Tuesday, February 05, 2008

'Network Docs' Revisited

About a year ago there was a series of posts here bearing on the health care crisis as seen from my perspective. Since our friend Dr. Hinchey from Texas has weighed in on this issue I thought it would be good for those interested to revisit the following posts (the comments are long and especially telling), the larger issue of patient responsibility for their own health care, AND the mess that is billing etc...

Hello Taxpayers

Customer or Patient

Customer or Patient (part deux)

The Joust, a Semi-Controlled Rant

Can't Stop Poking it With a Stick

I Swear it's Dead but Give me That Stick Anyway (the unintended consequences of EMTALA)

The Health Care Walnut

Charity Doc Taking a Breather

Hello Taxpayers (incident 3087)

I have promised in many posts to leave the ER when the opportunity presents. It has presented. In April I will be a part-timer, and if the new opportunity works well I will no longer practice in the ER. I am not alone. America will get what it wants, free health care, and it will be worth what other free stuff is worth. Good luck with all that, citizens and illegals.


  1. I am happy for you with your new opportunity, but also sad that your ER is losing a great doctor. I am really nervous about what is going to happen in the future with health care. As someone who has had a lot of medical issues pop up recently it all just really frightens me.

  2. Given your history, I understand your apprehension.

    I am scared too...for you me, and the whole system.

    Thanks to 911 for putting all of these posts together.

  3. Are you going to give us a hint about what sort of other opportunity you're pursuing. I'm only asking for selfish reasons - perhaps if you can get out I can too!

  4. amy,
    full details as it evolves but basically i'm staying in medicine and going to work for a group of non ER folks to bolster their ability to maximize their efficiency in clinic. i will also be doing some public relations stuff with them and helping in whatever way i can. the strength we, as ER docs bring to any practice, is that we are, more and more, the only docs who do the intial diagnosis and treatment on truly sick people. we are also the best at recognizing sick folks with very minimal lab and radiology studies. i have a feeling that what i am about to do will be something that becomes an alternative to practicing in the ER as a 'worker bee'. more later and thanks for your interest.

  5. Urgent care: The 2nd job of half of our ER physicians.

    I was hoping you'd do tutoring of children on capital letters as a karmic payback to your commenting, but that sounds good too.

  6. ERdoc, I too do urgent care, and see a fair number of illegals. They all have insurance though. Its possible to find health insurance at a resonable price. I paid more for my auto insurance in the 1980's than I do for my health insurance now (a long sordid story). Of course, I'd rather get it for free or better yet, have you pay for it.

  7. So is the ER destined to be one of those, "will the last person out please turn off the lights" situations? I weep for our country right now...

    Congrats to you, 911. I hope you find more peace and happiness in your new job.

  8. Hey 911, you and I have both expressed our deep respect for "clipboard nurses"....are you gonna be a "clipboard doc"? J/K

    Best of luck. I'd trade places with you in a heartbeat!


  9. haha,
    i'm not doing acute care. more later.

  10. What are people prescribing for kids coughs and runny noses now that the FDA has essentially put a black box warning on them. I've always thought the decongestant/anihistamines were worthless and just prescribed them to make people happy. Patients tend to think youre a quack if you tell them to take aspirin and chicken soup, but now I'm having to do that. (OK, TYLENOL and chicken soup for the kids)

  11. Hi 911DOC,
    I know this is a strange question given that you are leaving emergency medicine, but is there anything that you will especially miss about the ER? And by the way, I wish you the best of luck and much success in your new position.
    Take Care

  12. I'm just using Robitussin for the coughs....then I tell the parent that it doesn't work, so don't bring the brat back in because of a cough. If the cough persists...SEE YOUR PCP (but he isn't gonna do anything about the cough either).

    I also point out that the FDA is the one that won't allow docs to write meds that might help their child's cough a little because of less than 100 deaths over millions and millions of uses.

    I want them to respect our position and understand that the more the government gets involved in health care, the worse it will become for all of us.

