Tuesday, July 24, 2007


John Galt and Howard Roark had it right.

When the world disdains talent and the yes-men and bureaucrats are running the show, it is time for a revolution. You have read the gripes here, and they can be boiled down to this: personal responsibility will be the force that cures the medical system. But the question stands: how do we get there from here?

I don't believe the most obvious and simple solutions will ever be implemented - the simplest of which is a required, significant out-of-pocket payment prior to medical services being rendered. The application of this policy looks callous, and no politician would have the guts to push for it. So, if no one is going to help us, we need to help ourselves.

It is time to insist on our terms, and if not met, we will refuse service. Now, I realize this is going to look bad up front, and we may lose the public relations battle; but this is a long-term campaign. Physician organizations need to start acting like physician advocates. Unlike just about every other profession, our professional societies don't put their members first and fight for their rights. We, as doctors, can be individually compassionate; what we need are our representatives to take a tough stand and insist that we are paid for what we do, or we won't do it.

I'm not some cold-hearted bastard who wants the poor to suffer so that I can drive my Benz to the country club (I prefer a Lexus). The social contract between doctors and patients has been broken. The balance of power has perversely shifted. In the world of medicine, the doctors ARE the talent; without us there is no system. Let's use that power to force a cure that few people will support. It's time to take an unpopular stand - when the system works they will thank us.

Hasta la victoria siempè!


  1. sometimes medicine tastes terrible. at the same time you were posting this, i got the following EMAIL from our national college...

    CMS Proposes Big Cuts for 2008 Medicare Payments

    The now yearly controversy over cuts to Medicare payments has started again, and without congressional action, emergency physicians could see a 12% decrease in Medicare payments starting in 2008. The 2007 Medicare Trustees report predicts total cuts of approximately 40% for all physician payments by 2016.

    The proposed cuts are included in a draft of the 2008 Medicare Physician Fee Schedule that was posted online by the Centers for Medicare and Medicaid Services.

    Key policy makers on Capitol Hill expressed concern about the cuts and are working with ACEP, the AMA, and others in the physician community to develop a legislative solution for the next several years. The temporary fix would also allow Congress time to develop a comprehensive plan to change the sustainable growth rate (SGR) formula, the flawed metric used to set payment rates.

    The legislation could reach the floor of the House before the August recess or sometime in September. Rural legislators are also considering extensions of physician payment bonuses that expire at the end of this year.

  2. oh, and this is a business, right shadowfax?

  3. The more and more i read about civilian medicine, the more and more attractive being a military physician looks.

    I have to agree, after having read gruntdoc, trenchdoc (Blog-RIP) and a lot of Dr Panda Bear, I dont see any other way for people to start taking emergency medicine payment in particular and medical payment in general seriously until there is some good way to stick it to those who abuse the system. 4 yrs undergrad + 4 years med school + 3-7 yrs residency = time to get paid. Personal responsibility MUST be enforced and the road ahead is rocky. Good luck to all who will be in this fight. I will do my best to use my vote to support you.

    Doc H USN

  4. doc h,
    with some experience in the military myself i am curious... are you a corpsman? doc? pa? what is your plan? staying in? fair winds and following seas to you my friend.

    a little extra here too. if i'm not mistaken, given the huge portion of physician and hospital income made up of payments from medicare/medicaid, a 12% reduction in reimbursement dictated from above is the same thing as a price control, or, to use an anology, a fixed-rent apartment. tell me, anyone, please, where this has worked ever, in the world.

  5. I don't mind the reduction in pay/reimbursement because I just love people and would do this for free.

    Just kidding. As I have said before, even if they doubled my salary tomorrow, I stil don't believe it would be adequate. The unfortunate thing about medicine, is once you realize you are getting screwed, you have put so much time, effort, money, and sacrifice in it that is is very difficult to change to a new career, especially if a family is counting on eating and having a roof and clothing.

  6. 911 Doc...

    I am USN FMF Corpsman. Little over 4 active, currently in the reserves working on my undergrad. Hoping for HPSP and EM specialty.

    Btw, I hope you friend has received his award.

  7. One of my main points here is that it is somehow taboo for docs to demand payment for services. This is in the name of 'compassion'. It is completely self defeating and directly leads to a non-sustainable system.

    And yes 911 - price controls have NEVER worked. Ever. Concept: let's give poor people free stuff because they need it(sounds good). Reality: SYSTEM GETS ABUSED AND CRUMBLES UNDER ITS OWN WEIGHT. hmmmm, sound familiar?

    Cat - don't forget about "the children".

