to stop these doctors?

 

[docmirror]

I guess it was about a year before he retired, maybe less, that he started bringing his laptop computer into the exam room. In the good old days, he would come into the exam room with nothing but himself and his stethoscope. We would chat about this or that for perhaps five minutes or so.

Our conversations consisted of what seemed to be small talk, but mostly centered on my health and how I was feeling. My fifteen or so minutes he spent with me was usually him checking my heart and lungs, he would check my back which was usually an ongoing problem for me, and he would check whatever it was that brought me into his office. I always felt that I was the focus of all of his attention.

Then the laptop became part of my exam room time, well actually, it became the center of all of his attention, with him asking me a series of assorted questions that seemed to have been prompted by his computer. He would diligently type in each of my responses.

I visited my new doctor, er... primary health care provider, yesterday. It was the same thing. I went into the exam room, then he and his computer came in. We introduced ourselves to each other, then he set his computer on a little podium like table and we worked together on what seemed to be the patient, the computer, answering all of its assorted questions. At the appropriate time, he checked my heart and lungs, and felt the reason I was there, a lump under my arm, and then he went back to his computer.

All of this has got me to wondering how far away we are from eliminating doctors altogether. An exam could be conducted via e-mails, with a quick hop to the office to have a trained technician listen to my heart and lungs, and take other assorted vitals. Or perhaps computers could be equipped with Kromen revelators that would do all of that in your home.

I don't know the reason that a laptop computer now gets the bulk of a doctor's attention in an exam room, if it's due to insurance company demands or Obamacare demands.

I think this is actually the worst thing that has happened to our healthcare system, the self protection information gathering, or it could be more about payment gathering, I don't know.

One of the girls in the new office had worked for my old doctor. She told me he is now volunteering his time at a free clinic down in the Barrio.

I think I might wander down to Mexico and check out a few doctors down there one of these days.

-John

Yeah my internist does this too, and it grates on me as well.

BTW, if he's helping out in the Barrio, you might find him on this side down by Logan Heights, Shelltown. Look around near the base of the Coronado east side bridge. Don't have to go all the way to Mexico I'm pretty sure.

 

[Jthamilton]

With the 'cash on the barrel' method, he can put his price where he believe it is right and doesn't have to play the silly insurance game. Also if he has opted out of medicare, he can set his price ever which way he pleases without worrying about medicares wrath for not giving them 'his best price'.

I helped develop a clinic with a couple colleagues little over a year ago and backed out as an owner when we moved to Colorado. I still firmly believe in this model of healthcare. Especially this week when 2 ranchers with large operations had their insurance plans cancelled, ironically they had to advise the peruvian staff that help them of their free healthcare option.

Just this week I have started looking to develop this concept on much broader scale. It has been successful and my friend running it loves working there.

Whats general consensus on this? Is a $65 dollare flat fee for sick visit something others would like?

 

[Everskyward]

See the cardio one day, answer questions and fill out a metric excrementload of forms. Get refered to the hospital for a test procedure, and re-answer all those questions and re-fill out the excrementload of forms.

Haha true.

But I have no problem with doctors and hospitals using computers. Do people want to go back to the dark ages when there were pages of scribbled notes? Most pilots have gone to a computer model for flight planning, record keeping, etc. Why shouldn't doctors?

 

[Bob Noel]

Haha true.

But I have no problem with doctors and hospitals using computers. Do people want to go back to the dark ages when there were pages of scribbled notes? Most pilots have gone to a computer model for flight planning, record keeping, etc. Why shouldn't doctors?

Just in case you were wondering, I have no problem people using computers. Let's just do it with our eyes open. Interconnecting systems is not a trivial task and is not without cyber risks.

 

[weilke]

Wonder how long before the government steps in and tries to stop these doctors?

You mean for 'not pulling their weight in the kolchos ?' Only a question of time. Medicare already considers you a participating provider and limits your fees even if you never signed a contract. Only by actively opting out you can ge clear of their rules.

 

[weilke]

Just this week I have started looking to develop this concept on much broader scale. It has been successful and my friend running it loves working there.

Whats general consensus on this? Is a $65 dollare flat fee for sick visit something others would like?

For an initial visit I would want to take a bit more but once you are established that number could work, particularly if you can minimize your overhead by avoiding the documentation piles and billing expense.