    On a side note....in the "what I do for my own family" category. My 12 year old had a cough probably due to an atypical bacteria like Mycoplasma. He didn't feel sick, but his cough drove everyone crazy. The school kept sending him home. Nothing worked! I even tried the Hycotuss stuff, no success. Finally, I gave the kid 10 mg of hydrocodone with only modest success....the only thing that knocked out his cough so he could sleep (and we could too) was 10mg of hydrocodone and 10mg of diazepam (Valium). It worked like a charm.....and he had great dreams too!

    I know this is drastically overmedicating, but it made everyone happy. After a week of his Zpack and the above, he was finally well enough to go back to school....in the interim, he made level 43 general (or something like that) on Halo.

  13. I'm psyched for you to get out of that cesspool. Well done.

    Now, for all you readers out there, THIS is what you get when you shit on the people with skills and smarts. At some point, they are going to say "fuck this" and go do something else. You can blab on about 'compassion' etc... but THIS is the reality. You want free ER care? Well, now you have it. Pieceofshitfuckstickmotherfuckers.


  14. ahem,
    well, etotheipi, thanks for putting it so bluntly. the decision was one of self-preservation. i will make less money, at least initially, and will still do some shifts in the ER. there seems to be a 'critical mass', different for different docs, above which the ER starts robbing you of your soul. 'cat has spoken of this many times. this is not unique to the ER but is most commonly seen there. other docs, especially surgeons and all residents, get pushed to and beyone their limits too. i can not think of another profession like this. if i were say, in business or law, and if i were good, now would be the time for me to sit back (if it were my choice) and select the primo cases or primo jobs. my salary would be on an upward trend with bonuses and the like, and my ability to enjoy my off time would be preserved as i would not be perpetually sleep deprived. any wonder i'm opting out? the longer i work the less control i have. my pay in ER, as opposed to every other medical specialty, has actually risen a tiny bit last year, but this is cold comfort. my ability to do my job is decreasing every day due to a host of factors and the demands of my customers are increasing every day because a)they believe they deserve the best care available and b) they believe someone else should pay for it.

    but i am getting carried away.

  15. Ok, enough now. My time to vent.

    I resent that you generalize and lump everyone in the same category. I have insurance AND I pey my bills. In Full. I don't abuse the system, I have been to an ER once in my life and that's because I was taken there.
    For broken bones and whatever else ails me while keeping me conscious I go to a Doc in the Box or my PCP.
    So stop being so judgemental.

    Evidently, itis time to move on for you and I am sure you will be happy with your decision. Also, hopefully, it will give you a fresh perspective on life and people that is not so distorted.

    OK rant over. Now you can spew the insults, your standardized response to anyone who disagrees with you.

    And oh... all the best on your new job. :-)


  16. I meant *pay* my bills.

    It's all your fault. When I am mad, I don't see too clearly :-D

    But then, neither do you.


  17. I love the parents with their gifted children. Today I noted that a patients height was 68 inches, "YEAH I'm 5 foot 10" he proudly remarked, and his mother added that he was in honors classes at the local public highschool. Of course I'm probably just pissed cause I maxed out at 68 inches.

  18. amy,
    please. consider the following. i have seen about 40,000 patients in the ER. you have made the mistake of taking generalizations i have made regarding many of these 40,000 patients and applied it personally to you. i have no idea why you have done this but since, unless you and i are star crossed, you are not one of the patients i have seen and treated and certainly not one of whom i complain. go to your local trauma ER on a saturuday night. sit and watch for a few hours. then you may just begin to have an inkling about what we are talking about here. see how long people have been waiting to be seen and see how many ambulances bring folks to our doors in an hour. really, i have no idea why you have taken this personally.

  19. 911 Doc

    I guess I was not too clear. My fault.
    I did not take it personally, but I think I represent the silent majority of people who have a job,an education and do not take everything in life for granted.
    There are millions of us out there and your comments -today and on any other given day- often lump all ER patients into one big category: sytem abusers, drug seekers and who knows what else. We do show up at ERs too occasionally because we do get seriously sick or injured once in a while and it really bothers me that we are viewed right off as free loaders.
    You don't know who can pay or nor, so do not assume that we don't.

