Revolution (Part II)

Please see these links regarding ETOTHEIPI's prior post, "Revolution"...

1. Grunt Doc with a revealing graph.
2. Scalpel with a kick-ass analogy.
3. The inevitable.
4. An economist's view (a real asshole conservative type, typical!).
5. Monkey Girl sums it up.

Personally I can not live without a 60" plasma screen TV so I'm all for the government paying for it.

The "Jackrabbit" (double articulation with a rotating stimulator no less)

Revolution

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!

I AM NOT A FU**ING DENTIST

I am not a dentist. I know more about teeth and injured teeth and abscessed teeth than most folks but I can not fix your cavities, your meth-mouth, or your impacted wisdom teeth. I know you know this but you come to me anyway and I'm tired of it, especially when the conversation goes like this:

Me: "How long has your tooth been hurting?"

Patient: "Eight months, but it's much worse today."

Me: "What does your dentist say?"

Patient: "I don't have a dentist."

Me: "Why?"

Patient: "Because no one will see me without payment up-front."

Me: "Well how are you going to pay your bill here today?"

Patient: "Oh, the government pays for me to come to the ER."

Me: "The government?"

Patient: "Yeah, I have _____-Care, it's free."

Me: (swallowing hard and doing tantric breath control) "Well, I can't fix your tooth I can only make it feel better. You are going to have to see a dentist or you may end up with a severe abscess and have to go to the operating room. If you see a dentist they may arrange a payment plan with you and you can get your tooth pulled for a few hundred dollars. If you wait and have to go to the operating room your bill will probably be over ten-thousand dollars and some people die if they let these get away from them."

Patient: "I can't afford it."

Me: "Do you smoke?"

Patient: "Yes."

Me: "How do you afford your cigarettes?"

Patient: "My father buys them for me."

Me: "Maybe he can pay for you to see a dentist."

Patient: "Oh, he can't afford that."

Me: "How did you get here today?"

Patient: (cell phone ringing, pt answers it and tells caller that the doctor is in the room) "I drove."

Me: "Well how do you pay for your gas?"

Patient: "Oh, it's my brother's car."

Me: "Well maybe he can help you pay to see a dentist."

Patient: "No, he barely let me borrow his car."

Me: "Well, as I said, I can't fix this, only a dentist can, so you are going to need to figure out a way to afford the dentist. I can give you some motrin, pain medicine, and antibiotics but they won't fix this, only make it more tolerable."

Patient: "Do you have samples?"

Me: "No we do not."

Patient: "Well I can't afford any medicine."

Me: "Well why did you come in then?"

Patient: "Because it's free."

Me: "Your medicines will cost about $15. You will have to find a way to get them. Good day."


Dentists are outside the scope of EMTALA, they must have a good lobby. I don't blame them and, in retrospect, dental school looks pretty sweet.

Paul Krugman, an Eighth-Grader at Princeton

Evidently Princeton University thinks enough of the economist Paul Krugman to employ him to teach in their hallowed halls. Evidently the New York Times thinks enough of him to have him write a regular op-ed piece for them. It was with no small amount of amazement, therefore, that I read his recent NYT screed linked above entitled Universal Health Care Opponents Have no Case.

Back in eighth grade I learned from a very wonderful English teacher and debate coach what an ad hominem attack was and that not only was I never to use this gutter tactic when engaged in argument, that I was, in fact, to allow any opponent who used it to speak freely and at length as they would kill their own side. As briefly explained by wikipedia an ad hominem attack... "is most commonly used to refer specifically to the ad hominem abusive, or argumentum ad personam, which consists of criticizing or personally attacking an argument's proponent in an attempt to discredit that argument."

For instance, if I were to begin the rest of this post as follows, you, my friend, would do best to quit reading... "Paul Krugman, "professor" of economics at Princeton, besides looking like a cheap version of Wolfman Jack, is also well known for spitting on babies and stealing pension checks from the elderly while pushing them down flights of stairs. He secretly hates women, puppies, and eskimos and for all the above reasons can not be trusted when he speaks about economics."