 

[John Baker]

I think the some of problems associated with small independent doctors opening their own shop would be the hungry lawyers snapping at their heels. (liability insurance) They would have to have as much in house testing ability as they can afford to spend on the assorted contraptions and devices that do such things, or they would have to develop a good network of like minded specialists.

I know there are a whole lot of independents in California, and I think under all of this new government intrusion, and insurance company demands, there will be a lot more joining their ranks.

I think another big factor is that these people who spend many thousands of dollars and years becoming certificated and licensed to practice their craft, most all end up being very good at what they do, but have little or no clue on how to run a business, or even a rough feel for such things.

This leaves them wide open to theft and fraud from their employees. That happened to a friend of mine years ago, he almost lost everything due to his employees ripping him off, not charging friends and their families and such.

I think the ideal model would be several doctors and a business and accounting professional joining ranks.

The trouble with that is that many partnerships fall apart due to nobody having ever spelled out the rules for each others area of responsibility, they end up expecting too much and giving too little, then the squabbling starts.

It is rare to find a medical professional who is also a business major, but they are out there.

-John

 

[Everskyward]

Just in case you were wondering, I have no problem people using computers. Let's just do it with our eyes open. Interconnecting systems is not a trivial task and is not without cyber risks.

I can agree with that.

 

[Jthamilton]

For an initial visit I would want to take a bit more but once you are established that number could work, particularly if you can minimize your overhead by avoiding the documentation piles and billing expense.

The initial visit is higher. We have 3 levels of care based on necessity. We also have local arrangement with lab and diagnostic center for preferred testing i.e, CBC is $20. I chose $65 since this may be closest average, although I think its a little higher now. Full physical is something like $155 with EKG and full lab's.

It was after running my own businesses for close to 9 years with volume close to 30,000 a year that made me consider this model. The headaches I delt with daily pretty much removed most of the fun of practicing. Most of these were paperwork and hoops I had to jump through for privileges with facilities and requirements that differ with each payors. Overpayments and refunds. People not understanding their insurance and the requirements they have with copays or their portion of the bill. It is just messed up on so many fronts I don't see it being a smooth/profitable business to operate in my lifetime (the current model that is).

John
I didn't have business degree but did have some business sense. The workload I put in the beginning I wouldn't ask anyone to do again with 80+ hour weeks for first couple years (we were open 78 hours a week) this model is now becoming more established and I was little ahead of the curve with this model. If you want to outdo the competition, outwork them. I also set bar high for the staff and providers since I had already been there done that. Now days you can't reap any rewards for the schedule most demand. Most can't even earn what their paid after you put overhead in there.

You could put the brightest minds in a medical business with typical payor mix and they still wouldn't show a profit in my opinion.

 

[John Baker]

Maybe the old ones had it right, scatter some animal entrails in the dirt, spit on them, and shake a chicken leg at the patient.

-John

 

[Van Johnston]

Most pilots have gone to a computer model for flight planning, record keeping, etc. Why shouldn't doctors?

Agreed. But I can still do it without a computer if I need to. Computer/internet is better and faster than old school, but is not a GO/NO GO item for me to fly.

My PA referred me to a GI last year. Got to the GI office/ambulatory exam facility (~10 docs in the group) and the parking lot was practically empty. Went inside and waiting room was empty. On my previous visits parking lot was always full and waiting room packed. Girl behind the desk said their server had gone down so they had to cancel all their appts, and all the docs had gone home for the day.

 

[Everskyward]

Agreed. But I can still do it without a computer if I need to. Computer/internet is better and faster than old school, but is not a GO/NO GO item for me to fly.

We don't know the reason why the doctors couldn't or didn't take appointments in the post you referenced so it would be impossible to make any kind of comment. It might not have anything to do with their knowledge of how to practice medicine without a computer.

I guess your airplane is not dependent on computers. Some are.

 

[John Baker]

The old ones also had a saying: "Too many cooks spoil the broth." it was pretty much spot on regarding a whole lot more things than just chicken soup.

I think that is the major problem with health care, too many bureaucrats, public and private. It is probably the same reason many think our whole country is heading downhill.

We have traded our factories for bureaucracies, and now we are doing the same to our neighborhood doctors offices and our local hospitals.

We are converting them into bureaucracies. Hundreds of people doing busy work for every one health care professional who is actually trying to provide health care, and that poor sap has to pay for way too many of them, while us poor saps pay for the rest.

