Moment of Inattention

Just a few minutes. Just a call from a telemarketer. Just 5 minutes away. Just long enough for a 1 year old to die. This is truly the worst part of what I do. What can you say to the mother? What kind of fears does this dig up for me with kids at home around the same age? How can I describe what it's like to decide to stop trying to resuscitate the child even when the heart is dead on the ultrasound, and the paramedics did CPR for 45 minutes, and the drugs were pushed, and the purplish splotches start appearing, and the eyes that don't see anymore, and the soft, cold skin. Sometimes I hate this.

Doctors Vote With Their $$ in England

Click the title above for an intersting tidbit. Seems our British colleagues in medicine are overwhelimingly choosing to obtain their own health insurance and not rely on the government's system to care for them as they age. Me too. (from the times online- Britain)

Dr Sarah Burnett, a consultant radiologist in London who worked in the NHS for 15 years, said she took out private medical insurance while she was employed in the state service because she was unimpressed with the level of care she witnessed first hand.
“NHS treatment is not a pleasant experience in any way — from the standard of the food, to ward cleanliness and the chance of catching MRSA,” she said.

Press-Gainey

Please click on the ''Press-Gainey" header for an amusing take on this problem (link broken...sorry). S-cat points out that the sample size of these surveys is so small that a couple of bad comments can completely skew your numbers. The ''suits'' as our friend in the link calls them, are chasing shadows and making work for drones. I don't care how much medicine looks like a business, it has clearly not been one since medicare was created. Trying to fit this strange beast in a business cage creates huge wastes of time like Press-Gainey. Here's an idea, distribute the surveys only to those patients who are insured, at least we won't then have a bunch of folks rating us at ''zero'' because they just received a bill for $2500 with their survey.

Can't get no.....

Just a quick note about complaints and patient satisfaction. Our director was concerned that our scores had dropped over the past couple of months. Well, it turns out that the same scumbag drug seeker that frequents the ED and had threatened one of the docs had recieved not one but TWO of the Press-Gainey score sheets to rate her stays in the ED. Talk about selection bias. And to think, the suits in administration look at this crap.

Can't Win for Losing

I have written previously about patients using the ED for their primary care, usually ''because it's free''. Here's one better. I took care of a patient yesterday that I remembered from three weeks previously when I had evaluated him for shoulder pain. This young, otherwise healthy gentleman does a job which involves repetetive motion. He stated his pain was preventing him from doing his job. No problem, even though I do not do worker's compensation diagnoses I can certainly treat pain and refer these patients to a specialist who can address the issue more thoroughly. I got him a referral to a local orthopedist and some medicine and I explained all this stuff to him.

So he shows up yesterday with the exact same story not having followed up with the orthopedist. I asked him why he hadn't followed up and he stated that he had no insurance and didn't want to pay for this. In essence he was telling me that he came to see me because my services are ''free''. Also, he had been seen here one time inbetween these visits for the same problem, was again referred to an orthopedist, and again failed to follow the discharge instructions.

I did an xray of his shoulder against the remote possibility that I would see bicipital tendinous calcifications adding weight to my presumptive diagnosis of rotator cuff strain. It was, of course, a negative film. I again referred him to an orthopedist and explained that we had nothing more to offer him in the emergency department.

He then got mad and told me he had waited almost two hours for ''nothing'', that an xray was useless because it only shows the bones and he knew he didn't have a broken bone, and that the last doctor had at least given him a pain shot. He then asked for a complaint form which he filled out saying what a schmuck I was for treating him differently because he had no money, and left in a huff with a free shoulder sling and a perscription for motrin and lortab and another referral to an orthopedist.

How funny. He thought I did substandard care on him because he couldn't pay! The reason I did substandard care on him was because he was from Sweden, and I hate the Swedes with a passion.

Medications

DOCS ON THE WEB Speaking of meds, I would ask you all to join me in getting McNeil pharma (Tylenol) and all the makers of ibuprofen to remove their products from the market. It is obvious to me after 10 years and approx 40,000 patients, that "that shit don't work". I have failed to work a single shift where a nice hard working, taxpaying, multipierced, multitattoed young person has informed me of that fact. Therefore it seems obvious that this skam of billions of dollars worldwide has got to stop. Please join me in this crusade.