Imagine my surprise when this Princeton professor and New York Times columnist began a recent piece on "Universal Health Care" (again, linked above) with the following quote: "OK, it's not news that (President) Bush has no empathy for people less fortunate than himself. But his willful ignorance here is part of a larger picture: by and large, opponents of universal health care paint a glowing portrait of the American system that bears as little resemblance to reality as the scare stories they tell about health care in France, Britain, and Canada."

This guy is a famous economist? A Princeton professor? What follows in his article is a confusing mish-mash of pseudo statistics and anecdotal evidence (he cites a "recent Business Week article based on statistics and anecdotes") that our health care system is terrible because sometimes both the insured and the uninsured have to wait a long time for short term care. This is the best I can do at untangling this guy's logic. It seems he's comparing apples to oranges and complaining that the safety net which IS the Emergency Department is overcrowded and sometimes overcrowded to the point that that uninsured and insured alike must wait for a while to be seen. That's right, it's called triage, and thanks for the news flash professor.

To the extent that I can understand the rest of his piece it's no more than a pitiful attempt to gin-up an issue for the upcoming election cycle and confuse the public into believing that "universal health care" will solve all our ills. As has been detailed extremely well on Panda Bear, MD's site there's about a million reasons that this is a terrible idea. Having worked as an active duty military physician, a physician in the Veteran's Administration system, and in the private sector I can not imagine a worse idea than growing a government bureaucracy to administer a single-payer system. Do you enjoy going to the DMV? Are you a vet now? Do you get your care through the VA? Ever read about Walter Reed Army Hospital?

Krugman and his ilk, and pretty much anyone who comments on the current health care crisis neglect to mention what I believe to be the key factor to solving the majority of our problems. Patients, all patients, need to be made to be responsible for their health care. It is not a RIGHT it is a RESPONSIBILITY. Now there is ABSOLUTELY NO MONETARY INCENTIVE for patients to make healthy choices in their lives, to actually get a primary physician, to take their medicines as prescribed, or to get that operation they were told to get three years ago because THEY CAN, in fact, go to the Emergency Department 24/7/365 and have someone like me arrange it all for them.

The economics is simple. People have chosen to drop their health insurance OR have chosen not to purchase it because it is expensive (for me and my family of five we pay $460 a month) OR simply can't be bothered to open a phone book and call a doctor. Under EMTALA it doesn't matter, Emergency Physicians, Surgeons, and other specialists must see these patients in the Emergency Department regardless of their ability to pay, regardless of whether they are wanted by the police, regardless of whether they are in the country illegally, and regardless of the fact that many of them were seen just the day before for the exact same problem. And, as you know by now, the government that brought us EMTALA does not pay us anything for these donated services nor does it allow us protection from malpractice suits related to cases we treat under EMTALA.

When we make Emergency Department visits more expensive than a visit to the local pediatrician, internist, of family practitioner (and I mean collecting a small co-pay with EVERY VISIT) then the Emergency Medicine crisis will vanish. And no, what I'm proposing is not heartless, I'm not asking to bankrupt our underprivileged, I'm merely asking that they forego something, make some contribution towards their care, give up their 1800 minutes/month cell phone plan and settle on the 1400 minutes/month plan, give up their visit to the movie theater this week, don't get their nails done... you know, pony up $50 or so. It's amazing how behaviour changes when money is involved. I would think a brilliant economist like Professor Krugman would understand this, but then again he's just an ivy-league douche bag.

Circadia

I've been off for a week now. I have been going to bed at about 11:30 and getting up at about 8am. Wow. What the hell? I'm happy and content and had a great break with my wife. I cooked dinner tonight for everyone. What the hell is wrong with me?

To Kill is to Cure

The most recent article in the 'case records of the Massive Genital Hospital' in the New England Journal of Medicine discussed a patient with end-stage diabetes characterized by vasculopathy and multiple cerebral infarcts. The interesting aspect of this case was not the differential diagnosis or the pathological discussion; instead, it was the patient's choice to withdraw treatment and die that intrigued me.

The physician discussant points out that he was unable to offer euthanasia or physician-assisted suicide. They simply withdrew insulin, nutrition and hydration. She died two days later.