-John

 

[silver-eagle]

We don't know the reason why the doctors couldn't or didn't take appointments in the post you referenced so it would be impossible to make any kind of comment. It might not have anything to do with their knowledge of how to practice medicine without a computer.

I guess your airplane is not dependent on computers. Some are.

Sure we know. They were worried about the spread of a computer virus. Either that, or they had a TEE time.

 

[docmirror]

We are converting them into bureaucracies. Hundreds of people doing busy work for every one health care professional who is actually trying to provide health care, and that poor sap has to pay for way too many of them, while us poor saps pay for the rest.

-John

Reminds of a story about 8-10 years ago with the EPA. Someone diving off the coast of VA found a pile of lead/acid batteries that had been there quite a while. He marked the location and notified the EPA. They were REAL interested to find out whodunit. They sent divers to take samples, they did studies, and gathered info on the SN on the cases, and all kinds of forensic stuff. Yessir, they were well on the way to finding the dirty SOB who would dump hundreds of batteries into the aqua-system off the coast.

Finally, with some help from the battery maker and a bunch of sleuthing - they struck gold on one of the case SN! Victory! The guilty party was:

US DOT. Batteries came from a storehouse of old batteries that the DOT gathered up from various sources for reclamation and when they lost the storage facility, they dumped the batts in the ocean. So - they notified the DOT, and they did studies, and commissioned investigations, and hired contractors, and did research. All this work took more than 5 years, and not ONE battery was ever moved, recovered, or touched.

 

[weilke]

I think the some of problems associated with small independent doctors opening their own shop would be the hungry lawyers snapping at their heels. (liability insurance) They would have to have as much in house testing ability as they can afford to spend on the assorted contraptions and devices that do such things, or they would have to develop a good network of like minded specialists.

There is very little difference in medmal insurance between a individual provider and a larger group. There is no strength in numbers, the hyenas will come after you whether you are solo practice or mayo clinic.

I think another big factor is that these people who spend many thousands of dollars and years becoming certificated and licensed to practice their craft, most all end up being very good at what they do, but have little or no clue on how to run a business, or even a rough feel for such things.

Running a cash practice in a way that is transparent and makes sure you get paid is so much easier than a classical medical practice. You see the customer, you get paid before they are out the door as opposed to getting a couple of $$ up front and then seing the insurance money between 10 and 89 days later.

Doctors had no problem running their own offices before the goverment insurance buerocracy and lawyer hyenas became involved. A friend of mine ran an ENT practice and he had taken over some patients from a guy who retired at the time. He showed me the old guys 'medical record', every patient fit on one or two 4x6 index cards. Two lines for the initial consult, one line for the surgery and a one-liner for the follow up visit. The charges and check numbers from the payments were listed on the reverse side of the card.

 

[weilke]

It was after running my own businesses for close to 9 years with volume close to 30,000 a year that made me consider this model. The headaches I delt with daily pretty much removed most of the fun of practicing. Most of these were paperwork and hoops I had to jump through for privileges with facilities and requirements that differ with each payors. Overpayments and refunds. People not understanding their insurance and the requirements they have with copays or their portion of the bill. It is just messed up on so many fronts I don't see it being a smooth/profitable business to operate in my lifetime (the current model that is).

Hey, welcome to my world. God I am so sick of it.

 

[mnewb1]

The old ones also had a saying: "Too many cooks spoil the broth." it was pretty much spot on regarding a whole lot more things than just chicken soup.

I think that is the major problem with health care, too many bureaucrats, public and private. It is probably the same reason many think our whole country is heading downhill.

We have traded our factories for bureaucracies, and now we are doing the same to our neighborhood doctors offices and our local hospitals.

We are converting them into bureaucracies. Hundreds of people doing busy work for every one health care professional who is actually trying to provide health care, and that poor sap has to pay for way too many of them, while us poor saps pay for the rest.

-John

This...I used to work part time in an urgent care for a whale of a system locally, I'm still on the email list and I had to laugh today when I read the minutes from their last meeting, one agenda item was about the serious amount of money the system was loosing, and please be on the lookout for waste and ways to save money...I could save them significant money in two minutes...Dump 2/3s of the "managers" who have never brought in dime one of revenue and refocus resources on the providers who are responsible for every penny of income which comes in the door.