  8. Did no one get my referencing Ayn Rand and Che Guevara in the same post? C'mon people!

  9. Good Wednesday morning to you, Etotheipi,

    I adore Ayn Rand's writing. 'The Fountainhead' and 'Atlas Shrugged' were two of my life-long favorites.

    I think she was brilliant and far ahead of her time in being wise as to what makes sense and what does not.

    Your post was right on the button. That is the way things should be.
    I wish we lived in a world where the balance of power was where it belonged.

    Without doctors -- THERE WOULD BE NO MEDICAL CARE. Get it straight, people. And stop abusing the system. Pay for what you ask for.
    It's a privledge NOT a right.

  10. way to hit the nail on the head!

    Individual doctors have different obligations than the system, and that's where we get distracted...

  11. The people who truly lose in this are the unisured who try to pay their bills(I realize that they are few and far between). As medicare/aid lowers their reimbursement rates, guess what happens? The hospitals raise their base prices to make up for it, so they do not lose money. That is why a box of 99 cent kleenex that has the texture of paper towels cost $10 on an itemized hospital list. Big insurance sets their rates, as does medicare/aid, but the average person does not have this privilege. My Dad was in the hospital overnight in the ICU on a nipride drip. His hospital bill? 17435 and some odd cents. Insurance paid 9948, and he was left with $88 to pay. Now what happened to the other $7000 some odd dollars? You know that neither the hospital or the insurance sompany would lose money over this, so one comes to the conclusion that apparently this is how much inflated the "base rates" or hospitals are. And it is all medicaid/care fault for having such low reimbursements.

  12. I will weigh in on this one. Which is this: I am torn in both directions.

    I do agree that no serious solution will be sought until there is some sort of "crisis", like doctors refusing service or something....

    but then again, I sure would hate to be one of those poor sick people who get caught in the crossfire of this dilemma.

    Also, I also have a gripe about Podunk office doctors today and must vent---and I have a question for any doctor who cares to educate me.

    I don't think Podunk office doctors are reading their final culture reports. I think they just see a UTI on the initial UA and rattle off Levaquin orders and never look at the damn C & S at all.

    I had to chase down one of our doctors for the entire last dang week to tell him that Levaquin alone wasn't going to cut it for my patient's UTI. Her final culture showed E. Coli AND Enterococcus faecalis. Her last three Levaquin courses have not been effective---and it took me frigging forever to get him to address the E. faecalis. And then he prescribed Augmentin. When I called it into the pharmacist, he laughed his ass off and said: "That ain't gonna kill it, Bo--but I'm game, so go for it."

    Ok, I don't like being laughed at by pharmacists. So what the hell kills E. Faecalis? It's resistant to just about everything, right?

  13. So im thinking about all the information presented here again, and thinking....

    Why am i paying on my medical bills?

    Answer: I was seen by a private party surgeon in his private practice after my motorcycle wreck. After all was said and done with the insurance people there was still a bill of $1400 bucks that i owed. I didnt know it at the time, b/c i was still under my mothers health insurance and that was her arena. She thought the ins was covering everything. Guess what happened? 6 years later I am trying to clear my credit report of this unpaid debt on a payment plan to the collections people.

    Question: How can some people continually abuse the hospital ER and never see any financial penalty? If Ins, and medicare/aid doesnt cover it, ITS STILL THE RESPONSIBILLITY OF THE PATIENT TO PAY FOR SERVICES RECEIVED!!! I know, because they are still coming after me for it...

    There has to be some sort of way for a hospital to refuse services to patients who dont pay. Is there a legal mind out there that can educate me as to what the EMTALA requires you to treat w/o guaranteed payment. IE, if your drug seeker comes in complaining of back pain, and the workup is negative for the third time, cant you curb them on the fourth time?

    Gotta be something here. Anyone

    Doc H USN

  14. My feeling on this position are torn in two. I know that the medical profession needs and deserves to be paid; but I also know that there are those out there that work their whole lives only to have financial ruin brought upon them by a medical crisis.

    My daughter works, yet has no health care insurance. If she gets ill, which fortunately is not often, I am the one that helps her pays for the medication and doctor's visits out of my pocket. I am glad to do so because she is mine. But, I can't do it for everyone.

    I fear the day if she becomes seriously injured. Her finances would be ruined; along with hers, so would mine. I wish I had answers, and I wish they were as simple as "making everyone pay." Looks great on paper, but the reality is far from that simple.

  15. well my dear etotheipi, so far we have 5 or 6 fellow revolutionaries and a few who would probably come down on the other side. i know it's just a small movement now, much like the kind of movement that spurts, intermittently, from the anus of an 89 year old man who eats lots of cheese, but let's soldier on. then again we could quit. hmmmm.