Why? Why? I ask. Why can't we help people die? Fuck Hippocrates. When I'm a drooling vegetable, shoot me in the fucking head. Please. We have decided it's OK to let someone suffer instead of helping them with their wishes.

Fuck it. I'm moving to Amsterdam. Maybe I can score some spliff on my way to hell.

How Not to Die

Do not be a local policeman and a closeted gay transvestite with a wife and kids. Do not go to the local gay bar dressed as a woman with wig, fake boobs, stiletto heels, and mascara on. Do not have a fatal heart attack while sitting at the bar. Do not be brought in by ambulance to the E.D. where your colleagues who have heard of your emergency are anxiously waiting to find out how you are doing. That, my friends, is how not to die.

Customer or Patient? (part deux)

(FOR PART ONE CLICK HERE)

As many of you know from reading here I have a big problem with hospital administrators. It used to be that doctors, as they progressed in their careers, became hospital CEOs or Presidents or whatever. Doctors ran hospitals usually for the better in my opinion. Doctors in charge of doctors is really the only way it should be. Asking me to respect the judgements of a business guy regarding how best to run a hospital and therefore how to best practice medicine is simply foolish.

Medicine is unique, and applying a business model to our current 'system' is just insane. Now we have business folks who have trained in 'medical administration' as the captains of our ships. Most of them say they "would have gone to medical school but... (fill in blank here)". They have brought with them, the "customer" model from business and are flummoxed at how poorly it applies to medicine.

Now it's not rocket science why this hasn't worked out so well, or, as David Lee Roth said recently, it's not "rocket surgery". Medicine is not a business. Patients are not customers. Encouraging repeat "customers" in the ED LOSES us money as patients with insurance would normally go and see their own physicians. We collect 30% of what we bill so again, operatin' on rockets this is not.

Also, being mandated by a federal law to treat all-comers with an "emergency condition" (still waiting for the definition) without any money to back pay for it makes us more like speculators than businessmen. We hope that by mining a certain percentage of patients that we will strike enough hidden money to make it all worthwhile for us.

I have comprised the following list to help those having difficulty with the above concepts.

A Customer...

1. Seeks you out to purchase a good or service.

2. Knows the reasonable price of said good or service and agrees on a final price for said good or service prior to purchase.

3. Has, many times, special knowledge obtained about said good or service thereby becoming an 'informed customer'.

4. Can walk out the door at any time without paying prior to the sale.

5. Must pay for good or service or repossession of goods, arrest, or imprisonment for thievery after the sale.

6. Can rightly complain for poor service as, with a competitive business, making your customers happy, and making them repeat customers, helps your business to succeed.

7. The business owner can refuse to serve customers if they are disruptive or, as is often seen posted in businesses, "we reserve the right to refuse service to anyone".

8. The business owner expects a certain number of complaints. Certainly complaints should be a very small percentage of customers served, but let's face it, you can't please everyone and some people are just assholes.

9. A customer pays with his or her money or through an intermediary in the form of a bank card or a loan.


Patients (medical "customers")...

1. Never seek me out personally, they are either delivered to me by an ambulance that could just as well have driven twenty miles the other way to a different hospital, or end up on my doorstep as a 'last resort'.

2. Have no clue, ever, how much the goods and services I will deliver will cost, and, for that matter, NEITHER DO I!

3. Have, generally, no special knowledge about his or her particular medical condition (with some rare exceptions). Reading about something on the internet does not count and is the equivalent to learning where to place your fingers to play a "C" chord on the guitar as opposed to learning to play a classical repertoire like Andres Segovia. Let's face it, unless you know a whole lot about EKGs I could hand one to you and tell you that you were having a heart attack and you would have to believe me. You would not snatch it from my hand and argue that what I am seeing in the anterior leads is "early repolarization" and not "ST segment elevation".

4. Can walk out the door without paying at any time, even after delivery of goods and services (providing they actually can walk) and, even without paying, can complain about my service. This complaint will be dutifully typed onto an official hospital form and deposited into my box to punch me in the gut before the start of a shift. The burden is then on me to explain my poor "customer service".