 

[docmirror]

Every time I get an email from management that talks about waste, and useless overhead I just look at the 'From' line in the email, and I think to myself: "Gee, that was easy. How much revenue did YOU produce today?". But, then the chicken in me wakes up and I just hit 'delete'...

 

[Tom-D]

Reently I've had issues of dermatitis, I was referred by my Dr. to the Clinic up the road, I checked in and filled out their form, then was escorted into the little room where my BP/pulse was taken by the Nurse (?)

when the PA came in they sat at the computer and said I see your Dr has you on _____ and ____

Their computer was linked to my Dr's, I don't see this as bad.

 

[Jthamilton]

Hey, welcome to my world. God I am so sick of it.

Guess that's why I'm practicing in a laid back setting as an employed physician in small town America. I'm back to doing a little hospital work but only newborns and peds which isn't very often. I work 4 days a week and when I'm done I'm done.

I don't make the money I did but life sure is relaxing at times and I'm getting to be my 5th grade sons assistant basketball coach for the first time ever. I simply told the clinic manager what I was going to do and it was done. Real nice to work with folks like that!

 

[Tom-D]

If a DR wants to get paid by medicare medicaid, their office best know how to file by computer.

 

[weilke]

Every time I get an email from management that talks about waste, and useless overhead I just look at the 'From' line in the email, and I think to myself: "Gee, that was easy. How much revenue did YOU produce today?". But, then the chicken in me wakes up and I just hit 'delete'...

We went through a merger of hospital systems a couple of years back. Every other day I received an email who was appointed as 'Executive Vice President of Jello safety' today. One day I hit 'reply all' and announced that XYZ has been appointed 'Vice President of appointing other Vice Presidents'. Message went out to every provider and manager in the system (they hadn't locked down the 'everyone' mailing list.

I heard about that one from management , the only phrases I remember from that meeting are 'ripple effect' and 'too cynical'.

 

[weilke]

Guess that's why I'm practicing in a laid back setting as an employed physician in small town America. I'm back to doing a little hospital work but only newborns and peds which isn't very often. I work 4 days a week and when I'm done I'm done.

Those are really the only options. You either get on the treadmill and deal with insurers and regulatory bull##$# yourself, or you work as an employee 9-5 and leave it to admins who thrive on this ####.

 

[Jthamilton]

If a DR wants to get paid by medicare medicaid, their office best know how to file by computer.

Misnomer, getting paid by Medicare or Medicaid. You have to file electronically and your aren't even reimbursed enough to pay for equipment to submit electronically.

That's what makes Obamacare such a joke, expansion of Medicaid which doesn't even cover costs of the running a practice!

 

[mnewb1]

Misnomer, getting paid by Medicare or Medicaid. You have to file electronically and your aren't even reimbursed enough to pay for equipment to submit electronically.

That's what makes Obamacare such a joke, expansion of Medicaid which doesn't even cover costs of the running a practice!

absolutely true, I know I am not accepting any medicaid in my practice, I don't know who is going to see all these folks...I guess they will keep going to urgent care and ER.

 

[W. Stewart]

Misnomer, getting paid by Medicare or Medicaid. You have to file electronically and your aren't even reimbursed enough to pay for equipment to submit electronically.

That's what makes Obamacare such a joke, expansion of Medicaid which doesn't even cover costs of the running a practice!

I am an ophthalmologist practicing in rural NC, a state who's "governor" declined the Medicaid expansion, and I disagree strongly. Our hospital is losing money hand over fist. They cannot turn away people from the ER, so the hospital incurs all the expense of treating these folks, with no hope of getting paid. Getting paid a little (from Medicaid) is better than getting paid nothing.

How do YOU propose providing health care to the people of this country?

Wells

 

[weilke]

I am an ophthalmologist practicing in rural NC, a state who's "governor" declined the Medicaid expansion, and I disagree strongly. Our hospital is losing money hand over fist. They cannot turn away people from the ER, so the hospital incurs all the expense of treating these folks, with no hope of getting paid. Getting paid a little (from Medicaid) is better than getting paid nothing.

Do you take primary medicaid in your private practice ? (and if yes, what percentage of your patients can you afford to be on MA before you have to start laying off staff ?)

If hospitals see MA patients as outpatients in a hospital affiliated clinic, they receive multiples of what a private practice gets paid. And for ER and emergency admissions, relative to providing the care for free, whatever MA pays them is better than nothing. So yes, hospitals love medicaid.

