Reasons I'm Leaving Emergency Medicine (number 8)

The Business of Medicine:

If there's one thing that flips me out within the first two sentences of a discussion it's talk about our customers. I have beaten this one to death and will simply link to some older posts here and following.

Medicine, particularly Emergency Medicine, IS a business in that it runs on money, but it is in terrible trouble because a whole bunch of folks, mostly politicians, pretend it's a unique business not susceptible to silly things like supply and demand.

As a result of unfunded give-aways and mandates medicine is much more like a mob racket than a business.

Where is our money coming from, and how can we sustain ourselves doing what we do now? The answer is by stealing. All of us in this racket steal from folks with money to pay for those without. When it's done officially this is called taxation, but this kind of stealing is called compassion.

For God's sake at least call it what it is. We started losing this battle with a little teency-tincy program called medicare/medicaid that was only for the most down-and-out and most pitifully poor and debilitated. Now we extend these benefits to illegal aliens, criminals, folks with bogus diseases, and, basically, anyone who shows up at an ER.

In my town it is well known that for misdemeanor offenses and minor felonies that if you develop angina incarcerans that you will only be cited, and the cops will dump you in the ER to be released on your own recognizance after we determine the crack you smoked will not kill you this time (the police can't pay the bill either).

The ER has become very efficient at 'moving the meat'... winnowing through haystacks of primary care, medicine, and psychiatric patients to find the 'needle' patient who has heart disease, a stroke, or new onset schizophrenia.

In the meantime between the 'free' ambulance ride and the 'free' care mandated by EMTALA we lose hundreds of millions, if not billions of dollars doing this, and the there is no disincentive for the abusers. These costs are transferred directly to on-call specialists and the hospital who then transfer the costs to paying patients (and doctors quit or go completely private and otherwise solid citizens despair). Never mind that this "free care" is not tax-deductible, nor is it protected from litigation... not even capped.

If you sell cars it would go like this...

Government (to car dealer):

Ahmed here is new to the country, poor, and needs a car to get to work, give him one for free. Do the maintenance for free, and, if you give him a car with brakes that don't work and he gets in a crash he gets your house. No, you can't claim it as a loss you just need to "figure it out". And oh by the way, his wife needs one too. Pony up dude.

It is unsustainable idiocy and, in the end, hurts the very people it is designed to protect. Don't believe me about doctors quitting? Just within the linked blogs on my site my colleague at "Fingers and Tubes in Every Orifice" quit a year ago. I'm quitting in 8 weeks. Schrodinger's cat is quitting in 8 weeks. Two other friends in ER in another state are quitting (and just two years out of residency). And our impromptu poll is interesting, is it not?

At my hospital within the last four years we have lost three urologists to EMTALA, one general surgeon, and four of our six orthopedists in town are about to go private. We have no neurosurgeon, no pediatric surgeon, no plastic surgeon, no psychiatrist, no endocrinologist, no rheumatologist, we have neurology ten days out of the month, we have ENT fifteen days out of the month, and we have ophthalmology 24 days out of the month. We can not recruit new doctors or nurses. We are a town of 400,000 and we are the only game in town.

Private ERs are opening and insurance only (no medicare) hospitals are opening and doing well. Charity hospitals, our old stop-gap, are gone for the most part. Ten years from now without doing anything we will look just like Canada or England. That may make you happy but it should scare the shit out of you.

So asking me to improve my "customer service" (my Press-Gainey scores), and to get ready for JCHAO is a lot like asking me to put the cover sheet on my TPS reports. Business? Thievery.