5. Will get a bill for the goods and services provided. After sending a few of these and turning the bill over for collections the "customer" skates and maybe pays a little or pays nothing. The worst place to be here is to have a job. Then the collections agency will get something from you. If you are illegal or unemployed however, it's not worth it... blood from a turnip you know.

6. Can complain, rightly or wrongly, about the perception of bad care. I have had patients complain that I was "rude" or "brusque" or "didn't seem to care" only to review the chart and find that I have either saved them from imminent death, or had not had time to fully explain why the spider bite that they thought might be from a "brown recluse" was (a) not visible and (b) not a spider bite. Doesn't matter. Letter in my box.

7. Can not be refused service at any time. The only way for me to "refuse service" for someone is to have them refuse to let me care for them by signing a form that says they are choosing to leave "against medical advice". People know this and take full advantage by being loud, demanding more pain medicine, more blankets, faster service, a second opinion, more XRays, food, and television to be delivered to their bedside.

8. Can complain about anything and generate a letter to me. Hospital CEOs expect zero complaints. Idiocy. Physicians are experts in a specialized field of knowledge. Often the right answer to a patient request is "no". Often, the best thing for a patient would be to refuse to treat them with narcotics for the fortieth time this year for their 'migraine' headache and 'herniated disc' pain. Since receiving narcotics is the only thing that will make this large group of customers happy the right answer is, "No, get out!" The business answer is, "We have more pain medicine than you have pain."

9. Pay some mystical amount determined by the three fates for their medical bills. I have no idea how the amount at the bottom of the bill is calculated and how much becomes the patient's responsibility and how much is paid for by the taxes of the Smith family in Podunk, Arkansas. Besides the fact that the way our "business" collects money is some weird morph between a Buckminster Fuller contraption and a slick three-card monty game, acting like pleasing the "customer" will ultimately lead to a robust medical system sends me into fits of apoplexy and makes my tongue cleave to the roof of my mouth (not my fingers though).

Gloves Off, Doc!

Click above. Read. Ring a bell? I do my volunteer work at my job.

"Doctors" and UK terror

First things first. If I am in a hurry on my way to a night shift and need a little shot of caffeine, please, oh please, don't be in front of me at Starbucks if you are a MAN and order a grande low fat orange mochachino, with just a TINY amount of cream. Grow some balls and order a cup of COFFEE like your father and any respectable trucker would do. I don't care how thirsty you or your domestic partner are, I am in a hurry and there are LIVES to be saved. It takes a long time to make your "coffee". There, I had to get that off my chest.

Now, on to the Brits. It is amazing that some people were surprised that DOCTORS could be involved in the terror plots. Yes, they may be docs, but they are still Muslims who identify AS Muslims and NOT British or any other nationality, who were indoctrinated from youth in the madrasahs that they are oppressed, and must kill Jews, Christians, and just about everyone else. Not only must they kill, but to die doing so will bring virgins and paradise. So much for primum non nocere or the Hippocratic Oath. But the Brits have themselves to blame as well, for bringing them in to heal the sick in their NHS. You see, there is a shortage of docs in the UK so they bring in docs trained in places where hate for the West is a way of life (over 30% of the docs are foreign trained). It's kind of like bringing a hungry lion in your home to watch your kids, and then being amazed when your kids are eaten. And why is there a shortage of UK docs? Well, you could make more being a plumber (nearly), are burdened with government regulations, deal with decreasing respect from patients, etc. etc. I do admire those that continue to do it however, and met a few when I lived in England for a few months. And oh how I look forward to a National Health Service here in the U.S.

And before you moderate Muslims go on tirade, I know you are out there. And I also know that not all docs trained in the Middle East or SE Asia are going to be suicide bombers. But in recent polls (Dailymail,CBS,etc-just google Muslims and UK polls) a large number of Muslims in England, and not just the youth, either supported or sympathized with suicide bombings. A large number also want sharia law to be the law of the land. So, you moderates raise your voices, because the world can't hear you.


One more thing. I can almost guarantee those burnt krispy kritters in Scotland wouldn't have been taken into custody or to a hospital in the U.S. if some patriotic concealed-carry permit holder had been at the airport picking up his wife. At the sound of the first flaming "Allah Akbar" there would have been one empty snub nose 38. Here come the virgins.