 

[Gary F]

I am an ophthalmologist practicing in rural NC, a state who's "governor" declined the Medicaid expansion, and I disagree strongly. Our hospital is losing money hand over fist. They cannot turn away people from the ER, so the hospital incurs all the expense of treating these folks, with no hope of getting paid. Getting paid a little (from Medicaid) is better than getting paid nothing.

That might be true in the ED but then the hospitals are on the hook for routine care including expensive elective procedures like hip replacements

How do YOU propose providing health care to the people of this country?

Wells

If medicine was not practiced so inefficiently we could provide care for everybody for what this country currently spends. Tying up physicians with bureaucratic red tape disguised as progress is not the answer.

 

[W. Stewart]

Do you take primary medicaid in your private practice ? (and if yes, what percentage of your patients can you afford to be on MA before you have to start laying off staff ?)

If hospitals see MA patients as outpatients in a hospital affiliated clinic, they receive multiples of what a private practice gets paid. And for ER and emergency admissions, relative to providing the care for free, whatever MA pays them is better than nothing. So yes, hospitals love medicaid.

I do accept MCD, but I don't know the answer to your question. My post was talking simply about the hospital situation. I vaguely remember from microeconomics that as long as you are covering your fixed costs, the business might be sustainable, even if you are not covering the variable costs as well.

Like you, I hate the fact that hospital-owned practices receive more for the same services than non-owned practices. That is one of the largest travesties in this whole medicine business, and a secret that many do not know about, and nobody understands.

We understand the risk of a single-payer system, but I still would prefer it to this stupid system in which we have to deal with all these plans. The insurance companies still manage to lower reimbursements each year, complicate things, and suck off money for the "middle man". Look at the money they pay their CEO's! I have 5 employees in my front office due to the complexity of all the medical (not to mention vision) insurance plans.

I enjoy your posts a lot, Weilke, and I agree with you on most everything!

Wells

 

[W. Stewart]

If medicine was not practiced so inefficiently we could provide care for everybody for what this country currently spends. Tying up physicians with bureaucratic red tape disguised as progress is not the answer.

It is not that "medicine is practiced inefficiently". The PRACTICE of medicine is efficient, I feel. But the shenanigans of getting paid are quite complex, whether driven by insurance companies or the government. And to those on here who think that the current situation is a recent thing, driven by the ACA, that is not true. The whole EHR fiasco is a George W. program. And the ICD-10 changeover has been coming for years (despite my prayers that it simply go away).

Wells

 

[mnewb1]

How do YOU propose providing health care to the people of this country?

Wells

Well for one, as a primary care physician, I would do away with Fee for Service in primary care. I would institute a monthly per patient management fee. I would also do away with all co-pays and deductibles to be seen in your primary physician's office...I do not want to have barriers to people coming in. This also improves efficiency because now not everyone physically has to come in for every problem/concern. This frees up open time in the office for urgent visits that have to physically be seen.

It would have to be a fee more in line with the concept of Direct Care which was enshrined in the new law, not the ridiculous amounts HMO's paid in the last decade. It would be more user friendly for patients and less burdensome for physicians.

 

[nddons]

I hardly ever die in an emergency room. I had to go in so blood samples could be collected this morning. The young lady who drew them asked me what I thought of my new doctor, she used to work for my old one and remembered me.

I shared my thoughts about the computers and she confirmed what you said, no matter what doctor I went to, they all could access my complete, up to date medical information.

I talked to her a little about going down to Tijuana for my doctoring. She said she did not know if the level of care would be any better or worse, but it would darn sure be more personable. She said I'd have to find out about costs down there myself. She also reiterated the importance of all of this shared computer information, which they would not be participating in.

I don't know if I'll ever get around to checking it out, but maybe one day.

-John

As long as you don't find yourself hanging from a bridge in Tijuana. That would put a dent in any healthcare cost savings you may find there.

 

[Jthamilton]

It is not that "medicine is practiced inefficiently". The PRACTICE of medicine is efficient, I feel. But the shenanigans of getting paid are quite complex, whether driven by insurance companies or the government. And to those on here who think that the current situation is a recent thing, driven by the ACA, that is not true. The whole EHR fiasco is a George W. program. And the ICD-10 changeover has been coming for years (despite my prayers that it simply go away).