EMTALA

So the government has written a law to prevent patient dumping. EMTALA, the Emergency Medical Treatment and Active Labor Act. This prohibits facilities from transferring patients with an emergency condition that could be cared for at the facility to which the patient presents. Of course it is not that simple. It is hugely complicated and well intentioned but as with most legislation the uninteded consequences are legion. The first is that it's an unfunded mandate. In other words we have to take care of all comers regardless of their ability to pay. Fair enough, we are in the business of Emergency Medicine and I personally don't care what someone's financial status is when they show up sick in my ED. But since this is a government mandate it seems only fair that the government would subidize this. No. We have just been ordered to lose large ammounts of money. How does this work? Cost shifting. Costs for everyone else go up and our paychecks go down. So sad you say... poor rich doctor doesn't get his money. Well, okay, but I'm damn good at what I do and I'm the one who might save your life. Is this skill deserving of high pay? I would say so, we are, I think, living in a free society where people chose careers based on reimbursement (and many other factors of course). I'm also the one that can go do just about anything else I want to do outside of medicine. You will eventually get what you pay for. Oh, just an afterthought, government facilities are exempt from EMTALA. Neat huh? Today we got a patient by ambulance sent 30 miles from an active military base. She crashed her car on the base and was a few hundred yards from their emergency department. She is not on active duty. They sent her here.

Drug Seekers

What to do when someone fakes symptoms to get narcotics? Depending on my mood and how busy we are you might get lucky with me. Sometimes I don't care if you have come in every other day for a year for a demerol shot if it will just clear the bed to get someone who is very ill into the room. Sometimes I play possum. This involves treating the patient's pain with IV toradol, IM Zofran for nausea... anything but an opiate or opiate derivative. Then you wait and complete your evaluation. I have found that the true drug seekers will often seek greener pastures and will just get up and walk out. Sometimes you find a real cause for pain. These patients are needles in a haystack but they keep your sphincter-tone up when all the nurses tell you, "Oh, that's Mr. X, he's here all the time, all he wants are drugs." One day Mr. X will be sick and you can't afford to be wrong, not even once.

$ and Medical School

Here's a little bit of hard truth for those aspiring medical students out there. You will pay about $10,000 a year to attend a state supported medical school. You will pay up to $40,000 a year to attend a private medical school. These figures are conservative.

After medical school you might choose to become a general internist or pediatrician. That's going to pay you about $37,000 a year during your residency training (if you are lucky). During that time you will be very sleep deprived and work about 80 hours a week. At the end of your residency your medical school debt will be about $50,000 to over $200,000. If you happen to owe money from your undergraduate education you might find yourself $300,000 in debt.

What does a general internist or pediatrician make after passing the national boards and becoming ''board certitfied"? Anywhere from $70,000 to $200,000 a year if you work full time. You do the math. How long to get out of debt? Can you afford a house?

Assuming you go straight through from undergraduate school to medical school you will be about 28 years old. Maybe by the time you are 35, if you are very good with money, you can pay off the loans you took out to become a physician.

Let's assume you want to do the other extreme... neurosurgery for example. Well, how does eight to ten years of training after medical school sound? How does 110 hours a week sound? How does severe sleep deprivation sound? Divorce? How does being 35 with a few hundred thousand of debt sound? What will you make? Well, a lot really, perhaps a million dollars a year give or take a few hundred thousand. Assuming you make it through your residency without a crack-up and get boarded you might be out of debt rather quickly. Was it worth the 14 years you gave at the prime of your life? For many the answer is no.

It is no secret that many doctors do not want their kids to go into medicine.

What about business school or law school? Well, B school is two years. You will work hard. Graduates of Harvard or Kellog or an equally highly regarded school may start work with six figure salaries and then the sky is the limit. What about lawyers? Well, three years of hard work and pass the bar and if you did well and went to a good school you might start at $150,000 and on a partnership track, well, you will do much better than that. All of this without severe sleep deprivation, all of this without the not insignificant burden of having your clients die in spite of your efforts or even because of them. Your debt burden will also be significantly less and you can start your adult life a lot sooner. Does medical school still sound like a good idea?

One more thing. In business and law you operate, for the most part, in a fee for service environment. If your customers don't pay then they cease to be your customers. Also, except in rare instances, they do not sue you. How about this, as an Emergency Physician I am required to treat all comers regardless of their ability to pay. Our particular group collects about 30% of what we bill. However, even non-paying customers can sue me for damages without limit. Imagine that!

Do I have an answer? No, but I do know that when you make something free the demand increases. People routinely tell me that they can not afford to get a primary care physician so they use the ED as their primary care. Why? Because it's ''free''.