    All this said, I know the stress of working with the general public and how easy to it is to fall into the trap of "them against us" and "they all are morons and we are the only smart ones."
    I too made a change several years ago away from the public. The best decision I could have ever made.

    All the best,

  20. amy,
    thanks for your comment. it is not i who have lumped all patients into one category... it is the government and politicians. when you start from the assumption that the best health care available should be available to all for 'free' then what you have created is a sinkhole. the absolute least efficient way to deliver any resource or good is through a government program. the quickest way to kill an industry is with regulation from above or with an unfunded mandate. the people you should be mad at are those that demand that my services be provided regardless of their ability to pay and the politicians that get elected hustling their votes by giving away other people's money by force of the public purse (taxes). i don't want to work for the government... i did it for five years already.

  21. 911: Your previous post was one of those "nail on the head" posts! The politicians pander the "National Health Care" issue are probably going to determine our next President largely based on this issue.

    People like Amy come to the ED for legitimite reasons and get put off and forced to wait for hours because of the unfunded mandates (EMTALA) and "safety net" stuff. The politicians ain't workin' for free, but it's easy to "buy votes" by promising to force lots of docs to work for free or at least at a loss.

    I'll clarify myself before the anons jump on me...I don't mind caring for the true indigent EMERGENCY. I get fed up with the people who refuse to find a PCP, refuse to pay a PCP, refuse to make an appointment with a PCP, yet smoke, talk on their cell phones, wear the latest fashions, etc.....and then come to the ER for "free" care for their sore throat or chronic back pain.


  22. 911, I hate to see you leave but I understand. I am happy that you are making a change to improve your lifestyle and emotional well being. Maybe you'll return after Hillary fixes everything?
    Since you will continue to dabble in emergency medicine, I hope that you will continue to dabble on M.D.O.D. or somewhere in the blogosphere. Your posts are the ones I look forward to the most. Etoh is running a close second of course, but I just can't let a pathologist woo me like that, what would my friends say?

  23. Best wishes to you 911doc; will we still hear from you sometimes? You and 'cat are so right about the work and critical mass (=burnout) thing, and good on you for doing something to save your soul and health.

    You will be sorely missed ...

  24. You will be sorely missed ...

    Wait, screw emergency medicine, you're not LEAVING the BLOGOSPHERE are you?

  25. Don't worry, K. We can find him and drag him back by his Pepsi Can.

    Besides, don't you know the 11th commandment? "Thou shalt not forsake thy blogging compatriots when thou leavest Emergency Medicine, lest they find you and force you to referee a mud-wrestling match whilst blindfolded with thy hands tied behind thy back."

    He ain't goin' anywhere.

  26. Then when you remove the blindfold, you will discover that the wrestlers are Graham and Shadowfax.

    Good luck with the new gig. It sounds promising.

  27. chill bizzle-nizzles,
    going to keep blogging away. hopefully a change in my daily routine will produce happier posts with kittens and chocolate hearts!
    will dip my hand in the ER to remind me of why i've 'sold out to the man'.

  28. We can find him and drag him back by his Pepsi Can.

    That was kind of hot. Is it bad that I, all of sudden, want him to leave?

  29. Please, no kittens or chocolate hearts....don't go all girly on us.

    Or as ipi would say, gay.

  30. You know, I consider myself to be a fairly bleeding-heart liberal, and I almost lost my shit in the ER a few weeks ago, and Amy, I think I get why the ER docs get so frustrated. I'll explain. (and this is going to be a book. I'm sorry.)

    I had a C-section in early December. When my baby was not yet six weeks old, I stepped on one of my other kids' toys and wiped out, twisting really violently on the way down. My barely-healed incision opened back up and really, really hurt, and it was about 11 at night. I called my OB, who wanted me to go to the ER. I went.