Wells

Wells
Gotta disagree on this one! Primary care can be managed as efficiently as possible and you still cannot make a go of it. You can't see more patients and make more money, it only deepens the hole. Many primary care offices have Medicaid and up to 30% Medicare volume. Primary care shoulders the greatest amount of paperwork, prior authorizations and referral hoops then any other discipline and are reimbursed the least.

I didn't see Medicaid and had 4% Medicare population. My providers were able to practice in the 75% in productivity due to the structure I had created. I offered 401k and paid for my staffs insurance until the last year of my ownership. The last year they had to pay a small percentage. The following year after my departure even though I still managed them, even with better purchasing abilities, the practice was no longer generating a profit and continues to lose money today as I've been told.

Personally, providing a conversion factor for reimbursement based on administrative needs such as burden of requirements for payments shouldered by each medical discipline would be a start. I would call it a "cost of practice increase", determined by a independent nongovernment board with absolutely no ties to any payor sources. A minimum payment for services or a floor should be established for Medicare and Medicaid to offset the inability to pay for services.

I also feel that we will see a 2 tiered system in future, those with Medicare and Medicaid will see providers subsidized by the Feds, typical to how the VA works. The other will be for commercial insurance and will be managed by private physicians. Riddled with the problems it would create based on ability to pay, I see it as a possibility.

Curious, did George W implement the EHR in the VA system as this is primarily where the movement started? Maybe someone little older and wiser then me can attest to when they started. Interesting comments in Medical Economics this month. 70% or primary care physicians don't feel that EHR has helped them at all overall, most feel it has completely hindered their ability to practice.

Whether we like it or not we are moving towards government based healthcare and I truly hope I'm out of it in next 10 years.

 

[pilot_dude]

I helped develop a clinic with a couple colleagues little over a year ago and backed out as an owner when we moved to Colorado. I still firmly believe in this model of healthcare. Especially this week when 2 ranchers with large operations had their insurance plans cancelled, ironically they had to advise the peruvian staff that help them of their free healthcare option.

Just this week I have started looking to develop this concept on much broader scale. It has been successful and my friend running it loves working there.

Whats general consensus on this? Is a $65 dollare flat fee for sick visit something others would like?

That's about the going rate (specifically $75) for a general visit and he has no shortage of patients.

 

[nddons]

For sure. I recently referred a patient in the ED to the local cardiologist. Sent him a HIPAA-compliant e-mail with the particulars. Got a message back days later, "Please don't e-mail me about referrals. I rarely check my e-mail." Seeing that I work almost exclusively nights, and he only appears between 8 a.m. and 4 p.m., how's that supposed to work, exactly? Right...fax.

Email: the "snail mail" of the 21st Century.

 

[JOhnH]

Haha true.

But I have no problem with doctors and hospitals using computers. Do people want to go back to the dark ages when there were pages of scribbled notes? Most pilots have gone to a computer model for flight planning, record keeping, etc. Why shouldn't doctors?

Yeah, but pilots still pay attention to their surroundings. I had to ask my doctor to look at me one time when I was answering one of his redundant questions so that I could tell he was listening to me. He didn't like that.

I don't mind them using computers. Hell, I converted my veterinary hospital to all electronic medical records in 2007 and it has had a giant effect on efficiency and accuracy. But that doesn't mean the doctor can stare at the computer screen during the entire "exam". If so, I could see the nurse for vitals and the lab for tests and do the rest of it with the doctor on-line or over the telephone.

 

[Everskyward]

Yeah, but pilots still pay attention to their surroundings. I had to ask my doctor to look at me one time when I was answering one of his redundant questions so that I could tell he was listening to me. He didn't like that.

But isn't that a little bit of a nit pick? Maybe he never took touch typing in school and needed to look at the keyboard. When he was done asking questions didn't he do a physical exam if that's what you were there for? I can understand you not liking his style or bedside manner, so to speak, but I'm not sure that has anything to do with using a computer. In pre-computer days he might not have looked up from the piece of paper he was writing on.

 

[nddons]

But isn't that a little bit of a nit pick? Maybe he never took touch typing in school and needed to look at the keyboard. When he was done asking questions didn't he do a physical exam if that's what you were there for? I can understand you not liking his style or bedside manner, so to speak, but I'm not sure that has anything to do with using a computer. In pre-computer days he might not have looked up from the piece of paper he was writing on.

Good point.