  16. The doctrine of personal responsibility, as used by the so-called American conservative of the current era, is the one thing that makes upsets me to the point of frothing at the mouth. It is ironic that the idea appears to derive from the Christian right, a faith that understand grace and acknowledges the fact that all things come from God. THEN AND ONLY THEN CAN WE MAKE CHOICES BASED ON THE CIRUMSTANCES WE ARE PRESENTED.

    It's kind of like playing poker... you don't choose your hand, you only choose how you play it.

    People do not make bad decisions because they are assholes who have it out for you personally, although maybe it depends on which model of Lexus you were driving when you drove through the puddle next to the bus-stop.

    Personal responsibility, as is appears to be currently used, will not save the healthcare system. It will destroy the country, along with any human compassion we have left.

    Just so you understand where I am coming from, both Ayn Rand and Che Guevarra were unpragmatic lunatics with not an ounce of reason within their souls. You have a tough enough job without being painted as a ruthless selfish oaf by either extreme of the political spectrum.

    Someone once told me that tits on a nun were as useful as arguing on the internet.... so sorry, but I couldn't help it!!!

  17. dear anonymous.

    so courageous of you to post anonymously. glad you have ayn rand all figured out because i was a bit confused up till now.

    just so you know, etotheipi is an atheist, God bless him, and he posted this.

    since, however, you do not believe in the doctrine of personal responsibility i must assume that the reason you are a complete blithering idiot is beyond your control and i forgive you because, as it so happens, i AM a Christian. i also just said a short prayer for you.

  18. "The balance of power has perversely shifted. In the world of medicine, the doctors ARE the talent; without us there is no system."

    So true.

    Ayn Rand should be required reading.

    Posted by Anon:
    "Personal responsibility, as is appears to be currently used, will not save the healthcare system. It will destroy the country, along with any human compassion we have left."

    Anon...since when has personal responsibility ever destroyed anything? It means that I take care of myself instead demanding someone do it for me. I'm a huge fan of this idea. I have no problem with your being compassionate, just don't do it with your hand in my wallet.

  19. Anonymous:
    Really? Do you REALLY mean what you wrote?

    I will give you a chance to apologize to me and humanity - for YOU are to blame for the ills that will destroy the medical system. Once you tell people that they do not need to take responsibility for themselves, the outcome is inevitable - destruction of the system through abuse and neglect. If you don't see this, then you understand nothing of human nature. The historical examples are too numerous to mention, hmmm, let's see: communism, welfare, social security, medicare, medicaid, fascism, socialized medicine, entitlement states (think Europe), blah, blah, blah, etc., etc.....

    What's the theme? All of these isms are based on a 'higher purpose'. They subsume the individual and say "we are here to take care of you". The irony is that these systems are set up for the 'greater good', but, by their practical, real-life application, just ultimately do harm to everyone! We need to say: "you need to take care of yourself" - this is neither heartless nor exclusive of safety nets for the truly needy.

    Not only do you misunderstand human nature, you misunderstand the basis for the philosophy of personal responsibility: I'm neither a Christian nor am I a "so-called American conservative of the current era". Ayn Rand was an athiest philosopher, knucklehead. These philosophies have pre-christian roots, d-bag. The Che reference is what you call IRONY, bozo.

    I await your abject apology and admiration of my superior intellect and name-calling. Out.

  20. Speaking of nun's tits:

    On a hot summer day, two nuns - both young, blonde and beautiful are working in the church library putting away books. After working feverishly to get the job done, the first nun turns to the second and says, "I can't take this heat anymore! Do you think it would be all right if we removed our shirts to cool off while we worked?"

    The second nun, feeling the heat herself, decides that it would be acceptable since no one else was present. She locked the door and closed the curtains, and then the two nuns removed their shirts and kept working. Suddenly, there's a knock on the door.

    "Who is it?" asks the first nun.

    "It's the blind man," says the voice behind the door.

    "Well, a blind man can't see our nakedness. We can let him in," the other nun says, and opens the door.

    "Wow!" says the blind man, "Nice tits! I gotta run back to the truck. Where do you want me to install these blinds?"


  21. ok, one more:

    Q: How do you get a nun pregnant?

    A: Fuck her.

    I'm going to hell

  22. Etotheipi ---- you're starting to grow on me.... do they make medication for that and can I get some free samples?

  23. MOW: Note that my avatar is an actual photo. I think I need to get some sun.
    As far as medication goes, follow these steps: pack your Shisha with some Humboldt kind, ignite, inhale, repeat. Worked for me in high school.