    The ER was filled to the rafters with parents and kids. Kids who WERE NOT CRYING. AT ALL. They didn't even look sick (okay, I'm not a doctor or a psychic, but I'm pretty sure they were there for colds) Instead, they were running around screaming, throwing trash on the floor, eating cookies, drinking soda...you get the picture. They were, however, all snotty.

    I sign in. I ask how long the wait is going to be (just a ballpark range, nothing precise) (oh, and I said please and thank you) and she said she didn't know. While I waited about an hour, I saw some guy ask for pain meds while he was waiting. I saw parents just talking on their cell phones and going out to smoke while their kids ran amok in the waiting room. Then I heard the triage guy tell another person that the estimated wait time was NINE HOURS. This was not a county hospital. NINE HOURS.

    I was in a LOT of pain (and I had already taken my last hoarded vicodin from the C-section earlier that night.) but I told the triage nurse to take me off of the list, because there was no way I was waiting nine hours when I could just go see my OB in eight.

    Okay, I know for a fact that my neighbor with Medicaid uses this ER all of the time for things like ear infections, so I'm going to assume that a lot of the other parents in that ER were doing the same that night...so why on earth do I pay 300 dollars a month for my insurance just to go to the ER and NOT GET SEEN because it's too clogged with people that could have gone to a minor med? It really pisses me off. It's not fair that I'm going to have to pay out the ass for my C-section at that same hospital while I actually qualify for Medicaid, but I'm trying to do the right thing and carry my own weight, and I can't even get seen in less than 9 hours.

    You know, it sucks when you get it up the butt for trying to do the right thing, and as a patient, I'm pissed, so I can only imagine what the docs feel at having to see this kind of stuff day after day.

  31. dear elizabeth,

    without getting into the many other variables that define us as 'conservative' or 'liberal' let me say a few things. the main point is that what you experienced in the ER (and it sounds like all you needed was a wound inspection, Xray, and pain control), is a direct result of liberal politics and policy. on a day with a clear waiting room you would have been seen and treted inside an hour, but we don't have those much anymore.

    when the government decided to enact EMATLA doctors (and others) saw this coming. with all due respect, legislating that all facilities provide 'emergency care' for all comers regardless of their ability to pay has had an obvious result, the same result as yelling 'fire' in a theatre.

    first and foremost EMTALA has taken responsibility, assumed in all previous generations in our fine republic, out of patient's hands and placed it directly on physicians and hospitals. for instance, there is absolutely NO INCENTIVE for folks to budget for medical care anymore (there are exceptions but i'm speaking in generalities).

    consequently, an economic decision has been made by the bulk of our citizenry to view health care as a right. since we still have the best health care system in the world and the best doctors in the world then, whether they actually vocalize this or not (and believe me there are no shortage of patients who actually tell me that they came to the ER because 'it's free') the reality is that when a valuable service is made free by law then people will use it more. the terrible thing about our current situation is that for folks like you with jobs the burden of the uninsured is being carried largely by you and us. more on this later. basic economics is no longer taught or understood by the majority of the public. even though he is decried as an 'uncle tom' and a 'sellout' and if you are interested then i highly recommend this book by thomas sowell.

    also, since there is no money, docs in town default to the 'go to the ER' mantra almost without fail. i do not blame them. why lose money doing your job? when folks in other professions lose money at work they quit and do something else.

    the tentacles of the well intentioned law called EMTALA, and again trying to stay away from the politics a bit, are long and strong. this is my disagreement with liberalism in general. it is well intentioned yet myopic. the defects of human nature can not be cured by laws. they especially can not be cured by laws that are not enforced or paid for... but i digress.

    ideally all us docs and nurses would just love what we do and not worry about money. given that most of us finish training hundreds of thousands of dollars in debt and in our early to mid thirties EMTALA just becomes silly. doctors want what everyone wants... good jobs, security, and hope for the future. we are motivated and highly trained but EMTALA and centralized health care makes us technicians at best and indentured servants at worst. the CEO of my hospital corporation makes ten million a year, he has a masters in business and sleeps at night.