The good news? Most doctors did not go into medicine to become rich. Most decided on medicine for the challenge of a dynamic field, and the reward of making a real difference for their patients. Most of us do find rewards greater than money. It's a noble profession, but a sober look will often turn the most capable and dedicated students away from medicine for the reasons stated above.

We will get what we pay for. If you want cheaper medical care you will have it. You may not speak the same language as your physician, he or she may have trained outside of this country, they may not have the skills or knowledge that a graduate of any US medical program will have, but they will be called ''doctor''.

Tort reform needs to happen. Many states have already enacted monetary caps on damages at $250,000. We'll see how that works. The government run facilites such as the Veteran's Administration, Military Facilities, and City hospitals have always had this cap. Their malpractice insurance coverage is therefore affordable.

Cost shifting is killing us. The worst place to be is to be a gainfully employed citizen who can't afford or is not provided with medical insurance. They get the full bill. Unemployed? Free. The rest of us pay. There is a simple solution to part of this problem... a copay for all visits to the ED. A bit of responsibility placed on every patient. Not a popular idea with the left, they have the idea that if the government could just get a hold of the whole thing that they could fix it. I have worked in both military facilities and the VA. If you want your doctor's visits to mimick a visit to the DMV then go ahead.

Grist for the mill.

Darwin Award Candidate

One night when I was in residency we got a trauma patient into the main trauma bay. The paramedics called him in as an "auto-ped", automobile versus pedestrian accident. We see these all the time but this one was different.

He's drunk and complaining about being strapped on the back board. When I say drunk I mean smell it ten feet away drunk. I mean spit in your face drunk. Turns out he can only speak Spanish. Now this is a fine thing this Spanish. Who would have thought that after 8 years of post graduate medical education that no one told us to learn Spanish. Would you travel to a foreign country to live and work and not learn the language? Evidently the answer for many is yes.

And by the way, don't let anyone tell you that there are people in this country who are denied health care. Don't even let them tell you there are people in the lower socio-economic classes that get sub par health care. If there was going to be one of those people this guy was the poster child.

You see, at 27 years old he had crossed the US border, probably many times, and made his way to my city. Some years ago he lost one arm in some way that I'm sure would be a great story, but we never knew how.

So Jose, as I will call him, was out on this snowy night drinking beers and tooling around in a beater car doing reverse donuts in a parking lot. I think he was probably driving with his knees because if he wasn't he wouldn't have been able to drink his beer (or whiskey or vodka or Listerine or Rain hair spray). His circles are in the counter-clockwise direction and force him against his door, and yes, the door pops open. Out pops Jose and Jose's car comes back around and runs him over. No shit. He was the first and last patient I will probably ever see who managed to run himself over with his own car.

Jose is met in the ED by the finest team of nurses, doctors, residents, interns, and surgeons. The same team that would have met him had he been Bill Gates on a bender. Jose spits on some of them and then vomits all over himself. He's pulling at straps and trying to take his cervical collar off. He's cursing in Spanish and is soon given "chemical restraint". At this time in our practice it was droperidol intramuscularly. We called it "nice juice".

Jose went up to the operating room where he got the best care in the city. Jose had no insurance. Hell, jose wasn't even a citizen. Technically he was an illegal. The people of the city swallowed his bill for him. I have no idea how he did. I will venture a guess though. If he walked out of the hospital he walked right to the bar and here is where I would like to give you a great pearl of wisdom. Ready? Okay, the best predictor of future behavior is past behavior. May God bless you Jose. In the ED we say God protects drunks and fools and you were therefore double covered by the almighty.

Finally, another little pearl of wisdom. If you are very sick and get brought into the ED be as mean an nasty as you can. Seriously. Mean people don't die.

WELCOME.

Some friends and I have decided to try this blogging thing. We are all doctors of different training. I do not know where this will lead but hope it will at least be an enjoyable read. I myself am an Emergency Medicine Physician. It took me four years of college, four years of medical school, four years of residency, and a stint serving Uncle Sam to get to where I am now. Now that I'm here, well... business school may have been a better choice. That being said there are rewards for being the first physician to evaluate, diagnose, and treat all comers to the Emergency Department. And by the way, as one of my residency attendings was always emphasizing, it is the Emergency Department (ED), not the Emergency Room (ER). You may also read here some posts from a fellow ED physician, an internist, and a pathologist. I work for a great company with top-notch colleagues and consider myself very lucky. It is not the norm. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or have been digitally altered to preserve anonymity. Obviously these are still tricky legal waters so please excuse any obtuseness... I'm just trying to avoid meeting a lawyer in an unfriendly environment. Here we go!