    one of EMTALA's tentacles is this, which again, to all of us in medicine was clearly seen, but to those who pass laws was conveniently ignored. many of us are almost conspiritorial regarding EMTALA and think it was passed to intentionally wreck our system so that the government could grow another beaurocracy and grow it's hold on all of us.

    i am at work right now, we have eight patients waiting for a bed in our hospital which is FULL. the wait times are bad enough that a whole bunch of people have left without being seen tonight. probably no big deal but one might actually be deathly ill. the number of ER's in america has decreased by thousands in the past ten years and the number of ER visits has skyrocketed.

    our ambulance service, staffed by wonderful hard-working folks making about 14$ an hour, is in crisis as more and more of their jobs is to act as a taxi service both for folks who don't need to be here and for folks that need to go to the next town because we are full. the next town's hospitals are full.

    folks on the left side of the aisle want everyone to have the same health care as the wealthiest amongst us. folks on the left side of the aisle want everyone to have a nice home, security, etc... the difference between us is that, as a rule, conservatives think that people should be given free reign, within our laws, to make decisions for themselves and provide for themselves and hopefully get all of these things by their efforts. along with this come consequences but EMTALA is a shining example of what happens when consequences, however painful, are removed from the equation.

    add to the mix a small but significant number of attorneys who make a living suing us for stuff we need to be sued for and stuff that is ridiculous and you have a prescription for CYA health care. i dare not miss ANYTHING during my short time with my non-paying patient. john edwards for instance. i order much more stuff than i would if john edwards and people like him had not become filthy rich doing what they do. honestly, if i make, for the sake of argument, 200k a year after 8 years of specialized training going 300k into debt in the process, how much sense does it make for john edwards to make ten million in one judgement with three years of post graduate school? liability caps are the norm at the VA or in military hospitals as the government can't stomach being sued but are, again with some exceptions, not allowed for folks like me.

    idealism meets reality in the ER every day. reality has impacted you in an unfortunate way. i hope you are doing better after your fall and that your c-section incision and ankle are fine.

    finally, as you may or may not have read here, i have had enough. i make a nice salary and feel like i deserve it. in the past two weeks i have worked three shifts from 10p to 7a, two of which stretched to 9a. i have worked four shifts at 7am and three in the middle of the day. i have had to tell the parents of a 2 week old that their baby died, i have had to wade through hundreds of ER abusers to take care of lots of really sick people. the salary is not worth it. given that my efforts to change the way we deliver health care have all been thwarted (and i'm talking about local stuff... i am not a politician and not active in my college) and that the public seems to want a hillary-style 'solution' the writing on the wall is clear to me and this blog is my humble attempt to magnify the writing on the wall for the general public.

    i will take a pay cut and probably not be any worse for wear and tear. my tax bracket will decrease and i will keep more of what i earn. i will have regular hours. i've done my time in the box and i'm out. it is funny to me that 15 years after we destroyed the biggest threat to human freedom in the last 50 years (the USSR) that we are tilting towards centralization of things much too important to be left to politicians. as pj o'rourke says, 'if you think health care is expensive now, wait until it's free.'


  32. 911:
    Maybe if you saw patients instead of writing "War and Peace" during your shift the ER would clear out sooner.

    Kidding. I agree with everything you said. Fight The Power!

  33. 911: Not a single argument here! Right on the money as usual.

    Elizabeth: Welcome to my hell hole of a world. Last night, I had 3 kids with "a cold" whose parents wanted me to cure them. Two had already been seen in the ER twice, the other one at a minor care earlier in the day. None of the kids looked sick. I resorted to my well used line: "there's no magic cure for the common cold that we're with holding from you. If I could cure your child, I would...only time will do that so keep sucking out the nose and give Tylenol for the fever"

    Folks on the blog (usually libs like yourself) often respond to our complaints by saying "you went into ER knowing what you were getting into, so quitcherbitchin". But the ER of 2008 isn't the ER that we all went into and trained for 15 or 20 years ago.

    You needed to be seen and we don't like it any more than you do. The reason it's like this....government involvement....how do you make it even worse? You guessed it, more government involvement!

    I have a strict policy of hating all "go to the ER docs", so I also might suggest that your OB could have met you there if the ER was that busy! He certainly cashed the check for your C-Section.....he could have driven down to provide your necessary post op complication treatment too. But I forget that once the baby is out it isn't his/her problem anymore!


  34. Even though I'm fairly liberal, it still gets my panties in a bunch to see a bunch of not-that-sick kids in the ER, because there is a nice urgent care clinic RIGHT across the street that I've used several times for my and my kids' issues. It's open on weekends! It's open until 8 some nights! C'mon! GAH!

    I do believe people should have BASIC health care, but if I'm paying way more than we can afford, and my husband is working two full time jobs so I can stay home with our kids. My next-building-over neighbor, whose husband makes roughly about what mine does doesn't work (both kids are school-aged, so she could at least get a PT job), yet she gets disability/Medicaid for her kid with ADHD...and that seriously makes my blood boil over. ADHD!

    My oldest son has microcephaly, hemiplegia and cortical blindness, and when we applied for disability for him, so that we could get him those nifty things we couldn't afford on our own, like adaptive technology, they said our gross was too high. We're in that lovely gray area where we make too much to qualify for all of social services (we do qualify for Medicaid, but as I said, I prefer to keep my son on private coverage...it's really sad, but we do get MUCH better care and nicer doc's offices that way. Sure, I have to pay for it, and we can hardly afford it, but dammit, I have SOME pride. Plus, husband an I need insurance.), but not enough to actually live a decent life (decent is relative, I realize. My husband is from a third-world country and poor here is completely freaking loaded over there)

    Whew, I wandered completely away from my point, there. Back to it.

    I actually really respect what you guys do. I'm very interested in the medical field, and honestly, the most fulfilled I've ever felt in my life was when I worked as a translator for a missionary medical clinic in Honduras, so I can definitely see the appeal. I know you guys work hard and pay out the ass to get where you are, and I do think you should get some respect and get paid for it. I know you enjoy your jobs, and it's really sad when bureaucracy forces you to quit a job you love, or change your focus.

    I could be wrong, but I think I read somewhere that the docs that work the hardest get paid the least and have the crappiest hours (ER, GP, OB and Peds, right?) and it's certainly not fair. (Am I wrong about that, by the way? It's just something I'd read somewhere.)

    But don't tell my bleeding-heart friends I said any of this, okay? It'll be our secret.


    PS: I'm for tort reform, too. *gasp!*

    Son of PS: Oh, and I'm fine now. I just irritated my abdominal muscles. Hurt like a mother (ha!) but I'm better.

  35. Beth: Darlin' you can see the light, just come toward it!

    You're right about the poor pay and bad hours for ER and OB, I don't know about Peds and GP. Their pay sucks, but they don't have such horrible hours.

    For me, I just wanna manage emergent patients. That's what I love to do. Being the back door for every fossil on the planet to get into the hospital and seeing these freebie non-emergent cases over and over is what is burning me out.

    Some hospitals insist on payment for the non-emergent abusers of the hospital, and we should too, but EMTALA makes it such a slippery slope and is such a dangerous thing to screw with!

    I PROMISE you that more government involvement isn't gonna solve this....we need LESS of Washington. And we need to force these BS patients to pay....it would seriously cut down on their abuse of the system.

    I have more cogent thoughts, but I gotta nap before another night of fun, excitement, and snotty noses!

    Hope your "tummy" is doing better.


  36. EMTALA illustrates the core problem with government involvement in health care.

    They took an idea everyone could agree on -- you can't refuse to treat a guy having a heart attack in the ED no matter what. And then they implemented it in the hamhanded, unintentional consequence-ridden way that characterizes the claw hand of government. And so now, thanks to their mandate that every patient who wants some "free tussin" has to be treated, they have successfully ruined the emergency room for the vast majority of patients to solve a problem that wasn't even very widespread to begin with. Bravo, government, bravo. I can't wait until you get your hooks into everything else.